Chapter One – Sign on the Dotted Line

---

I stand outside of the side entrance with my employee badge in hand, primed to key the wall lock that opens the steel-enforced security door leading into the psychiatric ER and my upcoming 12-hour shift. I take a deep breath, mutter my mantra (“Showtime…”), and grasp the door handle, hoping that our locked-down dungeon of a day hall is empty, yet anticipating that there will be eyes watching me as I enter. Some sad and suicidal, a level of hopelessness seemingly beyond repair; others manic and labile, oblivious to the madness racing through their chemically imbalanced brains; still others demented or demon possessed, or perhaps just good ol’ boy inebriated eyes craving a smoke and another shot of liquid sustenance.

I scurry past an empty day room and unlock the door leading into the Birdcage, AKA our psych assessments office. The front and side walls of the Birdcage are primarily Plexiglas, providing staff the much-needed capability to monitor our patients’ every move in the hallway. Unfortunately, the Plexiglas allows patients the opportunity to watch us as well, oft-times glaring, their noses nearly touching our see-through office walls in their never-ending attempts to rush us along.

---

the rumbling female voice, like rapids on a river… building to a roar, stirring butterflies deep within my belly.

---

“So what did I do to deserve this?” I ask my co-workers, thrilled that the day room is empty and no patients are waiting to be assessed.

“You wish…” they reply in unison, pointing to our referral board where I see a female name on the board as having just arrived out front.

“How wild?” I ask.

I don’t have to wait for an answer. I hear a commotion rolling down the outside hallway and cuss under my breath, the rumbling female voice, like rapids on a river, growing louder, slowly building to a roar, stirring butterflies deep within my belly.

“Susie’s in the house,” Barry muses, turning towards me. “Your favorite kind of patient,” he says, handing me the referral paperwork.

“Big and bad to the bone,” Donna says, smiling.

I glare at my teammates. “Payback is mine.”

I scan the crisis team’s faxed description of her behavior — labile, agitated, pacing, openly arguing with herself, at one point telling crisis staff that God had told her she was the chosen one to lead the revolution and, “ain’t a damn thing anybody gonna do to stop me…” In addition, group home staff where Susie resides reported that she stopped taking her meds a week ago and had grown increasingly agitated over the past few days, culminating in the assault of another resident, prompting their police call earlier in the day.

When schizophrenics stop taking their meds and become psychotic and agitated, one way to safely subdue them is a chemical cocktail such as Haldol and Ativan together in a one-shot syringe. When that same schizophrenic is two-hundred-and-fifty-plus pounds and stout, as in Susie’s case, with a history of unprovoked assaults on staff and peers, the risk factor skyrockets in a free-standing psychiatric hospital where there is no on-site medical ER and no immediate access to a physician. Translation — We got no meds. Just our wits…

I step out into our hallway where Susie paces. I approach her slowly. “What’s happening Susie,” I say, low-key.

She turns and sizes me up, her chest expanding. She crosses her arms and glares at me.

I ease in closer to her, hoping to make a connection, and not of the left hook variety. “My name’s Joe.” I look down for a moment then back up, all cylinders firing in my spindly legs, ready to move if she lunges at me. “I’m one of the assessment…”

“I know who you are,” she growls.

“You hungry?” I ask, ignoring her comment.

“What you got?” She starts towards me.

I nonchalantly turn to walk with her, again ignoring her passive threat to see if I’ll flinch. “We usually got ham or turkey sandwiches and chips,” I say. “Might even find a coke or sprite.”

She walks on by me on her way to the other end of the hallway. “You got mayonnaise?” she asks, never bothering to turn around.

“I’ll find you some,” I say.

“Git me ham…”

“Comin’ right up,” I say.

I open the Birdcage door, slide over to the back portion where the patient refrigerator sits, and grab a ham sandwich sack, complete with chips and a cup of fruit. I fill a Styrofoam cup with Coke, nudge the frig door closed with my knee and start back out the door.

Donna flags me down.

I let her know who’s at the top of my food chain at the moment and hustle back out into the hallway. “Where you wanna eat?” I ask Susie.

