 Admission Form, Patient 17983, November 18, 2005, 312 p.m. Involuntary admittance requested by patients' relatives in response to apparent self-destructive behavior cycle, self-harm evident in physical exam, signs of past abrasions on head and neck apparently due to self-inflicted scratching and both fresh and partially closed surface lacerations on arms and legs, signs of extreme fatigue also evident in examination patient admitted insomnia for, as quoted, longer than you'd believe. Patient unable to give exact time for length of insomnia likely due to extended period of insomnia itself, confusion and moderate delirium evident. Pre-medication issued, triazolam 0.25 mg for insomnia, topical bacitracin for wound care. Admission Evaluation, Patient 17983, November 18, 2005, 4.56 p.m. Performed by Dr. Emil Lafayette, self-harm confirmed, patient removed dressings from arm lacerations, reopened wound while waiting for interviewer, definite evidence of somnophobia in patient justification for harm. Patient refers to sleep with anxiety and consistently acts against self to cause pain in response to lengthy periods of silence or other lack of stimuli. Issue of insomnia needs immediate attention given evidence of exceedingly prolonged duration. Likewise, possible agoraphobia, patient request and isolated bed becomes withdrawn and agitated when request is denied, refuses to cooperate fully with interviewer, offers vague suggestion of hostile other in justification but will not elaborate, as quoted, because you're not going to believe she exists until she hurts someone anyway. As for likely paranoid schizophrenia, recommend farther interview with full psychological spectrum testing for exact diagnosis. Final recommendation, admit patient, preliminary medication issued, cancel triazolam, instead 5 mg diazepam twice daily for insomnia, anxiety, and probable sleep disorders. Final admittance record, patient 17983, November 18, 2005, 513 p.m. Patient issued bed in room 409, current occupants, patient 17802, patient 17983, close from admission remanded to family of patient, three sets of common dress issued for immediate needs. Psycheval scheduled for 10 o'clock, November 19, 2005, determining future length of stay. Ward event report, November 18, 2005, 5.30 p.m. During routine new patient room check, patient 17802 places request with staff for transfer to, as quoted, some other room. Appears agitated, claims patient 17983 has been disturbing him. Patient 17983 likewise request transfer to isolated bed. Both requests denied. Orderly note, follow-up room check suggested to avoid possible intrapatient conflict. Ward event report, November 18, 2005, 7.00 p.m. Follow-up room check, patient 17983 claims Dr. Lafayette has ordered him move to isolation. Patient 17802 backs claim. Administration reports demonstrate no such order. Upon informing room occupants, patient 17983 attempts to assault staff. And patient 17802 becomes uncontrollably agitated. Additional personnel required to contain incident. Both patients restrained, sedated, forced into early, lights out. Orderly note, exercise caution in all future room checks for 409. Ward event report, November 18, 2005, 11.57 p.m. Staff on hall 1, floor 4 report loud sounds from room 409 after facility lights out, disturbing other rooms and patients. Patient 17983 found awake, extremely agitated, and struggling against restraints. Demand lights be turned back on as quoted before she comes. Self-sustained injuries to wrists and ankles at points of restraint. Patient attempts to struggle against staff during trade to more comprehensive restraint, requiring additional personnel to contain incident. Additional sedation required for patient 17983. Patient 17802 does not respond during course of event, likely due to sedation from earlier incident. Orderly note, maintain restraints on patient 17983 until further notice. Sedate patient before removing restraints for any reason. Recommend anti-psychotic be considered in future psych eval. Ward event report, November 19, 2005, 12.20 a.m. Staff on hall 1, floor 4 again report loud sounds from room 409. Patient 17983 found catatonic on floor with severe self-inflicted scratches on head and neck. Restraints are severed at connection points with severe bruising on limbs, possibly indicating more severe injury at restraint points with patient. Patient 17802 is found deceased, severe disfiguring wounds to face complete with destruction of patient's eyes. Moved to room 101, locker 2 awaiting autopsy. Patient 17983 transferred to isolation room 626. Given injected dose of 100 milligram zooclo penfixol on attending physician's orders to control acute psychosis. Orderly note, recommend video observation to allow better control of future outburst. Stay at least an arms length away from