Downey V.A. Hospital Was The Home of Polypharmacy and Megadoses

 

Desperate situations often produce less than optimum results. The patient population at Downey V.A. Hospital was an intractable bunch, tortured by some of the most severe psychopathology known to man. My first time passing medications was a real shocker as one pour soul was ordered 2000mg. of the potent major tranquilizer, Thorazine. Nursing school pharmacology taught me that a usual dose was 75-200mg of Thorazine. A ten fold dosage of 2 gms. was out of the ball park.

Another disturbing trend involved patients dosed with more than one major tranquilizer with some dispensed as many as four. When the V.A. administration discouraged megadoses, polyharmacy was haphazardly substituted. I don't know which practice was worse in fueling disabling side effects like tardive dyskinesia, polypharmacy or megadoses.

When I brought this up to our ward physician, Elihu Howland MD, he agreed that it was a less than desirable situation  and suggested that I do a study enumerating the problem and he would see what he could do. Good luck were his parting words which were uttered in a less than sincere manner.

I eagerly went to work and came up with the following.

There are a significant number of patients at Downey receiving  more than one antipsychotic drug or a witch's brew combination of these neuroleptics. Here on Building 66AB I found a patient receiving three different antipsychotic drugs with a PRN order for a fourth neuroleptic agent. This much chemical restraint could be as disabling as the underlying illness.

Many studies evaluating  polypharmacy under controlled conditions demonstrate that there is no effectiveness over monotherapy. There really is no basis in fact for the existence of polypharmacy as a treatment method nor empirical evidence for its continued use as an effective treatment modality. Additionally, polypharmacy creates an added risk, even a fatal outcome, from a combination of drugs with mutually additive effects. With polypharmacy it is nearly impossible to delineate which specific drug is the culprit inducing untoward side  effects.  Many articles conclude that single drugs are the treatment of choice over polypharmacy.

Furthurmore, a recent review clearly shows that  we have a number of patients on extremely high dosages of antipsychotics. Megadoses   seem related to poly pharmacy in that one poor option is often substituted for the other. When megadoses are discouraged, polypharmacy soon fills the void.

Megadoses indicate  we have a large group of chronic patients who have been receiving a very high dose for a long period of time and whose mental status has stabilized, yet no attempt has been made to reduce their dosage to the lowest effective maintenance level. This maintenance dosage should be as low as suitable for retaining therapeutic progress. Dosage should be gradually titrated down to avoid a sudden emergence of symptoms.

The notion of lowering doses is especially important when megadoses or high doses are ordered. The patient's symptoms , drug history, and general physical condition should be considered when the risk of megadoses is evaluated. The occurrence of side effects must be balanced the benefits in the chronic patient who continues to present psychotic symptoms endangering himself or nursing personnel.

Once control of target symptoms has achieved, the dosage must be be adjusted downward as most all patients could be maintained on a lower dosage level.

Perhaps we should start by eliminating polypharmacy and then carefully titrating down on some of the megadoses.

I submitted this report to Dr. Howland with a listing of the patients receiving polypharmacy and megadoses. While there was some success with reducing polypharmacy, there was much resistance to decreasing megadoses. The main argument was the patient was on these doses for a very long time so there was no rationale to decrease doses.

My frustrations working at Downey reached a boiling point a few months later when my head nurse recommended me for a grade promotion, but  it was rejected by the personnel office because I was 4 days shy of the time required in grade for promotion, but never fear, I could apply again next year.

I resigned from Downey V.A. on May 21, 1976 after working there 1 year, 5 months, and 28 days. It was a very long year and a half and made working in the OR seem like a walk in the park. I happily returned to my favorite stomping grounds in the O.R

Christmas Arrives at Downey VA Hospital With a Gift for Warren

 

 

Warren was a big, tall man with a complexion that reminded me of custard pudding, forty-one years old, with half a lifetime spent on the back wards of Downey VA Hospital, a warehouse for the mentally ill. Like most all the patients here he was branded with the diagnosis of schizophrenia, chronic, undifferentiated. By the 1970s psychiatrists had given up on the idea of delineating the various subtypes of the illness; catatonic, hebrephrenic, paranoid, or schizoaffective,  all permutations were treated the same at Downey. Determining the underpinnings and concocting efficacious treatments for complex mental disorders like schizophrenia made nuclear physics look like a game show.The brain was a complex organ with very complex disorders.

Warren's most visible problem was that he was literally lost in space and required constant contact with a wall to do just about anything that required movement. Staff members regarded this as a behavioral manifestation of his psychosis and dealt with it  accordingly by initiating harsh measures like restrictions on privileges such as smoking and moving his bed to a dark, grim, windowless  area for special observation with threats of physical restraint if he persisted in his wall rubbing routine.

Watching Warren navigate the subterranean world of Downey's interconnected tunnel system was like following a bumper car at the state fair. He repeatedly bumped or bounced his right shoulder off the rough red brick walls leaving a trail of textile shards in his wake, similar to the sparks trailed by the bumper car contact wire on the electrified ceiling. His posture resembled the letter "J" upside down with the end of the letter in constant contact with the wall as he gallivanted along his way.

Just about any staff  reprimand, which was nearly constant,  to cease this shirt/coat shredding behavior was meant with a look from Warren that could smelt lead. Out of pure frustration, Warren developed a unique skill that involved tapping on the few panes of glass windows that had not replaced by plexiglass, skillfully he increased the force of the impact until the glass shattered, leaving his hand virtually without injury.

I talked to Warren about his need for wall rubbing and came away with an assessment much different from my esteemed colleagues. I thought the  incessant wall rubbing was not a direct manifestation of his psychosis or voluntary acting out. Warren had a proprioceptive disorder where he really could not tell the position of his body in space. He felt that without contact with the walls while moving he  would follow a circuitous path and never arrive at his destination or fall injuring himself.

That evening while pouring medications my eye was drawn to the heavy plasticized bottle the pharmacy provided for a solution we mixed with Thorazine concentrate liquid to make it palatable. The side and bottom portion of the bottle had a contour that was a near perfect match to Warren's right shoulder where it interfaced with the brick walls.

