First Contact with Psychiatry Throuth Private First Class Smith

After the Marines and obtaining my undergraduate degree, I attended Uniformed Services University of the Health Sciences—the federal medical school that trains active duty officers. I had no interest in psychiatry and was dreading my mandatory rotation as a third year medical student. I reported to the rotation at the intensive outpatient psychiatric service at Walter Reed Army Medical Center in Washington, D.C.

My ultimate goal was to survive the rotation and check the box. The intensive outpatient psychiatric service cared for patients who were too ill for routine outpatient care but did not necessarily require inpatient hospitalizations. Often, patients from the inpatient unit are transferred there after reaching certain therapeutic milestones. This was the case of my first psychiatric patient.

This patient was a young Private First Class (PFC), infantryman. I will refer to him as PFC Smith, who was in his late teens. Immediately after joining the Army, he proposed and married his high school sweetheart. Two weeks later, he was patrolling somewhere in eastern Afghanistan. He received terrible news from his father that his wife has begun a physical romance with one of his friends back home. This news pushed him to decide to take his own life. As any soldier in deployed settings, he had been well equipped to kill if needed. The training, possession of weapon, and desire to commit suicide can be a deadly concoction. Military psychiatrists have to juggle these realities when caring for patients.

This kind of news received by PFC Smith is greatly feared by service members. When I was in the Marines, we would run to cadences that had different messages and themes to motivate us. Some of these would describe the sacrifices and risks Marines are willing to undertake for their Corps and Country. In these cadences that are known to most enlisted service members, one recurring character is called Jody. He is an imaginary but an omnipotent civilian character who is living a luxurious lifestyle, a complete opposite of the life of a soldier or a Marine in the deployed settings. Jody in one particular cadence lures a soldier’s girlfriend with his charm and steals her. The fear that their significant other might be seduced by this Jody is perpetually present among the minds of deployed soldiers.

PFC Smith’s fear of Jody had come true that day. Unable to cope with this news, he started to have panic attacks and restlessness-describing severe anxiety. He described in details that his mind was racing but came to a sudden stop and the answer was clear: kill yourself. This idea brought a calm and he was mentally prepared. He decided to spare his face and instead go for his heart thinking it would also be the most effective way of killing himself. Using his assault rifle and appreciating his anatomy, he pointed the muzzle at his heart. He placed it slightly left of his sternum with extending his right arm to reach the trigger. He used his right thumb to push the trigger away as the muzzle rested on his heart. The very act of pushing the trigger to overcome the resistance caused the muzzle to move slightly. He missed his heart and aorta by a centimeter and depositing the bullet in his back. Despite his best efforts, he miraculously missed major vasculature and organs.

His life was saved by the actions of the medics and surgeons in Afghanistan. He had significant thoracic wounds and bleeding but minor in comparison to the worst- case scenario. He was flown back within 72 h to Walter Reed on the Air Force’s “flying ICU” critical care aircraft. He underwent several additional surgeries requiring about 3 weeks of care on the surgical unit. The surgeons subsequently took a consultative role after he was transferred to inpatient psychiatric ward for his suicide attempt. He finally came to see me after spending a month on the inpatient psychiatric unit attempting to deal with significant losses.

PFC Smith was the victim of Jody back home. Perhaps he hadn’t been in the Army long enough. These cadences that perpetuate Jody’s fear in the hearts of young soldier end with a certain advice: “Ain’t no use in looking down, Ain’t no use in looking down, Ain’t no use in looking down ...” It’s repeated numerous times and the message is there to advice that being victimized by Jody is perhaps a fact of life with the intent to lessen the shame. Unfortunately, PFC Smith could do none but “look down.”

He was drowning in shame and guilt. He was sewn to perfection by his surgeons with meticulous attention. He was kept under watch for an entire month on the inpatient psychiatric unit for his safety, but his most difficult journey yet had now begun.

Although I would only learn the labels later, he was devastated by narcissistic injury, perceiving himself as a failure. He blamed himself for his wife’s actions, as well as “failing to kill when necessary” further devastating his soldier identity.

I learned a lot from PFC Smith for the one month I cared for him. He helped me realize the incredible privilege psychiatrists enjoy when permitted by patients to witness their utmost vulnerabilities and fears. He also taught me that the role of his prior surgical and medical care was to keep him alive but the role of psychiatry was to help him live again.

Over the course of years, I have understood that a lot of psychiatric disorders and disordered behaviors lead to social isolation. This fact is the complete opposite of what we desire from the moment of our birth: letting out a loud cry to surround ourselves by all that love us. This innate ability being present so precociously at birth places sociality as a top survival tool.

I had also realized that I was at great advantage with my cultural competency due to my prior service enlisted experience. It made it easier for me to connect with soldiers. I listened to PFC Smith, and my supervisor told me to help him reframe his aftermath. With that recipe, the soldier went from someone “looking down” from shame to eventually becoming a spokesperson for Army’s suicide prevention. He traveled across the country and shared his story with deploying military units. He had found a new purpose and begun to live again. Like many medical students, during my other training rotations, I felt like an accessory to the treatment team and did not value my contributions. It was different on my psychiatry rotation when engaged with PFC Smith and others like him. This was the first time I felt I had made a concrete difference in someone’s life. This gratification combined with superb role models were enough for me to want to become a psychiatrist.

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