"Lisa? I've assigned you a new patient." Lisa Yanagi walked behind the nurse's station to where her senior resident was standing. "This one should be interesting, apparently he only speaks Japanese."

"Really?" Lisa pulled his chart from the rack and looked at the history and physical. Skimming the first page, she marvled, "Oh, wow. You gotta be kidding me."

"I know, right? Apparently he kept Maria busy all night long. Anyway, morning rounds are going to start in a few minutes so I'll see you in the conference room." Grabbing some charts, he reached for his keys. It was a real pain sometimes – the constant locking and unlocking of the unit doors.

"Okay. I'll be there in a moment, Bruce." Flipping to the legal papers section, she saw that he had been declared involuntary ER status, which signified that the hospital was legally entitled to keep him against his will for fifteen days. "A good old 9.29," she drawled, quoting the number of the statute. "Not for long you won't be. You sound more like a 2PC to me," she thought aloud. If he was found to be dangerous by two certifying physicians, they could hold him for an extra forty-five days. The New York Mental Health legislation was somewhat unique in that aspect. Only one of two criteria could result in involuntary admission – danger to self or danger to others, and after what she'd read she had a pretty good idea which one he had met. Taking his chart, she peeked into the seclusion room to get a glimpse of him. Lying in the bed strapped down by his ankles and wrists, he seemed harmless enough. And only 16? She found it hard to believe that it took as many people as had been reported to bring him down.

"Attention all staff, attention all staff. It is now 9AM and morning report will begin in the conference room. All staff please gather in the conference room, thank you," Bruce's voiced floated over the intercom.

Sitting down at the oval conference table, the unit chief, Dr. Goldberg took out some paper. "Okay, shall we get started with the new admissions? Mondays are a bear aren't they?" He uncapped his pen and waited for someone to begin reading.

Opening the chart, Lisa replied, "I can start." Everyone turned their attention to her as she read the admission note. "Kazuya Mitsuharu, 16 yo Japanese man, ER involuntary status, insurance unknown, marital status unknown, residence unknown. Chief complaint is written as 'Violent, agitated behavior' per EMS. Patient is a 16 yo male with unknown past medical history and psychiatric history who was brought in by EMS after an unknown person called 911 from Madison Square Garden. Patient had apparently finished competing in a martial arts tournament which he won…" All eyebrows went up at this. "…when he suddenly became agitated, screaming in Japanese and behaving violently towards anyone who came near him. Patient was so threatening and violent that NYPD had to be called in order to subdue him." More sounds of surprise followed. "Upon arrival to the Emergency Room, patient had to be placed in four point restraints and was given multiple PRNs for agitation and attempting to abscond from the hospital, eventually requiring placement in locked seclusion at 4 AM. Pt was medically cleared prior to admission and is considered to be extremely dangerous. No further history could be obtained as patient appears to be Japanese speaking only."

Flipping to the next page she gave a wry grin at the blank form and continued, "Everything else is written as 'unable to assess'. All labs were within normal limits. Chest X-ray, CT of head, all read as normal. Utox was negative for all substances. Physical exam completely unremarkable. His vital signs were all within normal limits as well. So, assessment is written as 16 year old Japanese speaking man with unclear psychiatric history brought in by EMS for violent, threatening behavior, possibly psychotic. Axis I – Psychosis Not Otherwise Specified versus Schizophrenia versus Schizoaffective Disorder. Axis II – Deferred. Axis III – None. Axis IV – unknown. Axis V – 25."

Turning to the other residents, Dr Goldberg asked, "So, what do you all think? Interesting case, huh?"

"I've never really heard of Schizophrenia in Japanese people," one resident remarked.

"If this is his first break and it's a chronic psychotic process, things don't look so good prognostically," another commented.

"True, the earlier the onset of psychosis, the harder it is to treat the psychosis," Dr. Goldberg mused. "It's going to be hard to figure this out without any collateral information. According to Dr. Lim, there was a girl with him. If she comes and visits, let's see if we can get anything else in the way of useful information from her. In the mean time, Lisa, you and I will go see the patient alone. Having the whole treatment team in the seclusion room might be too overstimulating for him."

"Of course."

"How is your Japanese anyway, Lisa?"

"Semi-fluent," she admitted modestly. "We can always call a Japanese translator if we need to."

"Perfect. This should be an interesting case."

When the morning report had been completed, Lisa walked into the seclusion room with Dr. Goldberg behind her. "Ano, sumimaseng, Mitsuhara-san," she began.

Hearing Japanese, Kazuya looked up at the woman leaning over his bed. "Nanda?" he slurred groggily.

Continuing in Japanese, she said, "My name is Lisa Yanagi, I'm a doctor. Can you tell me where you are?"

"I don't know," was the stuporous reply.

"You're in the Bellevue Medical Center's Inpatient Psychiatry ward," she explained. "Do you remember being brought here?"

"Psychiatry ward?" he mumbled. He tried to sit up but realized that he was tied down. "Why am I tied up?" he demanded, his head clearing slowly.

"Do you remember what happened last night after your tournament?" she pressed on.

Kazuya thought back to the night before. "Yes, I got scared because something was happening to me."

"And what happened to you?" she asked patiently.

Looking at his bound wrists, he answered, "I transformed into something yesterday night – something horrible."