I took an empty bottle home that evening and went to work on a garment that could slide along those rough Downey walls and remain intact. Warren loved football, having played receiver  in high school, but while his team mates soared to the stars with their lives. he burned up as he plunged back through the atmosphere like the space shuttle Columbia.

After fashioning an appropriate skid plate from the pharmacy bottle, I drilled a series of tiny holes around the periphery of the plastic armor  and carefully sutured sewed the protective armor to the right sleeve of a Chicago Bears jacket  ala a craniotomy bone flap. A test drag across the outside wall of my apartment building proved successful. Warren was an avid Bears fan and I had a feeling he would really enjoy the jacket, especially if he could rub the brick walls without worry.

I carefully wrapped Warren's special Christmas gift complete with the  abrasion tested shoulder armor in a box that was emblazoned with the corporate jingle, "Tarreyton  100's for smokers who would rather fight than switch." He eagerly unwrapped the present half expecting a mother lode of cigarettes, but as he eyed the special jacket, his eyes gleamed. The look was priceless. He quickly donned the jacket with a renewed sense of purpose. When he spotted the shoulder guard, he couldn't wait to try it out with a quick mosey down along the hall walls. It doesn't take much to make some folks happy - one of the special rewards of working at a place like Downey VA Hospital.

Smokeeters Cleared the Air at Downey VA Hospital

That coffin sized brown box hugging the ceiling of a Downey VA Hospital dayroom was one of the most indispensable elements of the therapeutic milleu; a Smokeeter. This machine droned on with an intestinal rumble as it digested hazy nicotine laden air and expelled a mountain fresh breeze from the opposing end. In with the bad-out with the good.

Downey VA Hospital dayrooms had a dismal aspect about them with bars on the windows and the walls reflecting a gloomy potatoe-y  noncolor with brown gravy like nicotine stains in just about every nook and cranny. Worst of all was the unbearable effluvium of cigarette smoke combined with the scent of men densely packed into a confined area. A palette rinse and sinus lavage was mandatory at the conclusion of a shift. The place just plain stunk.

 The lighting cast a yellowish pall over the entire unsavory mess reminding me of a Foley bag long overdue to be emptied. Smokeeters were an acknowledgement of the foul conditions and an inadequate intervention to remedy the situation, a microcosm of the mental health treatment system.

Serious mental illness does strange things to folks. Emotional channels become intricately wound together so they coagulate and strangle each other. Recreational chemicals like nicotine, alcohol, and caffeine are some how involved in the masking of the pain induced by nervous dysfunction. One of the mantras often heard on the ward was, "nicotine cuts thorazine." Patients truly believed in the therapeutic effects of smoking and would go to great lengths to ingest as much nicotine as possible.

Smokeeters worked by electrostatic precipitation and the nicotine that adhered to the electrodes in the device required daily flushing. In an addition to an electrical connection, Smokeeters required plumbing to provide a water supply for routine cleaning. This maintenance operation called for twisting open the supply valve and making sure the drainage line to a utility sink in the laundry room was patent for the final journey to the sanitary sewer system.. A kink in the drain resulted a most unpleasant blowback of the toxic brackish nicotine concentrated effluent.

Curiously, there was always a contingent of anxious, over eager patients volunteering to flush the Smokeeter. I soon discovered their strange motivation one evening  while making ward rounds. I was perplexed to see a patient whose entire upper torso was contorted into the depths of the utility sink where the foul liquid from the Smokeeter drained.

As I eased his head from the sink a syrupy brown exudate covered his lips. He had been guzzling  the foul drainage from the Smokeeter.  "What in the world are you doing?" I asked. With an ear to ear grin framed in the brown nicotine laden sludge he replied, "I'm drinking nectar from the nicotine gods courtesy of the Smokeeter.Try a swig-it's like smoking a whole carton of cigarettes in one drag. WOW..what a rush." I declined and made certain the laundry room was secure prior to flushing the Smokeeter.

Downey VA Hospital Presents the Communication Book

It's been quite some time since I've written anything about the long ago shuttered psychiatric facility known as Downey VA Hospital. I worked there 1974-76 and recently discovered an interesting old tome in my basement junk pile extensive nursing archives.

Every ward at Downey VA Hospital  maintained a communication book which consisted of random comments by just about anyone involved in direct patient care. Relevant notes of significant findings during multidisciplinary ward rounds were among the more important recordings. The book was also supposed to contain notes of meetings with nurse officesitters and assorted busybodies, but any staff member with an ounce of sense steered clear of these crazy conclaves as a matter of survival. There is very little in the way of notes about meetings.   When one volume was filled it was tossed in the trash and a new one started. It just so happened that I rescued one of these delightful digests  from the dumpster and will share a few choice entries with my loyal readers. The entries provide a brief snippet into the life on a Downey ward. Patient names are all pseudonyms.

Insulin shock therapy was one of the more barbaric treatments administered to inpatients at Downey VA. The patient was given a significant dose of regular insulin and allowed to descend into shock The following note by a resident offers a valuable tip to ward nurses.
.All ward nurses should carry a round or two of Lifsavers brand candy with them in the event they have a patient that is slow to respond from insulin shock therapy. Each piece of candy raises the blood sugar approximately 10mg/%.

Mason, Wm -  admitted to drinking a pint of vodka under the water tower. Return to locked ward.

Ayers, Bob - No longer feels homicidal. Was under the influence of drugs and alcohol when he attempted to assault a psychologist with a dagger. Intelligent with insight into problems.

Farna, Kyle - Attempted to break into father and step-mother's home while on pass. Family does not want him back.

Grounds crew workers are busy spreading used grease and oil from the motor pool over the barrier wall around the building in an attempt to deter elopements. If you see a patient covered in grease you know what he's been up to.

Night shift- Please see  that patients remove pajamas before dressing in the AM

The roofers were a bit overzealous with spreading hot tar above the "C" ward dayroom. A small amount leaked down and burned the head of  Ronald Alt. Patient sent to Bldg. 133 for medical evaluation.

