Off the Rails

When I stepped of the elevator onto the medical wing I heard loud gospel singing, then a hard kick into one of the steel doors of a medical cell and I knew Mr. J had gotten worse. I had first encountered him on med rounds down in one of the pods. When I entered his pod I was met by the bald sociopath with glittering blue eyes and my initials tattooed into his neck barking at me about why he didn't have his asthma medication. "You should already have the records in my file, I shouldn't have to do this," he said when I tried to get him to sign a release of records so I could fax his doctor for his asthma history. He narrowed his eyes and leaned on the med cart until I put the paper away. Mr. Skinhead Sociopath had arrived at my fine jail without his inhalers and hadn't had an attack at the jail requiring medical intervention, so no records, no inhalers. When the officer next to me leaned in on the other side of the med cart and put his hands on top of my cart the inmate backed away into the pod. Then Haldol Boy approached the cart, "My mom says I should get back on my meds," he told me. His face looked smooth and white, his thin lips quivered only slightly. "You are looking so much better!" I told him, "But I think it is a good idea to look into some medications for you," I agreed and gave him a form to fill out for the Psych NP. I instructed him to fill it out in as much detail as possible and I would take it back up with me. Then an older black man came to the cart, Mr. J, he projected the imagine of a gentle giant standing over six feet and weighing over a two hundred pounds. "How are you today young lady?" he asked me as I handed him his meds in his little cup. "Just fine today sir," I responded, giving him a smile. He was a welcome relief from the assault of the sociopath and deep sadness of Haldol Boy. The next week he was brought to medical for his deteriorating mental health condition.

"He's the one who stabbed that guy in the neck, a friend of his," another nurse told me during report. I knew I had to develop some source of local news, I had no idea what she was talking about.
"No shit," I replied, glancing over at Mr. J in his cell. He had his back to us, staring out the toaster-oven sized window.
"Yeah, he's been doing OK here so far, but now he's pacing all around the pod and the officers feel like he might be dangerous, so they brought him up. So far he hasn't been any trouble up here, but he's bored."

He paced his cell and looked out the window with a strange intensity for my entire 8-hour shift at the desk. Occasionally he would gesture for me to come over. I stood at the door of his cell and listened to him through the crack between the door and the doorframe. The deathrow inmate at the women's prison taught me to listen at the crack when I was a a Newjack back in seg. "If you just need to talk to someone in here, don't drop the slot," she instructed me, "don't ever put your face near a slot, listen and talk into the crack." When I put my ear to the crack between her solid steel door and the steel doorframe I could hear her perfectly. From then on I communicated exclusively through the crack, even if the slot was dropped for meds or some other purpose. When I put my ear to Mr. J's doorcrack I heard pressured words pour out of his mouth "I need to go back to the wing, back to the wing, I could play cards there, walk around, do something, you know, back on the wing." When I tried to make eye contact with him and assure him he could go back to the wing once he was doing better he looked through me and kept talking as though he was addressing someone four feet behind me.

I worked the prison for a few days and when I returned to the jail and stepped off the elevator I knew immediately things had gone from bad to worse. Mr. J had refused all psychoactive medications from the start of his decent into mania, but now he refused all of his cardiac meds as well including some very serious blood pressure medicines and blood thinners. He thought he was fine. Jesus talked to him and told him that we were all crazy and he was fine. "What the hell are we going to do with him?" I asked the Psych NP.
"Well, since he's over 65 we can't get him committed at one of the regular state mental hospitals for meds over objection, he has to go to a special gero-psych facility, there is only one in the state with not that many beds. We can't do meds over objection here, and he can't go to the university hospital because he is an inmate, he has to go to a forensic unit now."
"This mental state is probably just an extension of his stabbing his friend, and now he's gone completely off the rails," I said.
"He doesn't have too much of a history before this, it seems like he was a pretty solid family man, I've met his family, they are very nice and very concerned. It sounds like from talking to them that he's had episodes of hypomania for a long time, having lots of energy, spending more than they could afford at times, but this is the first time he's really crossed over."
"How sad, to have your first decent into mania-induced pyschosis at such an advanced age, like, you'd like to think if you make it to your 30's without any sort of psychotic break then you can assume you're in the clear."
"It is unusual to have a first psychotic episode so late in life and not secondary to dementia, that's a whole other thing," he replied.
"Right, right," I nodded my head. I'd like to think there was a window between psychosis from mental illness and psychosis from age-related dementia. Like a break between acne and wrinkles. Mr. J made me feel less safe for myself, showing that after a long life of slow-simmering mania, the pot could still boil over at any time.

The Psych NP got Mr. J placement at the local gero-psych state hospital. By the time the social worker from the hospital came to evaluate him he would dress only in his boxers and pull his penis out at anyone who approached his cell, which was thoughtlessly assigned next to the high-traffic supply closet. When the transportation team took him to the hospital he kicked out the side window of the cruiser and they had to pepper spray him to subdue him, so he arrived with pepper spray covering his transportation orange. He is committed for 30 to receive meds over objection. The court order can be renewed for another 30 days as many times as needed.