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Thirty years ago, in my second year psychiatry, I suffered dread during on-call at Douglas Hospital. The hospital, set on 170 acres between Montréal’s Lachine Canal and the St. Lawrence River, had more than 1000 mental-health patients. I was the sole on-call, responsible for everything: medical crises, dressing and suturing wounds, monitoring infections, drug reactions and attempting to sedate violent and suicidal patients. If I didn’t know what do, I read manuals, spoke to nurses, called the staff psychiatrist and waited for the patient to get better — or worse.
On this particular on-call evening, the hospital was marooned by a violent blizzard. Lights flickered, broadcasts warned of whiteouts, falling power lines, school closures and airplane delays. Outside, the maelstrom roared and trees snapped; inside, the hospital was still and my beeper mute. By 11:30, the evening nurses were asleep in spare ward beds; night staff who were unable to reach the hospital remained house-bound. Unable to sleep, I threw on my boots and coat and trudged knee deep in snow as the savage sky whitewashed the earth. When I returned to my room, I crept into bed, sniffed my clean sheets and sank into a deep sleep.
An hour later, the irate head nurse phoned. A patient, sleepless for more than two days, threatened to leave. Where was I? My beeper was dead. Hurriedly I dressed and marched through a sombre underground tunnel to a locked ward and was informed about Sophie. I reviewed her chart, met with the head nurse and checked my psychiatric manual.
Sophie was on lithium, valium and thousands of milligrams of chlorpromazine. Nothing touched her. “Watch out,” the head nurse warned. “She’s sly, foxy.”
“Finally, a nice doctor,” a comely blonde in a hospital gown greeted us with a Lauren Bacall voice. “Silly nurse,” she grinned. “Doctor, you’ll send me home now?”
“I would like to talk to you.”
“You can take me home.”
Sophie spoke dry-mouthed and rapidly. Her eyes sparkled like icicles.
“The staff are worried you haven’t slept.”
“I sleep when no one is looking,” she winked. “You can sleep with me.”
After a fruitless talk with Sophie, the nurse and I walked into the hall. “Put her in a quiet room,” she advised. Feeling cruel, but knowing the nurse was correct, I explained the move to Sophie.
“Get out!” she cried. She hurled insults. She kicked the door. “I don’t trust you!”
“Sophie hasn’t taken liquids for over a day — she’s too hyper,” the nurse said.
We returned with a cup of ginger ale. Sophie flung it at us. As we left I heard her ranting tearfully, pounding the walls. “She’s getting more manic,” the nurse said.
I found a new copy of Freedman & Kaplan (1975) on the ward and reviewed drug treatment. There were not many options. “Now what do I do?”
“Sedation,” the head nurse said. I waited a half-hour during which time Sophie was mournful, cross, elated, removed her clothes and paced her room. When she did not settle I entered with four staff. I gave her haloperidol injections. Two hours and 20 milligrams of haloperidol later Sophie was worse — agitated, singing. I worried that restless patients like her developed dehydration, cardiac problems, pneumonia and infection.
“I am leaving,” Sophie said. “You’re not my friend.”
“It’s impossible for anyone to leave — see the blizzard outside.”
“I like the snow. I am like the snow.”
Clearly, we were not getting anywhere. “Sophie, we must treat your mania.”
“I am fine.”
I feared she might collapse of exhaustion. I checked her pressure, her heart and lungs, asking her about pain, cough or shortness of breath.
“Just give me a kiss and we’ll go home.” She paced relentlessly.
At 2 a.m., I dialed the psychiatrist on-call. Twenty minutes later, he phoned after struggling to shovel out his car. “It’s crazy outside. We’ll do this by phone.”
“She’s had enough to bring down a horse.” I reviewed her meds. “What do I do?”
“Is she medically stable?”
“Her lungs are clear. She denies pain. She’s flushed, but has no real temperature.”
“What’s her history?”
“It’s her third manic episode. She’s 35, twice divorced, lives alone. She’s half-finished a PhD in Russian literature — the notes says she discontinues her meds.”
“Sounds like mania — it might last for days. Watch her, she may deny symptoms. Make sure she’s taking fluids.”
“What if she gets worse?”
“I’ll see her tomorrow — if the storm lets up. We’ll discuss ECT.”
“I just wait?”
“Hydrate her; check her blood work, lithium level, screen for infections, minimize stimulation. That’s all we can do.”
“Can I use another drug?”
“Try chloral hydrate, 500–1000 mg. It’s relatively safe.”
Somehow the head nurse cajoled Sophie into swallowing two chloral hydrate and checked she hadn’t spit out the capsules or hid them under her tongue. Two hours later, Sophie showed signs of sedation, she had stopped screaming; her rapid speech decreased.
But there were more calls. A middle-aged schizophrenic man slipped from bed and gashed his head. I shaved his head and gave him 20 stitches. There were calls for hypnotics, diuretics, stool softeners, antibiotics and analgesics. An elderly diabetic patient was hypoglycemic. After stabilizing his meds, I returned to Sophie.
She sipped a Coke and asked to walk to the solarium to see the storm. Exhausted, I walked with Sophie, accompanied by the head nurse, an orderly and a security guard to watch the snow. “Snow is a leitmotif in Pasternak’s Zhivago,” Sophie said. “Snow, snow, over the whole land, across all boundaries — that’s from Pasternak’s poem.”
I returned to my on-call room and fell asleep at 6 a.m. to the sound of shovels. At 8:30, the duty psychiatrist phoned me to see about our patient. The snow had stopped. Outside the sun was so bright it hurt my eyes, sparkling over trees, roofs, fields and roads like baker’s glaze. I went to the ward. Sophie was fast asleep. My on-call was over.
Sophie was discharged in February. I never saw her as an outpatient, but she left me a worn paperback copy of Boris Pasternak’s Doctor Zhivago. After that white night 30 years ago, I never forgot the snow. In Doctor Zhivago the snow was everywhere.
The patient depicted in this story is fictional.