Jack Ray caught guzzling from a bottle of William's 'Lectric Shave. speech slurred with unsteady gait.

Cockroaches the size of a small Shih Tzu are taking over the  "A" ward dorm. Please be more careful about screening patients for foodstuffs before retiring to bed. Several partially consumed HO HOs were found under Harry Vonsickel's bed.

Ressary, Jorveit- Eating from garbage cans again and Linda is missing a box of paper clips. Abdominal flat plate X-ray requested.

Note from a nurse detailed from the medical building to cover a last minute call out on night shift: Unsafe to be in attendance in this building at any time!

Glen Rimes bit Thomas Reynolds on the calf without provocation. Since this is his second serious bite will refer to dental service for full mouth extraction.

Carlton Searing needs an ENT consult. He has been impacting his ear canals with Thorazine 200mg. tablets in a futile attempt to "stop the voices."

There is more, but I suspect you have read enough. I hope this has been a brief distraction from the Corona virus horrors. This pandemic sure has me concerned for all the whippersnapperns out there in harms way. I think of you often and hope that you are staying safe.

Clandestine Patient Restraint Techniques

Nurses providing ambulation assistance 

for an afternoon nap.

Restraining patients is probably one of the most unsavory elements of nursing practice and old school practitioners were masters of obfuscation when it came to forcible restriction of movement. Even office sitting nurses of the academic/administrative complex eschewed patient restraints. Everyone did their very best to find ways around outright restraint of those under their care.

Memos from on high regarding patient restraints were filled with officialese and gobbledygook in an attempt to camouflage what was really  going on. I found a VA restraint and seclusion Professional Services  Memorandum that illustrates this point: VA Form 10-2683, Report of restraint and seclusion.  "The doctor's orders (SF508) will be initialed by the GS9-11 ward nurse. The nurse will copy the prescription (form 10-2913) on the nursing notes (SF510) indicating the type of restraint and 24 hour report of patient's condition (VA form 2915). The nurse in charge of the ward during each tour of duty will maintain a record of each application of restraint on VA form 10-2683. After the last day of the month, the nurse will sign this form and forward it to the Registrar Division - 114A."  Some head nurses referred to the monthly reports as the "Funny Papers" because restraints were not always used according to Hoyle with the frequency of use almost always understated.

Downey VA Hospital, the long term psychiatric hospital I worked at in the early 1970s made extensive use of full restraints that consisted of heavy leather cuffs secured by robust belts. My ways of caring for these patients were unique and foolish, but averted some  of the unpleasantness associated with 4 point restraints. I began a patient enlightenment program that involved patients recognizing when they were beginning to escalate and request restraints before anyone was injured. A veteran of the Viet Nam war summed things up quite  nicely, "Restraints are just like an Asian civil war-much easier to get in than get out." I couldn't have said it better myself.

This illustration clearly shows the time tested maneuver aptly called "let me hold your hand...DOWN. Whether inserting nasogastric tubes or assisting with  excruciating procedures like the removal of Jackson-Pratt surgical drains, every old nurse had experience with this one. Initially, good intentions entailed holding the patient's hand for support, but soon evolved  into a vice grip not unlike the panic induced squeeze on the overhead bar of the Ravenswood EL train as it rounded an acute bend. Hold that patient's hand like a trapeze  artist grips the bar while the good doctor gives that J-P drain one final yank.




Distraction is another useful tool in the nurse's position inhibition  armamentarium   (please note, I did not use that dreaded "R" word.) This trick procedure does not work well with painful ministrations about the head and neck, but is very effective for procedures below waist  level like bedside urethral dilitations or removal of orthopedic external fixation devices. The nurse elevates the bed so that the patients eyes are close to the height of the nurse's ocular orbs. The patient's  head is immobilized between the hands as the nurse locks eyes with the hapless patient. Extreme eye contact seems to slow things down  and put a damper on some of the unpleasantness.

Children are especially vulnerable and the isolated snippets  in my mind of pediatric restraint have long sense departed. Whew! Am I ever happy for that. There is a harrowing  pediatric restraint device known as the  Pigg-O-Stat. Google it if you dare. This thing looks like a blender with the lid off and the youngster is dropped into it for X-ray procedures. It's no wonder so many people have claustrophobia later in life. They were probably popped into a Pigg-O-stat as a mere youngster.

 One of the more humane child restraint devices is a take-off on the old Trojan Horse idea. The restraint device is a toy rocking horse that lures it's young patients by whimsical looks, not brute force. While the child plays horsey, an X-ray plate is slid into position and the exposure made before anyone is the wiser. An elegant restraint solution! I wish they all could be so easy.

"Don't Worry, I Was an ARMY Ranger"

My obsession with surgical instruments and fondness of  esoteric operating room tales are not appreciated by everyone, so it's time for something completely different - a true story from that long term VA  psychiatric hospital, Downey.

It was nearing time for my annual proficiency review and I was beginning to feel nervous with an impending sense of doom. One of the key metrics in the evaluation other than restraint hours was avoiding patient elopements. The restraint hours could be managed with some clever slight of hand when filing reports and records. Maybe that's why all the nurses winked and called records of locked restraint hours the "funny papers." The favorite maneuver was to apply locked restraints and leave one of the locks open.  They were just as effective but technically not full locked leathers.

Mr. Dunkfeather who had been recently upgraded from head attendant to nursing assistant looked grim as he approached the nursing station. He had just completed the 2200 hour  patient count and came up one man short. "Fool, Hughes is not on the ward for patient count," he related. My first reaction was denial,  reasoning that it was impossible to elope from a locked ward. There were 3 sets of locked doors between patients and the outside world. Things like this never happened.

I quickly did a search of all the hiding places; shower curtains, under beds, and even inside lockers. Hughes had simply vanished. Next on the agenda was a review of the records. Whew..at least he was a voluntary patient. If a committed patient was lost, the notification process was quite onerous and time consuming and involved official notification to administration and law enforcement personnel. All that was required of a voluntary elopement was the completion of a 10-2633 form which was reviewed the next day at a treatment team meeting.

