Mickey Reichert - I, Robot - To Protect

Susan did not know whether to smile or grimace, so she simply nodded. She appreciated that the Doctors Anson had not given up on their wayward daughter, or her caretakers; but the poor family had surely suffered enough. “Please tell me Shaden’s not pressuring them for discharge.”

“Not discharge,” Saranne assured her. “Just a simple home visit.”

Though it pained her to do so, Susan gave the suggestion serious consideration. When she had brought up the possibility of institutional care at rounds the previous week, the nurses, Stony and Clayton, and even Dr. Bainbridge had laughed. Few enough places accepted any patient for lifelong care, and none would consider a child, especially one so young, particularly a female. That had led to a discussion about inpatient psychiatry protocol, reasonable expectations, and ultimate objectives.

Susan had always understood that the eventual goal for every patient was discharge to home as quickly as possible. No one wanted to stay in the hospital longer than necessary. The intrusiveness, exposure to superbugs, and 24/7 noise were bad enough; but most patients could envision their bank accounts emptying as the hours ticked past. Third-party payers, especially the government, allowed set amounts of hospitalization time for specific diagnoses. Keeping patients longer required a ream of paperwork that brought every administrator, from the charge nurse to the CEO, down on the doctors’ heads. Inquiries often seemed more like inquisitions. Denials occurred frequently, forcing the choice between premature discharge and personal payment, which few people could afford.

Patients such as Sharicka made life especially difficult for physicians. Unlike most of the other PIPU patients, she had no evidence of psychosis or dementia. Personality disorders, even the antisocial type, were not justified diagnoses for inpatient therapy. Her youth further hampered them, as they could not even officially use the ASPD designation until she reached the age of majority.

They had to settle for ADHD, ODD, and conduct disorder, none of which sufficed for inpatient care, especially long term. Sharicka had serious and permanent issues; weeks, months, even years on the PIPU could not change her underlying problem. The treatment for her, and other children on the conduct disorder spectrum, was to medicate them to some tolerable baseline of comportment, teach the parents behavioral modification techniques, and wait for the future. Concern for imminent criminal actions was not excuse enough to interfere with anyone’s freedom, especially a child’s, whether with prison, an institution, or long-standing hospitalization.

Susan finally understood why the PIPU staff had discharged Sharicka to a therapeutic foster home after her first couple of weeks on the unit. Ultimately, everything the care team did had to bring, or at least attempt to bring, each patient one step nearer to discharge. So far, the Ansons’ insurance company had proven reasonable, but Sharicka only had to go a week or two without a violent incident for them to refuse further payment. It seemed inevitable given that Sharicka did seem truly determined to change this time. All too soon, Susan would have no choice but to discharge her, if not to her parents, then to another foster home.

Susan realized that refusing any type of visitation, then dropping Sharicka on the Ansons the day of her discharge did not serve anyone’s best interests. The purpose of home visits was to ease the patient back into everyday life as well as prepare the family for the future in gradually increasing increments. A single overnight would also reward Sharicka for trying and, with any luck, rekindle the hope her family had all but lost. “Does Sharicka even want a home visit?”

“She’s practically pleading.”

Susan walked down the hallway with Saranne, pausing to glance in the open doorway where Sharicka snuggled on her mother’s lap, her father hovering like a guard dog. He looked up as doctor and nurse walked by and gestured silently to Susan.

Susan held up a finger and nodded to indicate she would return shortly, then continued to the second massive iron door with Saranne. The nurse unlocked it, and they walked onto the unit and straight into the staffing area. Saranne could barely wait to ask, “What do you think?”

Susan found herself nodding quietly for too long. From the corner of her eye, she saw Shaden coming to join the conversation. “I . . . think . . . ,” Susan started without a clue as to how she intended to complete the sentence, “. . . it might be . . . possible.”

Shaden jumped right in, easily guessing the topic of the conversation. “She hasn’t done anything wrong in a while, Dr. Calvin.”

Susan wondered if Shaden even remembered that, earlier the same week, Sharicka had put a piece of a latex balloon into another child’s medication cup.

“Since she started taking her meds faithfully, she’s been so different.”

Susan had to admit Shaden made a good point. Sharicka did seem to have made a miraculous change in the last couple of days. “Maybe we should demand a full week of positive behavior before we inflict her on the world.”

“It’s just a home visit,” Saranne reminded Susan. “It’s routine. Most kids start those a week after they’re admitted.”

“Besides,” Shaden added, “the Ansons are going away next weekend. It’s today, or they have to wait two weeks.”

The nurses seemed so earnest and eager, and both had excellent reputations on the unit. Susan sighed. “I do believe Sharicka is making an honest effort. But do you really think she’s ready?”

Shaden made an important point. “If she were on some of the older antipsychotics, no. They can take weeks or months to really work. But she’s on hefty doses of Antoladol and Vilyon.”

Susan knew the second-generation neurotransmitter stabilizers did act quickly. Some psychiatrists started at subtherapeutic doses and worked their way up slowly, but Sharicka was already at the maximum dose for her size. Her previous R-1 had raised it, not knowing that Sharicka had been hiding her medications. “You’re sure she’s swallowing them?”

Shaden could have taken that as an insult. It implied, and quite rightly, the nurses had not acted thoroughly and properly in the past. Providers assumed people took their medication; and, under most circumstances, would not bother to check. It was a patient’s prerogative not to fill a prescription or take a medication, even one he required to live. But an underage mental patient in a locked unit ought to have better than usual attention paid to such details. “Sharicka is taking great pains to prove to us the meds are going down her throat.”

Susan doubted she wanted the specifics. “I’ll talk to the Ansons,” she promised, “but I’m not going to push them. If they decide they can’t handle her, we wait at least a week before presenting the possibility again.”

Shaden bobbed his head, clearly finding the conditions reasonable. “I’d like to come with you.”

Susan bit her lower lip. She was not the sort of person to squash conflicting opinions, and he was Sharicka’s most frequent caretaker. Although he had a soft spot for the girl that did not always seem logical, he was a competent professional with far more PIPU experience than she. The Ansons had run into people like Shaden many times. They would understand his point of view. Just maybe, Shaden would learn to value theirs as well. “All right. When do you want to do it?”

Shaden smiled. “They’ve had a solid forty minutes together. How about now?”

“Now suits me fine.” Susan swallowed her misgivings, turned toward the door, and they headed for the conference room together.

Saranne handled unlocking the metal door and escorting Sharicka back to the ward, while Susan and Shaden remained with the Ansons. They looked different to Susan somehow: less morose, more animated and alive. Lucianne’s eyes had a faintly hopeful glimmer, and Elliot’s face bore just a hint of a smile. He stepped forward, his hand outstretched. “Good afternoon, Dr. Calvin.” He took her hand and shook it, nodding at the nurse as he did so. “Shaden.”