Early in my Residency in Psychiatry, at Bellevue Psychiatric Hospital in New York City, I was faced with a difficult situation which ultimately proved to be extremely educational. AT the time, the Psychiatric emergency room, after 4 PM and through the night, was staffed by PGY-2's (second year Residents in Psychiatry.) We spent our first month on -call with PGY-3's who supplied supervision on-site. After the first month, we were on our own, with the PGY-3's available for phone consultation and to be called in when necessary. Over the course of the first month of the residency year, July, we would each spend ~3 or 4 on-call nights with our more senior colleagues. The Bellevue Psychiatric ER at the time was a busy, often overly interesting, place.
On the night in question I was doing my second ever solo coverage of the ER. Parenthetically, we had some training in how to handle paranoid patients; the idea was to recognize how frightened they were and do nothing to increase their fear, which could inadvertently trigger violence. The Attending Psychiatrist had taught us that we should always allow our patients to sit near the door so they wouldn't feel trapped and threatened. I should also point out that there were essentially two means by which patients arrived in the ER and they presented (usually) distinctly different problems. Perhaps a third to a half of the patients were there because they had been acting in a bizarre fashion and were brought in by the police. In those cases, the patients were routinely restrained, in wheelchairs or on stretchers, with the police accompanying them in the ER until a Psychiatric evaluation and disposition could be made. It was relatively easy to do a quick ER evaluation, medicate when necessary and send the police on their way. The other type of patient was more complicated but generally less urgent. These people came in by themselves and typically, unless they were overtly agitated, would sit quietly until called for an interview.
On the night in question, I entered the ER to see a very large, but very calm and pleasant seeming man sitting quietly and reading a magazine. He was the first patient for me to see. There was nothing particularly threatening about him, he had no psychiatric history according to the triage nurse, and he was complaining of depression.
Remembering my training I introduced myself, brought him to an office, sat at the desk, with the patient closer to the door, and began doing what I assumed would be a routine Psychiatric emergency interview. About 2 minutes in I realized he was not the usual, depressed patient. His affect was flat (he spoke in a monotone with no evident emotional expression) rather than sad or depressed. About a minute later, I realized that his thinking was quite disorganized and my internal alarm bells began to ring. By the 5 minute mark, I discovered that this mild mannered, pleasant looking man was profoundly paranoid and overtly psychotic. He was the target of multiple nefarious plots, and as sometimes tends to happen with paranoids, his delusional system began to spread, widen, and intensify as we spoke. When he began to wonder if I were in league with his persecutors and stood up to his full 8 feet tall (all right, he was "only" 6' 9"), I realized it was time to go. He was one step from blocking my egress. With my internal klaxons blaring and the internal status reports showing red lights in almost all systems, I stood up as well; I told him that he was not in good control of himself, that his behavior was alarming me, and that if I were scared I would not be able to help him. I terminated the interview, strode out of the room with as much confidence as I could muster, requested intervention by the Hospital Police (HP), and their presence, as it usually did, calmed the situation down.
You will not be surprised to learn that from that moment on I always made sure I sat closer to the door than the patients did.
My experience was quite instructive and has lessons for our current dangerous uncertainty with Iran. The patients I knew to be dangerous were rarely problematic. They were almost always either brought in by the police, and thus restrained from harming anyone, or their agitation was overt enough that I could ask the Hospital Police to intervene prior to my evaluation to make sure everyone was safe. Return patients, with available histories, were predictable and thus, less problematic. On very rare occasions a new patient, about whom we knew nothing, would be in the ER of their own volition. Even if they were just sitting calmly, they could yet turn out to be a danger to themselves or others. In such cases prudence dictated that I speak to them in a setting in which I could be assured of my safety before arranging for their safe treatment.
[Of note, all patients were searched for weapons upon arrival at the ER and any weapons were removed by HP before the patient was allowed to enter the waiting room. Bellevue had instituted rules to search patients after a staff member was shot by a patient in the early 1970's prior to my arrival; in 1975, following an incident where a seemingly calm patient grabbed a Police Officer's gun and shot a staff member, the police were required to lock up their weapons upon entering the ER.]