When I unlocked the heavily grated main entrance door to leave at the end of my shift a surprise greeted me. It was Hughes bounding up the front steps with an ear to ear grin. I must have looked like I had seen a ghost. "How in the world did you get out of there?" I stammered in disbelief.

"Don't worry, I was an ARMY Ranger and was trained how to jump. There is a gap in the bars covering the back bathroom window so I squeezed out and jumped. I was just repeating an old Ranger training exercise. Now that I know my skills are intact everything is going to be OK."

Hughes was obviously uninjured but the window he jumped from was on the second floor  of Building 66 which was the equivalent to a 3rd floor level because the basement was elevated on that side of the building. He showed me the gap between the iron bars  and further explained some of the techniques used when landing from a jump. He seemed amused by my interest and added that he would be happy to teach me some of his jumping skills. Not tonight I muttered before stopping at the nurse's station and discarding my elopement reports. No harm..No foul.

Downey VA Introduces the Shoe Shine Nurse

 Downey VA Hospital, the agencies largest psychiatric facility, had an aloof contingent of highly

educated,  office-sitting nurses dedicated  to grinding  out an assortment of directives, memos, and program notes to lowly staff nurses for implementation.. These administrative hot shots even had their own building complete with plush Karastan carpeting, air conditioning and fancy  pictures on the walls. A far cry from the dingy, smoke filled  wards with cyclone fencing and bars on all  the windows where staff nurses practiced. These office bound nurses never ventured far from their comfortable habitats, but their word became law out on the wards.

Here is a real gem of a memorandum  from one of those office sitters with ample, well padded backsides that I recently  discovered in my basement junk pile  archives of old nursing paraphernalia, "Adjunctive therapy is utilized for phenomenologically promoting a patient's  self actualization when neutrality and anomia of traditional therapy are compromised. An  additional tool to augment the psychotherapeutic milieu." That one's a real head scratcher, but I guess, the general idea is to engage the patient in an activity program so he can find something to do.

Examples of adjunctive therapy include: psychodrama where the patient acts out a scripted scenario under  staff direction, token economy where the patient earns rewards and privliges as outlined by the staff, exercise group involving that old 1..2..bend and grunt routine, and work details such as the "spoon factory" where listless patients dutifully inserted plastic spoons in plastic bags for 8 hours at a stretch.

These adjunctive therapy all share a common thread and that's top/down delivery. A group leader instructed patients in a rigid, authoritarian manner.This did little to establish trust or facilitate communication.

Something different was needed here to demonstrate trust and caring. As I surveyed the ward, I noticed most of the patients were wearing scuffed and dull leather shoes. The ubiquitous athletic shoe was decades in the future. Low and behold, off in a distant corner, a little used and neglected  shoe shine bench sat gathering dust.

Suddenly an epiphany popped into my head. The next day on the way to work, I stopped by the local Ben Franklin store (remember those?) and purchased a few tins of Florshiem paste shoe polish. After gathering  a few worn out T-shirts, I was in the shoe shine business.  That evening after the head nurse departed I initiated my shoe shine therapy program. I pulled that old relic of a shoe shine bench away from the wall, dusted it off  and barked out, "OK fellas step right up. Let Nurse Fool shine your shoes. Let me buff them up to a brilliant shine in nothing flat."

Patients were reluctant at first, but after encouragement from the attendants,  a few disheveled  patients stepped forward and propped their lusterless shoes on the bench for an enthusiastic shine by my deft hands. At first I chatted with them about the condition of their shoes to get them talking. The role reversal and lateral delivery of care was off putting at first, but the shoe shine did help to build trust.

Caring and trust were in short supply at Downey VA, but at least I tried.

One Flew Over the Cuckoo's Nest comes to Roost at Downey VA Hospital

Cuckoo's Nest Nurse Ratched on the silver screen at Downey VA

Downey VA Hospital, the 1600 bed psychiatric warehouse hospital in North Chicago, Illinois had it's very own movie theater showing first run movies that had been carefully screened by an assortment of know-it-all, busy body administrators. Disney Movies, feel-good musicals  and an assortment of cartoons were the typical fodder. Someone must have been asleep at the switch in the movie review detail  because one afternoon the head nurse approached me with an agitated look about her. "Can you believe it..One Flew Over the Cuckoo's Nest is being shown this afternoon at the theater on base." Hmm..I began thinking it might be an adventure to escort a group of our locked ward patients over to view this movie.

One Flew Over the Cuckoo's Nest, based on a Ken Kesey novel, was a movie filmed on the back wards of an Oregon State  Hospital for the Insane.  It featured a down right despicable Nurse Ratched character that was domineering and abusive to her patients. She controlled everything on the ward from the TV to determining candidates for lobotomy. The scenes of the patients' on the ward was a spitting image of Building 66AB at Downey where I was working. Downey nurses, for the most part, were too burned out to dominate anyone. The modus operandi was just getting by until that Civil Service Retirement kicked in. There were no Nurse Ratcheds at Downey.

Downey had a rule that any closed ward group of  patients must be accompanied by an RN on outings. I made it my personal mission to get these guys off that smoke filled, depressing  ward as much as possible and organized walks, picnics, and even ball games. So when I heard about Cuckoos Nest  being shown on movie night, I figured, what the heck? These guys are just about living the movie and I was curious how they would respond. I strolled onto the ward after supper and called out, "Movie night, who wants to go?"

Two dozen or so of the patients stepped up and we walked over to the theater. Sometime movies elicited shouting and bouts of unrestrained laughter, but during Cuckoo's Nest there was a strange silence from the crowd. The experience of sitting in a long term psychiatric hospital watching a movie filmed in such a location reminded me of watching a war movie in the middle of an active battlefield. Today one of the most overused words that pops up in contemporary banter is surreal.