---

She starts mumbling to herself, cursing.

---

She stops pacing and looks at me from the other end of the hallway.

I ease towards her, sandwich bag and drink in hand. “You wanna watch TV while you eat, or sit over here in the big blue chair?”

She starts mumbling to herself, cursing.

I set her food down on one of the chairs facing the TV. “Make yourself at home.” I step away from her food. “If you need anything, let me know,” I say. “I’m working on getting you upstairs.”

Susie plops down and tears into the food bag. She struggles to get her sandwich open, an excessive amount of plastic wrapped around it.

“Here…” I ease down on one knee, take the sandwich from her and unwrap it. “Okay?” I nod, opening her potato chip bag.

She glances at me, then grabs her sandwich and devours an entire half in two bites.

I stand up, gently pat her shoulder, and let her know that I’ll check on her shortly. I start towards the office.

“Mista Joe,” Susie calls out.

I spin back around. “Yes ma’am.”

“Can I git another sandwich?”

“You sure can,” I say and head for the frig.

“What I wanted to tell you,” Donna says as I start back out again.

“Yeah…” I gesture as I unwrap another sandwich, hand it to Susie, and slide back onto my Birdcage perch.

“Dr. Ayottolah called.”

“He’s not on call,” I say. “Is he still here?”

“He was,” she says.

“Was?” I turn towards her.

“He called right before you came in,” she says. “I’d asked him to stop by on his way out to sign the second committal on Susie so we could get her moved upstairs.”

“And…?”

“That was him on the phone, saying that he forgot to stop by.”

“Is he coming back?” I ask as I sign onto the computer.

“He’s already halfway home.”

“He’s what?” I say, reaching for the phone.

“Who are you calling?”

“The units.” I look up and see Susie content for the moment.

“I’ve already called,” Donna says.

“Any other docs still around?” I ask, already sensing the answer from the look on her face.

“Not a one.”

“Son of a…” I mumble under my breath as I glance at my watch.

“That’s not even the bad news,” Donna says, then turns to Barry, sitting at his usual post to our right.

“We can’t get an ambulance to transport her to the ER for two hours,” he says.

“What?” I cry. “You’re kidding?”

“I wish…”

“So what do we do?” Donna asks.

“Can you call Dr. Thompson and ask him if we can have Susie sign in voluntarily?” I turn and walk back out into the hallway. “You get enough to eat?” I ask Susie.

She looks up at me and appears to nod, although I’m not positive.

“I’ll be right back, okay? I got some papers for you to sign, and then I can walk you upstairs where you get your own room. That sound okay?”

She looks at me again, this time nodding ever so slightly.

I return to the Birdcage and the good news that, given our circumstances, Dr. Thompson authorized a voluntary admission. I call the admissions clerk, letting her know that Susie is ready to be admitted. She thinks I’m crazy when I say voluntary (vs. involuntary) admission. I hang the phone up and see Barry and Donna gawking at me.

“You got any better ideas?” I snap.

They look at each other and then back at me.

I start towards the office door. “You want to do the honors?” I ask Barry.

“Oh no…” He laughs. “She likes you.”

“Donna?” I gesture.

“I wouldn’t do that to her,” she says, playfully batting her eyelashes.

“Yeah, right…” I start out the door.

“Have fun,” my comrades tease.

I ignore them as I turn my focus to the task at hand — convincing Susie to sign the admission papers. Otherwise, we’ll be stuck monitoring her for the next four hours without meds to give her, cigarettes to subdue her, or Jerry Springer on the boob tube to divert her.

“Susie, you get full?” I ask.

She nods without looking up.

I squat in front of her out of instinct, wanting her to sense that I respect her and trust that she will not clobber me. “Okay if I take your food tray away?” I ask.

She nods again, head down, body still.

I grab her empty food bag and juice box, along with a splattered mayo packet, chips bag complete with remnants and pieces of fruit under her chair, and scoop up as much of her mess as I can. “Be right back,” I say and dart to the office, fumbling for my keys.

The door opens, compliments of Barry. “You’d make a good waiter,” he says and grins.

