An excerpt from The Spattered White Coat: Intense experiences which formed a young doctor.

I’ll never forget one of the first patients I interviewed. When I went to get him, I could see him sitting in the waiting room, looking around and scratching his arms repeatedly. He was a very large middle-aged black man from the neighborhood. He looked like he could have been a lineman for the Chicago Bears. He had been sent over by the dermatology clinic at County.

He had presented to their clinic with the chief complaint of having bugs or insects jumping out from his skin, and he had badly scratched his skin to the point where it was bleeding. After careful consideration, no doubt with some tongue-in-cheek comments, they found no dermatological or parasitic abnormality.  They consequently made a referral to our psychiatry service.

Before I went to get the man from the waiting room, Dr. F said, “With this man, there’s probably a strong delusional component, assuming the dermatologists are right and he doesn’t have bugs. You might also want to take a look at his arms yourself, just to be sure. If he really is delusional, I want you to ask questions that would help reveal why he has deteriorated from a behavioral perspective. We need to find out what events may have caused him to decompensate.”

I nodded and went to the waiting area to lead the man into the exam room. We’ll call him Mr. Jones. He followed me into the interview room and took the chair closest to the door. I paused for a moment and then pulled the small table over to the other chair at the other end of the small room. I sat down and pulled The red phone next to me. I expected it would probably ring a few times.

I asked him to show me his arms, and he pulled up the sleeves of his sports jacket. There were deep gouges on his large, muscular forearms with scabs in different stages of healing. He scratched them again as we were talking.

I asked him some standard leading questions.

“Why do you think you are here, Mr. Jones?”

He laughed. “The people at County think I’m crazy.”

I gave him a classic psych response to that statement, “Do you think you’re crazy?”

“Hell no. My problem is insects. Parasites. Look at these arms. Do you mean to tell me that there’s nothing wrong?” He was starting to get agitated.

“I understand why you feel that way. Let’s just talk a little bit so I can evaluate you and get this thing settled.”

“OK.” He sat back, now scratching his belly.

In true psychotherapeutic style, I sat and looked at him, not speaking, to see what he would say next. He looked back at me, scratching his belly. At that point, I was hoping that the dermatologists were correct. I didn’t need to catch his bugs or whatever they were. His arms did look somewhat nasty.

We were getting nowhere, just politely looking back and forth at each other, when the red phone rang on the table. It startled both of us and I jumped. Trying to appear calm, I picked up the phone and just listened.

Dr. F said, “Ask him if he has ever been in trouble.”

This was a good general question. I nodded to the mirrored wall and hung up the phone.

“Sir, have you ever been in trouble … Like, with the law?”

A sly look crossed his face and he smiled. Then he took on a quizzical look and asked me, “You mean, with the cops?”

I nodded.

“Well, there was this one time …”

He proceeded to tell me that he used to have an old Cadillac convertible. One day, he parked it in front of a bar on the West Side, and left the top down when he went inside.

“When I came out of the bar a couple of hours later, there was a man lying across the back seat of my car! I said to myself, what the hell was he doing there? Then, I figured he was probably dead drunk or stoned on somethin’.”

I nodded, listening carefully.

“Needless to say, Doc, I was mad and I told him to get the hell out of my car.”

“Did he get out?”

“Hell no! He ignored me, so I commenced to beat on him. He wouldn’t even wake up. I guess I got carried away… I was hitting him with my gun.”

“A gun?”

“Yeah. Then a cop came and arrested me.”

“For assault?”

“No, for killing the guy. The cop said he was dead.”

I kept a straight face. “So, you went to jail?”

“Only for one night. Turns out, the guy in my backseat was already dead before I was beating on him. The autopsy showed that he died of a drug overdose a couple of hours earlier.” He chuckled.

“So, you beat him up with a gun?”

“That’s right, Doc. Here it is.”

With that, he produced a beautiful Colt Python .357 Magnum revolver from the inside pocket of his jacket.

I could hear scrambling on the other side of the mirror, chairs being pulled back and screeching across the floor. The red phone rang. We both startled again, and at that point I realized it wasn’t such a good idea to startle the man with the gun. I glared at the mirror.

Fortunately, he wasn’t aiming it at me, but the gun was pointing towards the one-way mirror … I imagine that’s why I heard the scrambling sounds. They were probably diving for cover. I guess they couldn’t tell that his finger was not on the trigger. I didn’t perceive it as a threat. He was just proudly showing it to me.

“It’s the Rolls-Royce of revolvers.” He said, smiling.

I nodded my agreement.

The red phone rang again and I picked it up.

My instructor nervously said, “Please tell that gentleman to put the gun away. Do you understand?”

I had to smile as I nodded toward the mirror and hung up the phone. The patient appeared quite harmless and he was not threatening me in any way. I’d certainly been in worse situations than this.

“Mr. Jones, I agree, it’s a beautiful piece of work. The problem is, the folks on the other side of that mirror are getting a little bit nervous.”

“You mean, the pistol scares them?”

I nodded, “Yeah, my supervisor would appreciate it if you would put your gun away.”

“I’m sorry, Doc. I didn’t mean to scare anybody. You know that, don’t you?”

“I know.”

He put away the gun and then turned to wave to the people behind the mirror, followed by a thumbs-up sign. I couldn’t control the small chuckle that escaped me.

“So, Doc, what else you want to talk about?”

“What do you do for a living, Mr. Jones?”

“I work as a security guard at a hospital on the south side.”

He kept scratching his arms and I also started feeling itchy. We spoke a little bit longer, and honestly, I couldn’t come up with any other delusions. I wondered whether the dermatologist had missed something.

Lesson learned: Not everyone is crazy.

Edmund Messina is clinical associate professor of medicine, Michigan State University, East Lansing, MI.  He is the author of The Spattered White Coat: Intense experiences which formed a young doctor.