Law #1: Don’t Panic!

One of the oft-quoted medical adages from Samuel Shem’s seminal work, The House of God, reads, “At a cardiac arrest, the first procedure is to take your own pulse.”¹ While very appropriate for cardiac arrests, this same rule can—and should—be applied more broadly. Many of the experiences that greet a third-year medical student are new and frightening and are best managed with a healthy dose of deep breaths.

No setting could be more foreign to a third-year medical student than an inpatient psychiatric unit. During my first rotation on the unit, I heard over the loudspeaker, “Code 99—1st North. Code 99—1st North.” The signal for an out-of-control patient blared throughout the hospital walls. Mr G was a 50-year-old man who had been admitted the previous night for schizophrenia and suicidal ideation. As I arrived at his room he was wild—tearing bed sheets, throwing personal items, and screaming. The attending psychiatrist was right behind me, and the security staff was steps behind him, but for a few seconds, I was on the front line.

In that brief moment my mind went blank. I was paralyzed by fear. No lecture or textbook could have prepared me for the first moment I confronted violent psychosis. There is no reasoning with it; there is no consoling it. There comes a point when the safest response for the patient and staff is “the cocktail”: an injectable mixture of haloperidol, lorazepam, and benztropine used to subdue a psychotic patient. I stood there, rooted to the spot, as the staff rushed in and medicated Mr G. Order was restored, and the sigh of relief was palpable as Mr G slipped into a medication-induced sleep.

My experience with Mr G was slightly terrifying but overall eye-opening. Patients I had seen during other rotations were clearly sick; they had kidney failure, bacterial infections, and a host of other problems, but nothing like this experience with Mr G. What I had taken for granted about patients during other rotations was that they could be active participants in their own care. I quickly learned that not only are many psychiatric patients unaware that they are ill, but sometimes they are completely unable to take orders, swallow pills, or tell anyone what is wrong—especially during an acute psychotic break such as Mr G’s. As caregivers, we must be able to step in and do what is right for our patients, even when it means placing ourselves in harm’s way.

Psychiatry is often maligned by the media, causing a misperception that propagates wildly in the nonmedical world. The “psychotic killer” is a familiar character that haunts many movies and books. Unfortunately, for many medical students, these preconceived notions persist as we enter our medical training and can eventually manifest as fear. We owe it to ourselves and our patients to educate ourselves about what is fact and what is fiction. A psychotic patient should be approached with caution, but an already volatile situation will only be inflamed further if the caregivers fall victim to fear.

The third year of medical school is an exciting time. For many students, it will be the first time that they will see the diseases and disorders they have studied so intensely up close. Students find themselves confronting cardiac arrests, traumas, and even violent, out-of-control patients, as I did. These experiences can be intimidating. I hope that students learn from my experience and understand that they should not fear the unknown.

We put ourselves through the rigors of medical school to care for these patients who need us. Mr G clearly needed us. He was in a state in which he could not control himself and could not recover without our intervention. The same can be said for many patients students will encounter during their medical training. My advice for future third-year medical students: Be prepared for these experiences and make yourself a useful member of the team. Breathe, don’t panic, and use what you have learned.