“Glorified Shoney’s waiter,” I reply as I dump the trash and wash my hands.

“She all signed in?” Donna asks with a sly smile.

I grab my clipboard and start back out. “You don’t think I can do this, do you?”

“It’s crazy that we have to even try,” she says.

“Yeah, well…” I open the door. “Welcome to psych assessments.”

“But she’s not voluntary material,” Barry cries.

“You want to be responsible for her for the next four hours and we got what,” I glance at the updated referral board, “two geriatrics with Alzheimer’s and an adolescent in route, and no extra help? We’re lucky Susie’s the only one back here right now.” I grab the admission papers from the printer and turn back towards my teammates. “It’s not fair to Susie either,” I say to them. “She’s psychotic and in need of meds. It’s not fair or even safe to expect  her to hold it together back here.”

I approach Susie again, slowly pulling a chair up to her chair so that I can assist as much as possible as to where to sign and initial the admissions papers. As I scoot my chair up to where the arm of my chair is aligned with the arm of her chair, she never flinches. She just sits, staring straight ahead, mumbling and cursing under her breath.

I turn towards her, my clipboard with the admission papers in my left hand, my right forearm resting on the arms of our joined chairs. “Susie,” I say, not waiting on eye contact, hoping to avoid any type of power struggle with her, “we have a room for you upstairs and it’s ready. I just need you to sign these papers agreeing to come into the hospital.” I hesitate, unsure if she’s grasping what I’m telling her.

She remains perfectly still.

I lean ever-so-slightly into her massive left side. “Susie? You with me? I just need you to sign these papers so that we can admit you upstairs where you have a room and a lot more space to roam. Otherwise…”

I never get a chance to explain the otherwise. She raises her arms without provocation, takes her sweatshirt off, tosses it in the chair to her right, and returns to sitting stone-faced as before. Luckily, Susie has a sports bra on and no one else is in the area. If Susie doesn’t overreact, I won’t overreact, at least for the time being.

---

reminding myself that there’s no need to startle her into slapping me

---

With clipboard in hand, I get back to the task at hand. “Susie…” I set the clipboard down in her lap. “I need you to sign your name right here.” I point to where I pray she signs and hand her the pen. “By signing, we can get you upstairs to a comfortable room as opposed to waiting down here,” I say, wondering what’s going through her mind in terms of getting more comfortable.

She sits motionless, her eyes looking down at the papers.

I take a deep breath, reminding myself that there’s no need to startle her into slapping me upside my head. “Susie… you think you can sign your name here?” I direct the pen she is holding to where the point of it is on the dotted line. “Just sign right there,” I say.

She never flinches, the pen dangling from her colossal right hand.

“Susie,” I say with more intensity, leaning forward, hoping to establish eye contact. “Can you please sign your name so that I can move you upstairs?”

The pen moves across the paper but stops. I lean in further to see if there’s anything legible on the paper. There is not.

I dig deep into my bag of behavioral tricks. “You almost got it Susie,” I say with a huge smile. “Let’s try it again.” I reach across her again, my eyes locked on pen placement, and place her right hand directly on the line. “Now, write your name.” I prompt her physically.

She makes a giant S on the line.

“Great job Susie!” I say. “Now finish it out.” I prompt her again.

She writes another giant S next to the first one.

I sink into my chair, close to calling it a day, but the thought of my co-workers chastising me for weeks on end about how I’d lost my touch with the big bad women of psych assessments prompts me to give it another try.

Actually, more like five tries. Same approach. Same encouraging words. Four strikes against me and I’m on the verge of walking away, when for whatever reason, on the fifth try, Susie signs her name just as pretty as you please.

I’m ecstatic and singing her praises as I skip the initials sections and move to the back page of the four-page consent in hopes of obtaining one more signature. “Okay, Susie,” I say, “let’s sign your name one more time, just like before.” I prompt her, placing the pen on the line.

She signs without hesitation.

I lean in and give her half-a-hug. “Thanks Susie,” I say, patting her hand. “Give me just a few minutes to get your papers together and we’ll walk upstairs, okay?”