Watching Cuckoo's nest at Downey VA with a group of schizophrenics was way beyond surreal. It was one of the most unusual experiences I've had as a nurse except perhaps for the time a patient filled his prosthetic leg with urine and asked for help putting it on. When I placed his stump in the prosthesis urine splashed everywhere to the delight of the young amputee.

After the movie ended, about half of the patients had no reaction what so ever, because the long term use of drugs like Thorazine had wiped out any trace of individual personality. A chemical lobotomy of sorts. Another group of patients had trouble separating reality from the movie characters and asked me to speak with Nurse Ratched to "straighten her out."  The other small group identified with the characters and  was delighted that someone had made a movie about them.

On the commute home, I kept thinking that I'm going to write about  that Downey VA movie night experience down some day. I knew my lackluster writing skills would fail to communicate the bizarre nature of watching a movie imitating a mental hospital in a genuine metal hospital. At least I tried.

Downey VA Hospital Restrains Assaultive Parients

Yes, I have a personal  history with patient assaults. Here is a link with the gory details if you would like to peruse the sad tale  http://oldfoolrn.blogspot.com/2015/08/knock-out-punch.html

Part of the problem with patient vs. staff  assaults  at Downey was the lackadaisical attitude of the administrators who were supposedly running the show. Assaults were so common that the hospital director's office had a form letter that was sent to all victims. The themes of this letter were that we were dealing with very psychotic patients and such unfortunate incidents were inevitable and oh, by the way, thanks for trying to help these poor unfortunates. Next time learn how to duck. OK I made that last one up, but that seemed to be the underlying message. There was no such thing as patient accountability or accountability of anyone for that matter.

The head nurse,  Matty,  of Building 66 where I worked  was a stout pit bull of a woman who rarely ventured past the safe  confines of the nursing office. She was an office-sitter of the highest order. Of course she had strong feelings about how to manage patients on the ward, but had no experience in the clinical realm.

Miss Matty loved to pontificate about patient assaults on employees. It was one of her favorite topics and her main point was that the employee's insecurity and lack of confidence communicates a sense of vulnerability to patients who then slug them. Her favorite refrain was, "Carry yourself with a sense of authority."  This made no sense to any of the staff. Ward attendants and nurses used to discuss this while on the ward within earshot of patients.

I quickly deduced that some patient on staff  assaults were entirely unpredictable and were deeply rooted in the psychopathy of the patient's illness. See, I can use that psychobabble speak just like all those highly educated big shots! Other assault episodes seemed to follow a pattern of escalation and were somewhat predictable. Some assaultive patients even expressed regret for the incident.

After an assault the patient was always placed in full leather restraints with a robust leather cuff around each extremity which was anchored to a steel bed frame with a heavy leather belt. The cuffs had a sliding lock mechanism that required a key to release. The bed itself was bolted to the floor to prevent the patient from kangarooing the bed around the restraint room. Some of the more experienced patients knew how to bounce an unbolted bed up and down when in restraints to move about the room. "Kangarooing" was a very good, descriptive  term for this phenomenon.

Putting an uncooperative, assaultive patient in restraints was not a pretty picture. One technique involved at least 4 nursing staff members to do the dirty work. A secret code word was agreed upon and since I was always hungry, "Big Mac" did the trick for me. After hollering the code word each staff member grabbed one extremity and physically carried or in the case of a really big patient, dragged him to the restraint room and tethered him to the bed with the leathers.

The alternative  technique involved a couple of staff members grabbing a twin mattress and while holding the mattress vertically, force the patient into a corner. Once cornered, the patient usually surrendered after an interval of punching and kicking at the back of the  mattress. It required a seasoned nurse's best judgment to ascertain when the pugilistic activity subsided enough for restraint application. The attendants were fairly good evaluators of the degree of "fight" left in a cornered patient and I usually left the decision up to them as to when restraints could be used. If a patient had too much "fight" in them when the mattress was retracted, it could always be pushed back into position pining the patient back in the corner. I always thought that the sudden eruption  of the punching  fists on the surface of the mattress looked just like that carnival whack-a-mole game. When the surface of the mattress settled down, the game was over.

I really detested the drama that accompanied the restraining process. There were about 4 patients out of 40 that required restraints. The youngest, Danny, was a Viet Nam veteran and had a predictable pattern to his violent outbursts. He would scream like a Howler monkey before striking out and once secured in the restraint room, he voiced remorse for his behavior. Danny told me that he felt like striking out when he felt threatened and out of control. I assured him that he was safe and maybe the next time he felt the urge to strike out to come and talk with me and we could figure something out to avoid that unpleasantness of being wrestled into the restraint room.

Whenever Danny approached me with that rage in his eyes, I always asked him what would work to make him feel better. Sometimes he just needed to lie down for a spell and other times he requested restraints. I complied and after the restraints were on, I always said, "Just let me know when you feel like coming out and I will release you."  This worked well for Danny and we established mutual trust because I promptly let him out at his request. For Danny this worked really well, but when he made his request to other nurses, I got called out by the head nurse who thought my interventions were unwise to say the least. Oh well, at least I tried.

Danny's schizophrenia suddenly went into remission and he was discharged to live happily ever after. APRIL FOOLS on that last sentence.

Nursing Career Choices - My Journey from the OR to Downey VA

It's so easy to get locked into one particular nursing specialty and latch unto for life. The problem is further exacerbated by seeking more education in that particular area which further encapsulates a career within one particular bubble. Stepping outside your current nursing  comfort zone and engaging in something completely different can bring a new perspective to a divergent specialty arena. Maybe if psych nurses ventured into the OR they could ratchet down some of the everpresent angst and emotional hub bub. Maybe if OR nurses tried psych, they could implement some useful interventions. Who knows? I figured it was worth a try.

I had a life long interest in OR nursing or  in the vernacular of you whippersnapperns "perioperative" nursing. I still like the old fashioned scrub nurse terminology, but then again, I'm an OldfoolRN. Psych nursing always seemed so very different. The long term custodial care of chronic schizophrenics seemed to be the exact opposite of slapping instruments into a surgeon's hand for an immediate solution to a health problem.


