I first met Ruth in the emergency department (ED) when I was a third-year medical student on my psychiatry rotation. She was an “elderly female with psychosis — medical workup negative.” My resident had received a page with a request for her admission and sent me to the ED to speak with her first. Eager to check off another required history and physical from my rotation to-do list, I went to meet her wearing my short white coat, weighed down with the knick-knacks that I thought made me a better medical student.
As I walked towards meeting her, I still felt guarded. The word psychosis painted heavy imagery of flying chair strokes, violent shadows and blossoming profanity. When I reached the raucousness of the ED, there she was. Amidst the countdown of sweaty CPRs and the moans of withdrawal, the most peaceful entity in the ED was Ruth — a thin, frail, white-haired woman who soundly slept on a stretcher. Her loud snores ricocheting off the walls were the only movements in her lonely room.
I tapped her bony shoulder once … twice … and she opened her eyes on the third. She slurred her words as though she had been chemically restrained, but she could still smile through her yellowed teeth. When she answered my introductory questions as appropriately as anyone else, I wondered why her doctors had tagged her as being psychotic.
She, at first, entered a twisted storyline about her husband, Frank, his infidelities, deceits and lies; their four daughters and their no-good lovers; and the youth she had given up to build their trailer home. However, the more I asked Ruth about why she was there and who brought her to the hospital, the more jumbled and riddled her answers became. She told me about the shadows that chased her, the names of the angels who protected her, the devil’s impersonation of her husband of 50 years and the tales God told her throughout the day. The longer I listened and tried to decipher Ruth, the more questions I had about her identity, but her own tale soon put her back to sleep mid-sentence.
I revisited Ruth as her student doctor the following day — this time in the inpatient psychiatric unit. She once again lay in bed with the covers pulled up to her wrinkly chin, but her chemical restraints had been released. In her muffled smoker voice, Ruth was in the midst of an elaborate story about Frank’s theft and sale of her jewelry to a pawnshop for money to spend on his mistresses. Her pearl earrings bounced from her sagging earlobes in rhythm to her story, and her frameless glasses reflected the image of the nurse in her room, taking notes. Although Ruth had seen me less than 24 hours ago, my presence upon walking into the room this time appeared nothing short of miraculous for her. Her pupils magnified, and she quickly shot up in bed. While pointing a shaking finger at me, she said, “You’re … Mary — Jesus’s mom!” Unaware of how to respond to Ruth’s hyper-religious delusion at my expense, her nurse quickly walked out, and I returned Ruth’s accusation with a smile.
Throughout my month-long rotation in the inpatient unit, I visited Ruth daily. On days she felt well, we sat in front of the common room windows, watching the leaves fall as she told me about Frank’s sins. On days she felt restless, we shuffled down the hallways together, and she told me about her mother. On rare days when she did not feel well, I pulled up a chair near her bed in the dark room, and she responded to me with one-word answers. Some days, her delusions and hallucinations overpowered the effects of her medications, and on others, we only talked of the weather.
I also met the infamous Frank. He was a foot taller than Ruth, wore a checkered flat cap and a thick wool coat with a small tote bag at his side. His hands wrung in worry, his eyes tired. Every other day, he visited the unit, bringing in a clean set of clothes, and taking home his wife’s dirty laundry. Ruth often refused to see him. Some days, he waited in the waiting room throughout the visitation hours in case she changed her mind; some days, he also was too tired. Soon after meeting Frank, I also met the couple’s oldest daughter, who told me that Ruth’s accusations of Frank were unfounded; he had never been unfaithful.
With a combination of daily medications and group therapy, Ruth began to show improvement in her judgment and insight. She spoke less and less of hearing God’s voice and more about her visits with Frank; how he had brought in her favorite clothes, how she would return to their home after being discharged, or how he was now just “okay.” Occasionally, she slipped and claimed God had given her the pearl earrings she wore, “as if Frank could ever afford them.”
While her treatment of Frank varied during all of her care, Ruth had always been kind to me. When we spoke, she looked intently and purposefully into my eyes, as if trying to understand me. I wrote progress notes on her daily, but I felt that she was also keeping score.
On the day of her discharge, I told Ruth I was glad she was feeling better and that she would get to go home. She hugged me and said she had always liked me. While holding onto my hand with her dry bony ones, her dry lips twisted into a devilish smile, and she said, “I know who you are.”
“Who am I?” I asked.
She replied, “If I tell you now, they’ll never let me out of here.”
Author’s note: Names and details have been changed to protect the identity of the patient.