She looks me right in the eye, holding my gaze.

“You’ll be okay,” I say. “We got good people here who will treat you right.” I stand and reach for her sweatshirt. “Can you slip this back on for me please?” I hand it to her and start towards the office. “I’ll be right back, okay?”

She watches me, shirt in hand, as I disappear around the corner and into the Birdcage.

“You want me to call security to escort you upstairs?” Barry asks.

“No thanks.” I grab a blanket from the warmer as back-up.

I approach Susie, who remains seated. “Can you slide your shirt back on?” I ask.

She doesn’t flinch.

“Let’s wrap up in this, okay? We’ve got to walk down a few hospital hallways.” I unravel the warm blanket and gently place it around her. “That feel okay?”

She nods, with a hint of a smile.

“You ready?” I ask.

She nods again.

“Let’s go.”

I unlock the side door and escort her down a back hallway, teetering beside her, all the while praying that she chooses to walk with me and not bolt for one of several doors leading to the outside that we’ll pass along the way. I try to engage her in conversation, however she does not respond.

She stops in the middle of the second hallway, looks down at the blanket loosely wrapped around her upper torso, and then over at me. I have no idea what she is thinking, but I do know that the longer she stands stagnant, the more likely we are to have the blanket flying off just as we approach the main hallway of the hospital to get on the elevator.

---

her massive hand squeezing my left hand so hard that it throbs.

---

“Susie, you okay?” I say, reaching out to touch her shoulder. “We’re almost there. Just a few more steps and we make it to the elevator.” I move beside her and gently prompt her to move forward. “C’mon, we can make it…”

She looks at me with a perplexed look on her face, and then looks down. I see her right hand starting to move as if she is going to tear the blanket off.

“C’mon Susie,” I say, “I know you can do this.” I gently take her right hand and place it in my left hand. “We can make it. C’mon…” I start moving forward, her hand in mine.

She follows my lead, her massive hand squeezing my left hand so hard that it throbs. We make it to the elevator and step on without incident. I quickly tap the close door button, followed by the number six to take us to the sixth floor and our acute psych unit.

The elevator doors open and we depart hand in hand, the blanket shifting and moving about but still covering her front side. I open the door to the unit. “We made it, Susie!” I pat her hand with my free hand, praying she releases my left hand from her vice-like grip. She does not. “You did great, girl,” I tell her. “Thank you for walking up here with me.”

I breathe a huge sigh of relief as the acute unit door closes behind us. We stroll down the hallway towards the nursing station, Susie still clutching my hand. We finally make it to the nursing station where I prompt her to sit in a hallway chair to wait on staff. I squat down beside her and ease my left hand free from her grasp. “Let me drop these papers off to the nurses and I’ll be right back, okay?” I pat her hand and stand, nodding and smiling at her. I duck into the office and hand the papers off to the nurse.

“What’s with the blanket?” the nurse asks as I start out the door.

I turn and smile. “Precautionary measure.”

She looks at me like I’m nuts.

I laugh and head out the door. “Just another day in the Birdcage…”

I stop by Susie one last time. “You take care of yourself.”

I reach out to pat her shoulder, only to have her snatch my sore right hand and place it on her cheekbone. Susie looks me in the eye and nods.

“They’ll take good care of you up here,” I say, slowly easing my hand away. “If you need anything, you let them know.” I smile and touch her shoulder. “You’re gonna be okay Ms. Susie. You hear me? You’ll do just fine.”

I give her a brief hug and hustle down the hallway, making sure, as always, that no one is behind me as I scurry out the locked door, bypassing the elevator for the stairs. Within minutes, I’m sliding out the ground floor side door and up the hill to a grassy knoll where my favorite one-hundred-plus-year-old tree overlooks the hospital. I stand underneath my old oak friend and share my latest Birdcage experience.

How ironic? Susie’s locked away on an acute psych unit and I’m outside talking to a tree about Susie’s genuine reaction at the end of our excursion.

We connected. If only for a moment.

She felt my kindness. She knew I cared.

That’s all I need to sustain me in the Birdcage for another day.