I thought that this  expertise, if you could call it that, could be applied to another nursing specialty like psych. Youngsters do indeed generate some foolish ideas when they are out to cure the world and I was no exception. I like dramatic quick fixes and doing something to really cure the underlying problem. Proven interventions that get sick people back on their feet and back into the business of life. Psych was to be my new alternate universe and I would somehow help those institutionalized souls with novel and pioneering interventions. I was probably as delusional as some of the patients!

Downey VA Hospital, just north of Chicago was to be my new stomping ground. I was hired and told to carefully review the employee orientation manual. They actually wanted me to start working on the very same day as my interview. Desperation does not make for clear, level headed thinking so I declined and agreed to report the next morning.

The nursing supervisor escorted to my new assignment, Building 66 ( AB  ward) in a VA facility that was indeed  providing long term custodial care to chronic schizophrenics with a smattering of manic depressives thrown in for variety. She opened the massive door which resembled a bank vault with heavy robust hinges   to "A" ward and as we stepped in, a pool ball thrown with the velocity of a Nolan Ryan fast ball whistled just over my head. In the far corner a patient was doubled over in pain after beintng "bayoneted" in the abdomen with the end of a pool cue. The blue pool chalk was mixing with a small amount of bright red blood. I remember thinking to myself..how patriotic his plain white t-shirt looked with a red and blue stain.

"Is this the therapeutic milieu  mentioned in the orientation manual?" I foolishly asked my orienting supervisor. "Not exactly," was her reply as she quickly wrestled the pool cue from the agitated patient who was brandishing it like a he was preparing for another vicious  strike to the body. The supervisor complained bitterly that she had ordered the pool equipment locked up and set about for an attendant to shoulder the blame.

After resolving that issue, she suggested that I remain on the ward to observe. There were 40 patients in the cavernous, exiguously furnished dayroom, most of them pacing to and fro muttering unintelligible ramblings. Everyone smoked and a thick blue cloud enveloped the entire scene. A huge ceiling mounted unit that whined and whistled like a 747 on a take-off roll was sucking up some of the cough inducing smoke. I asked one of the attendants about the strange device and was told that it was a "smoke eater." At least they are trying, I thought to myself.

There was no danger of anyone leaving this facility. The windows had heavy wrought iron bars that rivaled the entrance door in terms of shear mass. The place reminded me of a maximum security prison or a Fort Knox for people.

I concluded that I needed to do something physical to establish mutual trust and get the ball rolling with these guys. Attendants and other ward personnel were chatting with some of the patients, but from what I observed, this did nothing constructive. These guys had been talked to for years and it did not seem to do much for them

I noticed that they were all wearing scuffed, dirty, leather dress shoes that they had obtained from the hospital canteen. The ubiquitous athletic shoe of today's world had yet to be invented. In a supply closet there was a shoe shine set-up complete with a fancy gizmo to prop feet up at the optimal level for a seated operator to shine the footwear.

I had an epiphany. This is how I could engage some of the patients and develop some sort of therapeutic relationship with their tortured souls. I think it was called making therapeutic inroads or some other term firmly rooted in the rubric of psychobabble nonsense. Anyhow., I decided to give it a go and  when I returned the next day  I reported to the ward with some newly purchased tins of shoe polish and a couple of worn out scrub suits that I had collected from my previous nursing life. I knew from experience they were perfect for buffing shoes to a deep shine

"Shoe shine..Get your shoes buffed up to a nice shine," I shouted out toward the pandemonium emanating from the dayroom. Whenever a patient approached the door, I greeted him with a friendly smile and cheerfully offered my shoe shine services. Even some of the more withdrawn patients began accepting my services and this was a great way to learn their names. One of the attendants cautioned me to limit my shoe shine services to when the supervisor was off ward, but I did not worry about that too much. After all, I was doing a heck of a lot more than they were to help the patients.

It touched me deeply when after about a week of my shoe shines, a motley collection of disheveled patients approached me and asked to polish my shoes. I was really getting somewhere with these guys.

For my next Downey VA post, another OldfoolRN innovation: Teaching violent patients to request restraints to avert injury. Supervisors thought I was a nut, but the proof was in the pudding- It worked

Downey VA Hospital in the News

I was really surprised by the number of people that read my post about "Downey VA Hospital a Lost Empire." I thought that Downey had probably disappeared for good and that there would be little interest. I was going through my collection of old nursing junk memorabilia and lo and behold I came across some yellowed newspaper clippings about assorted trials and tribulations at Downey. As you can see bad press about the VA is not just a recent phenomenon.

From the Suburban Trib May 12, 1975:
The FBI has begin an investigation into the operation of Downey Veterans Hospital. The Suburban Trib learned of the FBI investigation on the heels of an announcement that the General accounting Office was studying the administration of the hospital at Buckley and Green Bay Roads.

Sources will nor specify what FBI agents are studying, except to say the probe is in the initial stages.

F.E. Gathmann, acting Downey Director, said Tuesday that he was not aware of any FBI investigation other than into the murder last month of a 45 year old patient found stabbed at the hospital. A 17 year old Waukeegan IL youth was charged with the murder.

The hospital has recently been embroiled in controversy. John Reeves, a cook at the hospital and president of Local 2017 of  The American Federation of Government Employees, recently charged that former Downey director was transferred because he stepped o too many toes trying to convince the VA to fire incompetent employees.

Reeves has also charged that:
There has been mismanagement of funds at the hospital.
Drugs used in treatment programs are missing.
More attention is being paid to the needs of the Chicago Medical School  formerly  at 2020 Ogden Ave., Chicago than to patients.
Hospital employees have been threatened with reprisals for making public concerns about patient care.


I am not sure of the exact date of the next one, but I think it was from a local newspaper, the Independent Register. Perhaps a bit later than the previous article

Downey Veterans Hospital in North Chicago has launched an investigation into why 7 psychiatric patients took their own lives during the last 11 months.