patient's upper body restraints at all times, just in case. Autopsy report, patient 17802, November 19, 2005, 9.44 a.m. Performed by Dr. Julius Tweed. Ragged lacerations prominent around subject's head and neck, increasing in severity and depth on the regions of the face itself. At several points, the flesh is cut to the bone. More disconcertingly, subject's eyes appear to be violently removed from their sockets and are missing. Cause of death. Exinguination from wounds. Final judgment. Homicide. Coroner note, recommend consideration of patient 17983 as dangerous to staff and facility residents. Urge continued maintenance of restraints and isolation from contact with others in patient population. Also recommend digestive endoscopy to determine fate of missing tissues for staff cohesion purposes. Orderlies from floor 4. Suspect cannibalism. Promise to refuse isolation shifts until such belief is disproven. Medical report, patient 17983, November 19, 2005, 10.07 a.m. Performed by Dr. Antoinus Kyle. Patient is cooperative if withdrawn during examination. No outburst or threats. Current drug regimen appears effective. No unusual tissue or objects discovered in digestive endoscopy. Radiology tests discover hairline fractures in tibia, fibula of right leg. Severe abrasions evident on skin of restraint points. Also head and neck, necessitating topical treatment. Troubling instability and vitals. BP is acutely elevated, pulse rapid and weak for patient size. Extended stress from anxiety, elevated mood, and insomnia likely cause. Physician note, patient must sleep to begin recovery process. Recommend elevated dosage of diazepam to encourage this result. Farm contact point restraints not recommended for this patient due to risk of further injury. Full body restraint must be considered as alternative. Psychiatric evaluation, patient 17983, November 19, 2005, 10.39 a.m. Performed by Dr. George Talling. Definite evidence indicating disassociation of identity from actions. Patient expresses remorse for death of patient 17802, yet refuses to admit responsibility for actions in said event. Instead, externalizes blame into antagonistic female other. Same figure, apparently referenced in prior evaluation, seems to be central actor in patient's paranoid psychosis. Behavior and actions of said other justified through magical thinking, despite recognition of depicted individuals a logically defined capabilities to sustain reported antagonism. As quoted, I don't know, you don't know, and she doesn't care. Patient request observation of a room be terminated, grows agitated when request is denied, makes threats, refuses to continue interview. Diagnosis, paranoid schizophrenia manifesting in somnophobia, violent psychosis and disassociative episodes. Medication issued, up dosage for diazepam to 10 milligrams twice daily. On 11-24-05, begin issuing 2.5 milligram doses of haloperidol twice daily for psychosis. Interviewer note, utilize patient observation protocols and ward rounds to check for possible drug interaction effects. Follow-up immediately if found or on 11-30-05, otherwise. Ward event report, November 19, 2005, 232 p.m. During standard rounds, patient 17983 request that observation of room be terminated, warn staff of perceived threat inherent in observation protocol. When request is denied, begin struggling against restraints and screaming warnings to staff, observation camera operator regarding disassociative antagonistic, other. Acting physician note, reject recommendations from orderlies to sedate patient 17983 unless medically or procedurally sound. Sedatives are not a safety blanket. Orderly note, they say this guy is at his sedative limit and he was nearly pulling his bed off its bolts. Use double staff if at all possible when dealing with him. Whatever's in his head, it's strong. Staff communications, November 19, 2005, 453 p.m. From Charles McKinney, head of patient care division, to patient care staff list, subject, patient 17983. Ward event report, November 19, 2005, 844 p.m. During standard rounds, patient 17983 request that lights be left on after scheduled lights out time. After consultation with attending physician and therapist, request granted. Room check proceeds uneventfully until staff move to depart at which point request is made for observation to be terminated. Upon denial of request, patient instead request for lights to be doused as usual. Request granted. Another request is made now for red bulb sleep lights to be doused during scheduled lights out time. Patient understands that low level light is necessary for room observation. As quoted, that's why I want them off. Warns observation camera operator against her. Attending therapist denies request. Sorry, Jacob. My computer shut down. This has officially gone far enough. I did not