I Must

*This is an amateur translation of the original piece found on the Polish version of the blog.

Most esteemed Colleague, Dear Jan,

We would like to inform you about the course of treatment of Mr. Robert Skiba, born on December 15, 1991. The treatment took place in our hospital between September 5, 2017, and September 21, 2017.

Diagnosis:

Chronic dependence on a respirator due to severe obsessive-compulsive disorder

Medical history:

Substance abuse (THC)

Paranoid schizophrenia

Tonsillectomy circa 1998

Course of treatment:

Mr. Skiba voluntarily admitted himself to the psychiatric ward of our hospital with suspected recurrence of previously diagnosed paranoid schizophrenia. The patient suffered from a compulsion of "leaving the world a better place." Through a thorough interview, we were able to rule out symptoms such as auditory hallucinations, derealization, or feeling controlled from outside.

Mr. Skiba is well known in our center, and his medical history was available to us. Previous interviews conducted during relapses of the illness indicated significant persecutory delusions, visual and auditory hallucinations, as well as a strong sense of being externally controlled.

The aforementioned desire to improve the world seemed to come directly from the patient in a manner uncharacteristic of schizophrenia. The reason for his admission to our hospital was not the unfamiliarity of this kind of compulsion, but rather his previously unknown affinity with it.

During this interview, we tentatively diagnosed obsessive-compulsive disorder. Due to Mr. Skiba's socio-economic situation, we decided to initiate inpatient treatment. The patient received Citalopram 10 mg daily, with the dose to be increased weekly until optimal effects were achieved. We initiated cognitive-behavioral group psychotherapy under the supervision of our psychotherapist, Mr. Marcin Kulesza. The previous dosage of antipsychotic medications remained unchanged, with the patient receiving 20 mg of Aripiprazole daily.

On September 6, 2017, the patient repaired a leaky window in his room by tightening the adjustment screws with a butter knife. The next day, he began working on a leaking shower. He cut the gasket from his rubber flip-flop with a nail scissors. In the following days, he started wandering between the rooms of other patients, sequentially replacing leaking gaskets. He went to the last room barefoot, having completely cut up his footwear. Attempts to stop Mr. Skiba always ended in aggression. The antipsychotic medications were adjusted, and Aripiprazole was increased to 25 mg/day. The patient only attended psychotherapy sessions to neatly arrange leaflets and auxiliary materials on the shelves.

The patient showed visible signs of exhaustion, both physically and mentally. His face lost expression day by day, and his skin grew paler. Soon, it resembled a pale canvas stretched over a marble mask in the shape of a human face. Physically pulled away from work, the patient habitually continued the same hand movements in the air. Only after some time did he begin to turn his cold, motionless face towards the obstacle. He looked straight into the eyes, without blinking or moving a single facial muscle. His icy gaze was inescapable, with empty, cold, almost glassy eyes relentlessly following whoever disturbed him. Aripiprazole was increased to 30 mg/day, and Citalopram was prematurely increased to 20 mg/day.

The patient refused to eat or drink. Feeding and medication administration occurred when the patient was focused on his work. Only then, almost automatically, would he allow himself to be fed and given medication. Attempts were made to administer fluids intravenously; initially, Mr. Skiba agreed to this compromise. His agreement ended when all the wheels of all the IV stands were oiled or replaced, and all screws were tightened. According to our findings, the patient was not visited during this time, and we were unable to identify the source of the replacement parts. When asked why he continued his work, he only replied, "I must."

Finally, after days of chronic illness, his eyes sank. Wrinkled and yellowed like dried apricots. From continuous work, the skin began to peel from his hands, but no connective tissue or muscles protruded from under the skin. The wounds did not bleed or seem to hurt. "I must," he repeated. "I must," nothing more. Attempts to dress his mutilated hands ended in aggression and that terrifying, empty, piercing gaze. All humanity behind those eyes disappeared, no shadow of understanding or soul. "I must." After a long discussion between the heads of the psychiatric and neurological clinics, Aripiprazole was increased to 50 mg/day, well above the recommended dose. Citalopram was prematurely increased to 60 mg/day, the maximum dose.

On September 17, 2017, an incident occurred during another attempt to dress the wounds by the trauma nurse. Mrs. Nowicka had not previously met the patient and was sent to him after a surgical consultation. According to Mrs. Nowicka's testimony, the patient did not respond to her questions and was uncooperative. The nurse decided to grab his hand and forcibly pull him away from adjusting the medication cabinet doors. His arm was cold and smooth to the touch, like polished stone. Like a worn-out railing, slippery from a thousand touches. His skin was pale and marbled, crossed with thin black veins, unlike anything found in an anatomy textbook. The nurse could feel bones, tendons, and muscles, but they seemed to move spontaneously beneath the diseased skin. Moving in a way muscles, and especially bones, shouldn't. This movement was slow, like a sliding tectonic plate, but disturbingly perceptible. Initially, the patient did not react to the nurse's pulling, continuing mechanical hand movements. Only after several attempts did he turn his gaze to the woman. "I must," he said. There was no sorrow, sadness, joy, or any other emotion in that word. "I must."

On September 17, 2017, Mr. Skiba tore the right arm off of trauma nurse Teresa Nowicka.

We attempted to sedate the agitated patient. He received a total of 20 mg of Haloperidol intramuscularly. This slowed the patient enough to attempt to insert an IV cannula. Cannulas of standard sizes pierced the skin, but were unable to penetrate further tissue. Using a larger diameter cannula still did not locate blood vessels. We decided to perform intraosseous access in the tibia. The patient received muscle relaxants and sedatives, was intubated, and transferred to the intensive care unit in a pharmacological coma. Despite deep general anesthesia, the patient continued to make delicate hand movements, as if repairing things in his sleep.

Attempts to wake him up immediately resulted in extreme agitation. The patient knew which items in the room were faulty and immediately went to them. Attempts to restrain him ended in extreme aggression and re-sedation. On September 20, 2017, a tracheotomy was performed. The next day, the patient was transferred to a hospice.

Teresa Nowicka was treated urgently and survived her encounter with the patient. She was found to be completely unfit to work in her trained profession. Her arm could not be saved. An accident report was prepared and forwarded to the appropriate authorities.

With best regards,

Prof. Dr M. Juszczyk	Dr A. Steczkowska	M.A.G.Jagielski
Head Physician	Psychiatrist	Resident