Five of Diamonds

Today was our first patient contact day in medium security forensic nursing. Our cohort of 8 split up into four groups (all the men were separated, of course) and checked in to four different units in the building. In the hallway between units, a xeroxed sign hung on the door. It read "Due to increased acuity..." and then a bit I can't remember now. Due to increased acuity something. You'd think that would be an important thing to take note of, eh?

Our instructors introduced us first to the unit's head nurse, a cute young RN from Jamaca. She selected a couple patients that she thought would agree to talk to us, and who aren't currently decompensating or in crisis. The other student and I hefted our charts and started perusing (a word that, you might be interested to know, means to examine in detail, not to browse quickly).

Paper charts seem so weird to me. I've heard stories of the state's massive warehouse repositories full of old charts. These charts were massive, by med/surg standards. People's entire life stories, sometimes from birth, just like the instructor said. Reams of incomprehensible hand-written notes from psychologists, nurses, MDs and social workers. All the gory details.

The chart in front of me was for a male, very close to my age, hospitalized because of a long history of pedophilia and child molestation. As the instructor predicted, an equally long history of being abused as a child was present. I've seen classmates shake with anger and say some rather uncharitable things when faced with the hypothetical prospect of having to care for someone who had committed the crimes this person had, I suppose this is where a little detachment is healthy.

One thing in particular caught my attention in the chart, while examining assessments of ideation and fantasies, a comment was made that the patient "admits to masturbating regularly". No mention of inappropriate sexual behavior was made, just that the patient masturbates regularly, in private. He's a young adult male. We tend to do that. The word "admit" gave me pause, as if he were admitting to drug use or criminal urges.

I sat and talked to him for a while, he mostly talked about his involvement with the unit's steering committee and peer advocacy, where he would speak on behalf of fellow patients who are pleading for a loosening of restriction or progression in therapy. He had a "group" to go to and I asked if I could come with. He invited me along enthusiastically, saying it was an "open group", but the therapist asked me not to attend. It was something called "dialectical behavior therapy", which sounded to me just like group psychotherapy. They sat in the dark, I think because they couldn't find the television remote to turn the TV off, and couldn't just unplug it without powering everything else in the room off. That was the last I saw of him for the day.

While my classmate hid in the nursing station, I hung out in the day room and had long conversations with 5 or 6 other patients. I reversed my technique for these, having the conversation first and reviewing the chart afterward. Some interesting patterns emerged, notably the presence of..how did they put it..."fixation on female staff"...acting as a barrier to therapy. Another pattern was the prevalence of sexuality in their psychoses and conduct disorders, in ways that were more subtle and indirect than the first chart I reviewed. Nearly all charts and plans stressed the importance of the patient's involvement in their own treatment, and required it for therapeutic progression.

I spent most of my down-time (it was all down-time, really) hanging out in front of the nurses station, chatting with staff and passers-by. I met a British LPN, a lively older chap who went to great lengths to introduce me to patients and explain the procedures and routines. One of the other RNs was orienting to her first day there was well. She immigrated to this country from one of the scandinavian ones about six years ago, and just switched jobs from high-security forensic psych to the medium-security one I'm observing. She seemed bored by her work, after challenging the boards she jumped right into forensic nursing. I asked her how maximum-security compared to this, she shrugged and said it was mostly the same. The nurses I saw there passed medications and plowed through paperwork. Specialized members of the health care team were carrying out assessments, providing therapy and doing the bulk of the patient contact.

My classmate and I sat in on the morning Report, attended by a couple of nurses, an aide, a physician and a social worker. The physician seemed gravely worried about everything that was said, his bald head and rectangular glasses emphasizing his furrowed brow and concerned expression. Some quick notes were given about behaviors and medication adjustments, and then it was back to work.

While we were reviewing charts, a jolly, rotund physician sat next to us and quizzed us on gastrointestinal diagnoses. I nailed his questions about antibiotic-related psuedomembranous colitis, but he tripped me up when he asked me to name the three etiological agents typically responsible for diarrhea. Microbiology isn't my strong subject, mostly because I had a miserable teacher for it. Salmonella, campylobacter jejuni and....crap, forgot the third one already. He smiled smugly and told me "don't worry, that's post-graduate stuff". Meh. If you say so. I still should have known it.

Out in the unit, a large bearded hispanic man with wild eyes walked back and forth. Obviously psychotic, with unintelligible speech, disorganized movements, sometimes a dance step or two. Smiled at us a lot, seemed quite pleasant, actually. I nodded and smiled whenever he went by. Eventually, he squared himself in front of me, and rather than speaking unintelligibly, said quite clearly "wanna pick a card?". I responded affirmatively and he motioned for me to follow him. Mindful of our instructor's warnings, I didn't follow him into his room, but took the opportunity to take a peek inside. The furniture reminded me of the furniture we had in the dorms at our state university, a comparison I would have been considerably less amused with while I was a student there. He returned with a deck of rider playing cards. He bent forward at the waist, painstakingly moving the cards from one pile to another with his thumbs, leaning forward all the time. Instinctively, I repositioned my feet just in case he fell towards me. I wouldn't have been able to hold him up, but I could at least help him land softly. Just when I thought he was about to topple into me, he snatched a card out of his thumb-shuffle, and held it so neither of us could see it. With a huge grin and a flourish, he flipped the card over. That was the trick. He started to go back to his room, but came back when I asked him if I could pick a card, His impossibly broad grin got even broader. I chose the Five of Diamonds.

Having been a bit of a cartomancer in the past, I couldn't help but think of it's meaning.


"The two figures on the Five of Pentacles are cold, hungry, tired, sick and poor. They show us what it feels like to be without - to lack the basic ingredients of life. This is the specter that haunts so many in our world - a reality that is all too immediate. Those of us who are more fortunate may not have experienced this extreme, but we still recognize suffering. When we do not have what we want and need, it hurts.

In readings, the Five of Pentacles can represent several kinds of lack. First, there is poor health. It is hard to tackle life's challenges when we do not have our vitality and strength. This card can be a signal that you are neglecting the needs of your body. You are moving away from complete physical well-being, so you must take steps to discover and correct the problem.

This card can also be a sign of material and economic setbacks. There is no doubt that life is harder when we lack money or a decent job. When we are struggling to make ends meet, all other problems are magnified. Even if we are comfortable, we can still feel insecure, afraid that misfortune will take away all that we have worked for.

The Five of Pentacles can also represent rejection or lack of acceptance. We are social animals and feel pain when excluded from our group. We want to be included, not only for our emotional well-being, but also for mutual support. Being rejected can mean physical hardship as well.

The Five of Pentacles relates to material lack, but it also has a spiritual component. From the stained glass window, we can guess that these two figures are outside of a church. Comfort is so close at hand, but they fail to see it. The church symbolizes our spirits which are perfect and whole in every way. We are meant to enjoy abundance in all areas of life, but sometimes we forget that this is our birthright. Whenever you experience hardship, know that it is only temporary. Look for the spiritual center that will take you in and give you shelter."

I think I may rely on this fellow for oracular guidance from time to time, at least for the remaining 32 hours or so of this rotation.

At lunchtime we brought our food to the basement of the unit and watched Sling Blade for the rest of the day. I hadn't seen it. It wasn't bad, but I couldn't help but think our time might have been better spent in the milieu, even if most of the patients were participating in vocational rehabilitation at the time. I should be thankful for the easy clinical time, but I can't shake the feeling that I'm slacking off, even if in a structured, approved manner.

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