intervene in this matter before because I was under the impression that the men and women under my supervision were beyond such things as this. But circumstances have proven me to be mistaken and I will not allow these rumors to progress any farther. The only thing wrong with patient 17983 is that he is seriously ill and dependent upon us for care and assistance in his recovery. He is not the first patient with explosive episodes we have treated. He is not even the only one currently in our facility and he will not be the last. It thus pains me to discover that one singular breach of safety, which was properly addressed by facility protocol, has left my staff whispering superstitions to one another and accepting the delusions of our patient as truth. We are better than this. There are indeed risks inherent in this profession, risks we all knew upon assuming it. But that is the burden we bear to render aid to those who find themselves in our beds. Unless otherwise noted, I will not approve of any shift changes from scheduled isolation hours. Our staff counselors are always available during standard hours for those who need to consult with someone in light of the recent event and associative workplace anxiety. It is a fringe benefit of working in mental health and I suggest anyone having difficulties make use of it. This matter is closed and I want to hear no farther mention of it. As previously stated, I expected more from all of you. Charles Staff Communications November 19, 2005 9 12 p.m. from Dr. Emil Lafayette to patient care staff list subject lights in 626. I happen to notice today while in final checks that the sleep lights in isolation 626 were turned off after standard rounds without my knowledge or consent. As I am sure you are all aware, this is a severe breach of facility protocol. When video observation of a patient is recommended and approved, there is a reason for such a decision to be made. Patient 17983 has violent episodes and must be monitored to minimize the risk of him causing further harm to his already precarious physical state. You have absolutely no authority to override decisions made by the medical personnel of this or any other facility. None. I have been hearing talk around the halls that some of you are afraid of this man. He is bound to a bed under the highest sedation we can medically provide and both physically and mentally suffering from acute fatigue. Do you also jump at shadows? Regardless of the reason, I will not permit untrained orderlies to begin interfering in the care provided to our patients. If such an event occurs again, I will inform Mr. McKinney and see the entire night's orderly staffed barred from the premises. Do I make myself clear? Dr. Emil Lafayette Ward Event Report, November 19, 2005, 11.27 p.m. Patient 17983 won't stop screaming. It just won't stop. Hours of it. It echoes in my ears and my skull. Whenever he's coherent, he begs us to turn the camera off or the lights off or just make everything go away. I'm sorely tempted, but Dr. Lafayette pulled Jake up from observation and is watching everyone from the video room for the rest of his shift thanks to Michael's business with the lights earlier. Last I saw of him, he was headed for the elevator with his jacket, saying he just can't do this to my kids. I don't know why I'm here anymore. I just keep staring up at the cameras. I'd only need one more needle to stop the screaming. Staff Communications, November 20, 2005, 12.04 a.m. From Dr. Emil Lafayette to all. Subject, Patient 17983. Again. I said no one is to enter isolation 626 without my express permission. I will have all your jobs for this. Admission Evaluation, Patient 17986, November 20, 2005, 9.25 a.m., performed by Dr. George Tulling. Former staff member, Dr. Emil Lafayette, discovered in locked observation rooms setting fire to equipment and recordings, attempted suicide in flames before rescued by staff, claims to be antagonized by same-female other as former patient 17983, possibly involved in death of said resident. If so, evidence obvious for disassociation of self from actions, likely paranoid schizophrenia, patient will not respond to further questions. As quoted, don't go looking for her. She'll find you. Final recommendation, Admit Patient Preliminary medication issued, 2.5 milligram doses of haloperidol twice a daily for schizophrenic psychosis. Staff Communications, November 20, 2005, 9.36 a.m., from Dr. George Tulling to Charles McKinney, Head of Patient Care Division. Subject, I've just heard. Seal him in isolation, wait her out, cremate both bodies. As far as the relatives are concerned, patient 17983 died in the fire set by Lafayette and committing suicide. That's all anyone needs to know. Let's just hope the rest of us don't wind up needing time in these beds as well.