The gray-haired Irishman walks around the wards quietly, avoiding eye contact. He touches the walls, as if to reassure himself of the world around him. He says very little, and the little that he says I find difficult to understand. I have been in England for only a month, and I assume it is his Irish brogue that I find difficult to follow. The consultant psychiatrist I am working with tells me otherwise. "It’s the antipsychotics he’s taking," he says on rounds. "He has major depression with psychotic features. Nihilistic delusions, thinks he is going to die." Dr. Anwar speaks in clipped Oxford tones, tinged with a trace of Southeast Asian inflection. I find myself modulating my own Indian accent when we talk. "What about ECT?" I ask.
"Refused it," he says. "Until he changes his mind, we’ve to keep plodding on. I just increased his olanzapine and reboxetine." He pauses and presses the intercom for the nurse. "Betty, can you send Tim in now, please. We’re ready to see him." This manner of rounds is new to me. We wait here, like judges in a courtroom, while patients are summoned like penitent prisoners, so that we may examine and interrogate them. I know the real reason for this method is to protect the patients’ privacy since they have roommates, but I can’t help wondering if patients feel like we pass sentences for crimes of depression, psychosis, or attempted suicide.
Betty leads Tim into the room and seats him on a chair that faces a grimy window. Outside, the Birmingham landscape appears bleaker than usual. Smoke rises from steel mills in the north to join nimbus clouds in the sky. Birmingham is a city in flux, attempting to shed its industrial past, and old Gothic houses lie side by side with modern town homes. It is early afternoon but dark enough inside the room that the fluorescent lamps are switched on. Dr. Anwar and I sit opposite Tim, a small low table stained with coffee rings between us.
"How are you, Tim?" Dr. Anwar asks in the gentle manner that he reserves for patients and also (I know this because I have heard him on the phone) for his wife.
Tim does not say anything for a while. It is quiet and all I can hear is the incessant patter of rain against glass. Finally, Tim looks at Dr. Anwar for a brief moment before staring at the floor again. "Feeling all right, Doctor," he says. "But not for long, I reckon."
"My heart’s going to give out soon."
Dr. Anwar has been down this path before. He sighs and says, "Your heart is fine, Tim. We got it checked out by the cardiologist. Your blood pressure is fine, your cholesterol is excellent, and you are the only patient we have here who does not smoke."
"It’s going to give out," Tim repeats. He stands. "Can I go now?" he asks, but he leaves before Dr. Anwar can reply.
A few days later, the morning starts as any other. A customary cup of tea with the nursing staff during a report from the night shift and then rounds. By noon, we are finished, and I have a quick lunch at the cafeteria. There’s a special on the fish and chips, but then, there’s been a special on that all week.
Things are quiet today, and I even have some time to play snooker in the doctor’s lounge, usually the domain of the dermatology trainees. Back in the ward, I am finishing up some notes before I leave to catch the train home, when suddenly there is a shout and then an overheard page: "Cardiac arrest in ward 10. Cardiac arrest in ward 10." It takes me a moment to realize that this is ward 10. I rush outside in panic. A man has collapsed in the corner of the hallway next to a television set showing the 5:00 news. Betty and another nurse are already there, administering cardiopulmonary resuscitation. I recognize the gray beard and the white hair.
The crash team arrives and hooks up a monitor. They administer medications, intubate him, press on his chest, inflate his lungs, and shock him several times. I look at the monitor—ventricular fibrillation and then asystole. His heart has stopped. After 20 minutes, they call it off. The medical resident, a balding Asian man, shakes his head. "No use, not a flicker. We did what we could." He pauses. "So what kind of psych problem did he have, anyway?"
"He was psychotic," I say. "Thought his heart would stop."
"I don’t understand," he says.
"Neither do I," I tell him. "Neither do I."
Address reprint requests to Dr. Bhat, Department of Psychiatry and Internal Medicine, Southern Illinois University School of Medicine, P.O. Box 19642, Springfield, IL 62794–9642; firstname.lastname@example.org (e-mail).