Hospital administrators told the Independent Register the "suicide rate at Downey is no greater than at like institutions around the country, but what disturbs me is what we can do to spot the potential suicide and stop him before it is too late."

Administrators, who promised a report in two weeks, took action following Lake County Coroner Oscar Lind's charge of lax security at the hospital. Those who died were:

Robert King, 51 a patient who leaped from a 3rd floor window.
Thomas Azzano, 26 a patient who stepped in front of a Northwestern train in North Chicago.
Robert Horwitz, 40, a VA patient who stepped in front of of a train.
Michael O'Mera, 37, a resident patient who jumped in front of a train.
Allen Hamburg,37, a resident patient who committed suicide on the same spot he saw O'Mera die.
James Caba 57, who leaped to his death from atop the hospital water tower.
James Zvala,27, who committed suicide by a medication overdose.

Lind expressed his concern for increased security at the hospital and with the number of pills some of the patients had in their possession at the time of their deaths. "From our investigation...and results we believe this must be negligence," Lind said.


This is from a Chicago Tribune Column from October 29, 1976 by Jeff Lyon called: "The Law on Insanity-Time for its own Trial?"

There is a paradox here.
Wednesday night, security guard Sam Valenti,66 was killed in his cargo-gate guardhouse at O'Hare Airport. He was beaten and stomped so much that his face was caved in. His nose was nearly cut off with a pocket knife.

Police arrested a man outside the guardhouse. they said he was singing when they found him. He told them Valenti had refused to page an airport employee for him and explained his own gashes by saying  he had slipped on Valenti's blood and fell thorough a window.

The man was a former Chicago fireman and Golden Gloves boxing champion James O'Malley, 55. He was indicted for murder before in 1972.

On New Years Day that year, James O'Malley walked into a pizzeria and shot a stranger to death. Moments before he had pistol whipped another man who offered to help move his stalled car. shortly afterwards, O'Malley was found incompetent to stand trial. He would not understand the charges or cooperate with his attorney. He was remanded to the Illinois Department of Mental Health for treatment. Last year he was at last pronounced able to face trial.

During the trial psychiatric testimony was brought before Circuit Judge Romiti: O'Malley had been "schizophrenic," "delusional" at the time of the murder. He had been hearing voices. judge Romiti did what he had to do. He found O'Malley not guilty by reason of insanity. But he also found him in need of further treatment and sent him back to the DMH, apparently confident that mental health authorities would do what they had to do. And that simply, would be to keep n mind O'Malley's past violence and make sure he was well before he was released. That is where Judge Romiti was wrong.

O'Malley spent 22 days at Manteno State Hospital before he was sent to Downey Veterans Administration Hospital on April 21. Downey discharged him on May 26 ruling he could function in society. For nearly five months he did. Until the explosion in Sam Valenti's  guardhouse.

Valenti did not have much time to think much about the aw before being fatally beaten. The law says that if a man is unfit to stand trial, the courts retain jurisdiction. Once he comes to trial, after treatment, he is likely to be found innocent by reason of insanity. That means he is not guilty. It does not mean he is sane. but that's when the courts lose jurisdiction over him; psychiatrists not judges can decide when he returns to society.

The judge can scream as loud as he wants. If Downey VA says he goes out, he goes out.

I had n interesting chat with Marjorie Quant, Administrator at the Downey VA Hospital. Miss Quant said a treatment team of doctors, nurses, social workers, and the like deemed O'Malley ready to be set free. She said she could not reveal what  their reasons were, because of the Federal Privacy Act.

But she said, "I think we followed our normal procedure here. If  you're assuming there was an error here, that would not be correct." When they released O'Malley, did they take into account that he had committed a murder?  "I'm assuming something to that effect would have appeared in the medical history," she said.

Wouldn't that have made a difference? "What made a difference was his medical condition at the time...A patient is discharged only if it is determined he is well enough to live in society. If he is well enough to go home, he has the same rights as anyone else."

Judge Romiti declared Thursday that "you don't just put a bombshell back on the street." DA Bernard Carey called O'Malley's release "outrageous."  There are those who might even call releasing O'Malley from Downey something else. They might call it insane.

Downey VA Hospital..... A Lost Empire

Decades ago VA Hospitals were divided in 2 camps, General Medicine and Surgery or GMS and
Neuropsychiatric or NP. Downey was an NP  faciltity  and the countries largest VA Hospital at 1800 beds. It was located about 35 miles north of Chicago adjacent to Great Lakes naval training center. It was constructed right after WWII and designed to provide a lifetime of care via institutionalization for people with chronic mental illness. There was even a full scale medical hospital with ORs and critical care units with strange names (critical care units were called GPUs or General Purpose Units)  The OR was always called EOR or emergency OR. God forbid anyone should mistake them for a "real" medical surgical hospital. That is the only rationale I could deduce for the funny names.

It was really a self contained city with it's own zip code, 60064. There was a movie theater, bowling alley, golf course, swimming pool, and various work areas for the patients such as the spoon factory where patients spent the day tossing plastic spoons into plastic bags. There was a greenhouse where the most common activity seemed to be digging compost and also a metal and wood shop. All the buildings were connected by underground tunnels which always reminded me of catacombs, with poor lighting and spooky dead ends. Staff moved from building to building topside whenever possible.

Patients were housed in multiple 2 story brick buildings with 2 wards on the first floor and 2 on the second with  total census of 104 patients n each building. Windows were covered with vertical iron bars. There were no elevators and the stairwells had imposing walls of cyclone fencing through the middle core to prevent patients from jumping. Radiators provided heat and there was no air conditioning. The buildings were like brick ovens in the summer. Open windows had no screens and various birds and flying insects entered the buildings. Electricity was delivered by underground lines which were not very reliable. Building 66 where I worked was once without power for 3 days. We used flashlights and battery operated lanterns as a backup. The patients barely noticed, but there was definitely a Halloween atmosphere with bizarre shadows and spookiness throughout. The souls of over 100 schizophrenics all in one poorly lit area.  Yikes, get me out of here!

