Shrouded

She entered the room for her daily meeting with our team.  She had been on this inpatient psychiatric ward for several days already but it was Monday morning so she would be greeted by some new and unfamiliar faces.  I was one of them.  She was covered nearly from head to toe in lengths and layers of clothing and she wore a bath towel tied around her head as if it were a wedding veil.  She was exceedingly thin, an aspect which was still quite evident despite her many layers.  Her frame supported her garments with the same effect as clothes hangers holding their wares in a closet.

Just before she had entered, I was informed that she would be my patient to follow for as long as she was still admitted during my two-week Psychiatry rotation.  As a result, it was my task to start our daily interview.  I worried how frightening and offensive our sheer volume would be to her: a care coordinator, an attending physician, two residents, two fellow medical students, and myself.  I remember the unease I had in knowing I would be asking her questions, being someone she had never met before.  But I was hopeful I could convey enough empathy in my conversation to blanket us all.

As she sat down, I will never forget my first glance into her eyes.  I saw nothing.  “That must be wrong,” I thought to myself, “I must have looked too quickly.”  But again, I looked and was internally startled to find a void.  I had only seen such absence, such shroudedness, in a few of my previous Alzheimer’s patients, but never in someone so young.  She was my age and I think this disconcerted me all the more as I continued to search her eyes.  It was as if her soul and essence had been a lamp covered with a thousand shawls to obstruct its glow.  A gaze so tenebrous, I was caught completely off-guard.

As I asked her my questions, she would look from me to the group and back.  There were no expressions in her face or body as she replied.  Her words were brief, apathetic, and void of all intonation making them very dry and bitter to take, as if she were serving us dry rye crisp with no butter.  She affirmed my questioning that she did in fact feel as if she may harm herself, a definite red flag. This symptom caused us all great concern, requiring a change in care plan to provide 24-hour direct supervision for this poor woman, cloaked inside and out.  Remaining expressionless, she quietly arose from her chair and walked out of the room at the end of our meeting.

The next morning, before we were to meet again, our team was alerted of concerns from the charge nurse.  “She was up walking all night,” the nurse began, “The staff walked all night to keep up with her.  She never laid down, just kept pacing the hall from one end to the other.  And what’s worse is, she has no shoes!  She has been walking all night in her slipper socks on our hard floor.”  A second red flag, and care plan concern, for this unfortunate young woman.  Another flag she further affirmed during our daily interview shortly thereafter.  She said, in her unchanged affect, that she had walked all night to keep from hurting herself.  She said the only way she could feel somewhat safe was to walk continually and sing hymns to herself.  I had never seen someone so uneasy, so perseverating in their body movements, and yet so flat and devoid of all expression.  Our team hoped she was only overmedicated.  We discussed with her that we thought this may be a side effect, that medications would be decreased, that new meds would be started.  Then we would have to wait to see if our changes would be helpful.  She apathetically agreed.

The morning of my third and fourth days on the ward resulted in the same interactions with my patient. She remained draped with the same clothes I had seen in her since the first day we met and with the same towel wrapped around her head.  No change in affect.  No change in motion.  No change in shroudedness.  But, on day four, there was one change. . .on her feet.  She finally had shoes, kindly brought in by her mother the evening before.  I surprised myself in how much seeing shoes on this woman’s feet brought me relief and comfort. Despite her tragic situation, we had achieved some protection for her, even if only for her feet.  She wore them without dispute and continued to walk, incessantly, reminding me of the ever-moving monotony the taffy puller figurine has as he turns his perpetual crank.

On day five as I entered the ward, I expected to see her as I had for the last three days, mid-lap, headed down the only hallway of the ward, but she wasn’t there.  Was she okay? Could she be resting?  Oh, how I hoped that would be the case.  When it was time for her daily interview, she entered our room in new clothes, a new towel on her head, and a couple other surprises; a slight upturn to the corners of her mouth and a new tip of her head as she spoke.  As I looked into her eyes this day, I saw a glimmer.  That must be wrong, I thought to myself, I must have looked too quickly.  No, there really was one!   It was the first glimmer I had ever seen in her.  My soul jumped in recognition of that small light she emitted.  She had enough light now to be able to break through her void, like a single firefly disrupting the darkness of a moonless night.  Such a small precious twinkle, a twinkle of hope.  Now the team could again make adjustments in her medications after discussing them with her because the first changes were starting to help.  We could stop the 24 hour watch too, as she was able to tell us that she didn’t feel she had to move all the time and that she no longer felt unsafe to herself.  As I left the ward later that day, I had more hope for her than I had felt all week.  I would now await the coming of the next Monday when I could check on her again.

My second week came bringing with it more good news each day.  Although in small increments, each day revealed more expression, more emotion, and more hope.  For the first time since I met her, by Wednesday, she used the words “placid” and “hopeful” to describe how she felt.  Instead of the “okay” she had reported every day previous.

As I left the ward on my last day I knew her journey back into the light, back from under the thousand shawls that covered her lamp, would not be hurried.  It would instead be gradual and ongoing.  I knew her journey would, at least for now, remain burdened with shrouds, isolation, and sometimes sorrow.  I saw her soul as being so brave, slowly walking on its pilgrimage from tenebrosity to light.

She is on a journey that I, in some ways, parallel with her through my attendance in medical school.  My soul is shrouded with the thousands of pages I have yet to read, thousands of practice questions and several exams I have yet to take, hours of course work I have yet to complete, and the innumerable diagnoses I have yet to decipher.  Yet as I strive daily to complete these tasks I too remove, slowly, the tenebrous layers that cover the light of my soul as a physician.  Amidst the hope of the resurfacing of our light, we have similar burdens of shrouds, isolation, and sometimes sorrow.

These journeys can make us feel lonely at times, but with our families and our supports by our sides, I know we will not be alone.  As we walk, we are surrounded by many who offer encouragement and refuge.  I know our hearts are grateful for the gifts and protection they provide us as we walk toward our reemergence.  I hope our souls continue to be persistent and brave, to uncover our light and show our potential.  I hope the hymns we sing in our hearts and the shoes we wear on our feet give us the courage, strength, and protection needed to keep navigating our parallel journeys.