Lisa nodded attentively. "Tell me more about that."

"I – I turned into some sort of monster." The memory of his transformation caused him to shake visibly in the bed.

"A monster?" She tried her best to keep her face neutral.

"Monster, or devil, I don't know. My skin changed color, I grew claws and wings and it caused me a lot of pain," he said flatly.

Visual hallucinations. That was interesting. Usually people heard voices when they hallucinated. "Was this the first time this experience happened to you?"

"Yes," he nodded. "Please, why am I in a psychiatric hospital?"

"We just want to make sure that you're okay. You accidentally hurt quite a few people last night, probably because you were in pain," she hypothesized.

"Oh, I see." He still looked uncertain and shot Dr. Goldberg a wary glance.

"Can I call you Kazuya?" She continued after he nodded again. "Kazuya, do you have any psychiatric history? Hospitalizations, medication trials, an outpatient therapist?"

He seemed confused by her question. "No, of course not."

"Any family history of psychiatric illness?"

Do not answer her. This woman is trying to hurt you. She will use what you say against you.

Narrowing his eyes, he regarded her with suspicion. "Why are you asking me all these questions?"

"We just like to have as much information as possible," she said soothingly.

That is a lie. Do not tell her anything. You have no reason to trust her.

Lisa noticed that he seemed to be listening to something. "Kazuya, are you hearing something right now?"

You cannot tell her about me. Do not answer.

"No," he lied, but she could see by his face that he was listening to something in his head. So he does hear voices, she thought to herself.

"Well, in the meantime, we have some medication that will help you feel a little better." This was always the hard part with involuntarily admitted patients. "Will you take it?"

They are trying to paralyze you with drugs. Do not be fooled by her solicitous exterior. It is an act. They wish to harm you.

"I do not need medication. There is nothing wrong with me," he declared defiantly.

Yep, no big surprise there, she noted silently. "Well, something strange did happen to you last night. This medication might help keep it from happening again." This line of reasoning never tended to work, but the attending physicians liked for the residents to give it their best shot anyway.

"No, I will not take anything," he repeated.

Looking over her shoulder at Dr. Goldberg, she saw him nod and continued. "Kazuya, is there anyone we can talk to get some more information about you? Family, friends, anyone? Do you live in the United States?"

The voice burned in his ears. They are trying to find things to use against you. Do not give them any advantage.

"No, I won't allow it. Take these things off me, now!" Thrashing, he rattled the bedframe loudly, causing curious staff members to peek in.

"Maybe in a little while, Kazuya. I have to make sure that you don't try to hurt anyone else again." Lisa hated having to treat people admitted against their will. It never made for a good therapeutic alliance.

You see? They do want to imprison you here. How often must I be proven right?

"Kso!" Straining harder, he continued to shout, "Let me go!"

Before leaving the room, she told him, "I'll come and chat with you some more later on, okay? I'll be your doctor while you're here. Remember, my name is Dr. Yanagi." Closing the door, she let out a sigh of relief. "Oh god, am I glad that's over."

"So, what did you think?" Dr. Goldberg asked.

"Well, he's guarded, paranoid, blunted in affect, and I think he was responding to internal stimuli while I was interviewing him," she assessed.

"He was definitely hearing voices," Dr. Goldberg agreed. "So what do you want to do?"

"He really does look like early-onset Schizophrenia. I say give him Haldol. If he refuses to take it by mouth, we can give it IM, and maybe give him the depot formulation eventually." Tilting her head to one side, she looked at her attending. "What do you think, Dr. Goldberg?"

"Sounds like a good plan, although I am betting he won't take PO. Just check his CPK levels periodically to make sure they're not too high. With all the IM injections he's been getting, I'm sure it's already gone up a little." After signing the chart, he handed it back to her with a smile and prepared to go see the next new admission with her co-resident when someone called to her.

"Dr. Yanagi?" The unit clerk turned to her, her hand covering the mouthpiece. "The new patient's girlfriend is outside and is requesting to see him. It's not visiting hours. Should I let her in?"

"Perfect. There's your collateral information," Dr. Goldberg said in a satisfied tone. "Let me know what you find out."

Unlocking the door to the ward, she motioned for the girl to come in. "Ohaiyo," she said with a smile. The girl looked so relieved that she spoke Japanese that she let loose a torrent of sentences. "Matteh, matteh," Lisa warned, trying to slow her down. "You have to go slower, I'm only partially fluent."

Taking a moment to collect herself, the girl tried again. "You are?"

"Dr. Yanagi." Lisa extended her hand. "And you are?"

"Jun. Kazama Jun." Her eyes flitted nervously across the ward.

Hoping to put her at ease, Lisa tried to make her voice extra friendly. "Are you Kazuya's girlfriend?"

She looked down. "Yes. Is he alright?"

"We're not sure yet. We're a little concerned about what we heard and what we're seeing from him," she explained.

"Oh." Looking tentatively at her, Jun asked, "What do you think is wrong with him?"

"We can't be sure just yet. We don't have enough information and he doesn't want to talk to us. It would be of great help to us if you could fill me in on what he's like typically."

Nodding timidly, Jun agreed. "Where should we talk?"

"Come this way. My office is over here."


sumimaseng: pardon me

nanda: what

kso: shit

ohaiyo: good morning

matteh: wait