Almost every patient had the same diagnosis (SCU) or schizophrenia, chronic undifferentiated. About 2% of the population was bipolar and added some spice to the mix. All patients smoked constantly while in the dayroom producing a dense ever present haze. Smoke Eater machines mounted on the ceiling did little to clear the air. A typical ward included the day room with connecting hallway to the dorm which was just a huge open room with beds. Just off the hallway was a restraint room with four heavy beds bolted to the floor. The beds were usually all occupied. My claim to fame at Downey was teaching a couple of very violent patients a self restraint technique. I got them to the point when they felt like slugging someone to come to me and ask to be put in restraints. I readily complied with their request and let them decide when they should be released. It worked like a charm for a couple of patients and I always thought I should have received some kind of performance bonus for my idea. The VA was always handing out bone head awards of one type or another, but I got passed over.

In the mid 1970's things began to change at Downey. When liberals and conservatives have common objectives, things happen in a hurry. I really hate political labels and politics in general, but the liberals thought chronic psych patients needed to be freed from the chains of custodial care and some thinkers like R. D. Laing even questioned the whole concept of mental illness. According to R.D. "Insanity was a rational adjustment to an insane world." The conservatives did not like to spend tons of tax dollars on what seemed like a lost cause. Downey began to change. Long term patients were discharged with terrible end results. Patients wreaked havoc in the community by strolling into restaurants and failing to pay. Camping in city parks and the homelessness we still witness today.

The "Downey" name was first changed to "North Chicago VA" then "Great Lakes VA."  The Chicago Medical School built a huge campus smack dab in the middle of the golf course. Today Downey is gone for good replaced by the James Lovell Federal Health Center. Real medical stuff without EORs or GPUs.  I tried Googling Downey and nothing even came up. I guess some things really are best forgotten.

Knock Out Punch

It was close to where I was living and I did not like long commutes so I strolled in for an interview. This place was an old time government psychiatric facility with about 1800 beds. It was really a self-contained little city complete with a golf course, movie theater, bowling alley and farms that the patients worked.  I interviewed at about 9AM in the morning and the director of nursing asked if  I could start that afternoon. There were some loose ends to tie up at my old job and I was able to defer the start date to Monday. I was getting weary of being called in for late night trauma cases in the OR and tired of being yelled at by surgeons. It was time for a change. I wondered how difficult it would be to transition from scrub nurse to psych nurse.

My hero Cherry Ames (did you know her real name was Charity) had a diverse career from department store nurse to jungle nurse, so I figured that it was worth a try.

This place  was more of a prison with heavy iron bars everywhere than a hospital.  I had to enter via 3 massive bank vault type doors just to reach the ward I worked on. The FBI and Secret Service made regular visits to our ward to verify the status of various patients that had threatened past presidents. They were checking on incidents that happened 30 to 40 years ago. We used to joke with them and ask if the patient had threatened Garfield or Lincoln. They were not amused, but I made a mental note to never run afoul of the US government. Their resources were impressive.

There were 4 wards in my  2 story building and I would be working in Wards A and B which were on the first floor. I was the only RN in the building, with an LPN passing meds upstairs. The place was run by orderlies that had just been upgraded from being called attendants. I quickly befriended the big burley ones, the type you knew could win any bar fight.

Fights were frequent and there were usually 2-3 patients in each ward that were kept in full leather restraints in the "side room." This was a small windowless closet of a room between the dorm and dayroom. One of the most violent fights I witnessed involved pool balls thrown with such velocity that they could have killed an elephant on impact. Anyone surviving the barrage of the balls was gored with the pool cues. Blunt force trauma was a daily occurrence.  The orderlies were adept at "charging" fighting patients with a mattress and getting them to the ground so they could be transported to the restraint room.

The first thing I usually did coming on duty was to check the patients in restraints. I was  about to enter the side room one afternoon and the next thing I remember was waking up in an ambulance.

One of the patients had struck me so hard that my head hit the wall knocking me unconscious. According to the attendants orderlies the next thing the patient did was take my keys and stuff a letter in my pocket. I was hospitalized for 3 days with a concussion. When I was getting dressed to leave, I found the following letter was in one of my pockets. The orderlies account of the events that transpired proved to be accurate and I had the letter to prove it.

Here is the knockout letter that was delivered in  an impressive manner:

I wondered what this letter had to do with being punched, but you cannot make sense out of a madman. I took notice of the frequent religious themes and concluded that religion and psychosis do not mix.

Why is it that the most violent patients are having religious delusions?  It seems like every schizophrenic assaulted someone because God told him to do it. It was always the same  sort of universal response, like the alcoholic telling the cop he consumed "a couple of beers."

Psych was always difficult for me to make any sense out of. At least in medical surgical nursing the diagnosis had a purpose in that it dictated a treatment course. Appendicitis?  Take out the appendix. Diagnosing  Paranoid Schizophrenia did not give a clue as to the course of treatment. I thought it would have more utility to diagnose them as Holdolphrenic or Thoraholics. At least you would know which drug to use. When I asked the psychiatrists a question, they would mutter and spout off an incomprehensible answer. At least surgeons could provide a straight, albeit gruff answer to questions.  Perhaps I have a low emotional IQ (my old bat of a psych instructor labeled me with this deficit) or psych was to contemplative for my technical nature, but this job was not going to work for me. I began dreaming of Mayo Stands and steaming, hot autoclaves.

After about 18 months of the psych hospital, that distant  siren  of the OR beckoned and could not be ignored. I figured it was a heck of a lot safer arguing with surgeons and anyhow, the OR was my first love. I do not recall my psych experiences very well, but I found "the knockout letter" along with some yellowed care plans in my basement stash of old nursing documents. I left psych for good and never went back.  Psych  gave me a new sense of appreciation for being able to work with surgeons again. Sharp metal instruments, hot autoclaves, smoking Bovies  and cranky surgeons were easier to deal with than flying fists and whacky letters. They even gave me a raise when I returned to the OR. Back home at last.