Consider a patient who enters the ER and refuses to be searched while making threats to kill staff. That patient is going to be pounced on by a plethora of HP along with multiple aides (Psychiatric aides tended, at Bellevue, to be physically imposing, for which the staff was always grateful) and safely restrained.
Compare this to Iran. Multiple Iranian leaders have threatened to commit mass murder of Israelis and Americans. (Don't forget we are the Great Satan to Israel's Little Satan.) They coyly toy with the West around the question of nuclear weapons. Here is how The New York Times summarizes the current situation:
"The irony is that this is the opposite of Iraq," said John J. Hamre, a deputy defense secretary from 1997 to 1999. "We know a lot about what they have because the international inspectors have been there." Those inspection reports have helped Pentagon planners who, in imagining every contingency, have already mapped out Iran's most vulnerable facilities.
"Elimination of the nuclear program is not possible, but with the right strikes you could decisively set them back," said Ashton B. Carter, an expert at Harvard on proliferation problems.
They add that the after effects would be horrendous and almost impossible to predict or control:
But if Iran knows the United States and its allies ultimately have no stomach to put military muscle behind their demands, what is its incentive to give up its weapons program? .... (The Iranian) leaders have been threatening retaliation, even to measures as weak as a letter of warning from the United Nations Security Council.
They have threatened to cut off oil exports and send the markets into a panic, though most experts said an embargo is not something Iran could execute for very long without damaging its own economy. Iran could also step up interference in Iraq and dispatch Hezbollah on terror missions. In addition, the Iranians often boast that their missiles can reach Israel.
I suspect the amount of mischief that Iranian supported terrorists could do would dwarf the capacities of al Qaeda. However, the Times closes their article with this, seemingly more benign, commentary:
Some of those threats may be inflated. And for now, at least, Iran's centrifuge program appears to have hit some technical hitches. I.A.E.A. inspectors are still in Iran, and the Iranians have not yet dared throw them out, as the North Koreans did three years ago. A senior European diplomat involved in the talks with Iran dismissed most of the country's threats last week as "bluster meant to buy them some time, and keep us paralyzed."
But, he added, "it may work."
Several American officials, when promised anonymity, said they thought that in 5 or 10 years, Iran will most likely have a weapon.
The emphasis is mine. Contrast this assessment, with the comment posted at Debka.com today:
Tehran plans a nuclear weapons test before March 20, 2006 – the Iranian New Year, moves Shahab-3 missiles within striking range of Israel
January 22, 2006, 9:30 AM (GMT+02:00)
Reporting this, the dissident Foundation for Democracy in Iran, a US-based watch group, cites sources in the US and Iran. The FDI adds from Iran: on June 16, the high command of the Revolutionary Guards Air Force ordered Shahab-3 missile units to move mobile launchers every 24 hours instead of weekly. This is in view of a potential pre-emptive strike by the US or Israel.
I appreciate that Debka needs to be treated with the proverbial grain of salt, however, after the debacle of the missing WMD in Iraq, our CIA's complete surprise at the Pakistani nuclear bomb, the surprising realization that Libya was only 6 months from a bomb when the AQ Khan network was unraveled, and so many other "misses" in the last few years, can anyone feel confident that Iran is 5-10 years away from a nuclear weapon, versus only a matter of months.
Unfortunately, there is uncertainty around every aspect of this terrible situation. I would like to offer my advice, free of charge, to some of the important people involved in this:
My first suggestion is that the editorial board of the New York Times, along with Harry Reid and Nancy Pelosi, speak up and explicitly state that there is a bipartisan consensus that the US will not tolerate Iran having a bomb, and that they would support military action against Iraq to prevent them obtaining a bomb. This would remove some of the uncertainty of the Iranians.
My second suggestion would be for the Iranians to find a way to convincingly reassure Israel and America that they are not planing a bomb test.
If both of those suggestions are taken, we can all be reassured that no miscalculation will plunge the world into chaos.
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