Things Unseen

You might have heard the stories about how and where Steve Jobs got his design sense and his obsessive attention to detail. Steve’s father Paul Jobs was a good  mechanic with (from his son’s perspective) a decent sense of design. He worked with cars, metal and wood and could build most anything his family needed. Jobs said that his father cared about how things looked, but he cared even more about how the things that were hidden from plain sight looked also. He would never put a flimsy section of plywood on the back of a fine piece of furniture. He would build the back of a fence with the same care that went into the front of that same fence. He cared about the things that were unseen.

Jobs carried that aesthetic into his own work at Apple. He would have rough seams on plastic computer cases sanded and polished. He rejected components that were not precisely made. He wanted employees to sign the inside of some of the computers they made, even though the buyers of those machines would never see the signatures. This was to get them to own and be proud of the quality of the work they were doing.

Today, many of us are working from home. We have set up office space with desks, computers, lights, printers and screens by which we can interview, assess, meet with and deliver services to our patients, customers and coworkers. We spend many hours in front of a glowing screen that is anywhere from five inches to three feet or more across. We are highly visible to the people we work for and with, except for one small detail: the part of us that is unseen.

We are working from the waist, or the mid-chest, up.

I have had several people, when finding out that I do telemedicine from home or office for ninety five per cent of my work nowadays say things like, “Cool! You can go to work in shorts or pajama bottoms or sweatpants! You don’t even have to wear shoes. You can work barefoot!” Yes, that would technically be an option I suppose. Like a television anchorman, you would know what kind of shirt I am partial to (cotton Oxford button down), what kind of ties I wear on the job (NONE!), and possibly a little bit about my taste in jewelry and watches (currently wedding band, Medical College of Georgia senior ring class of 1983, and Apple Watch Series 5 WiFi and cellular capable).

Like Steve Jobs, I believe that the things that are unseen are just as important as those that are. The rest of my working clothes get me into the right frame and state of mind to listen carefully, think clearly and act decisively. You may not see them, but I know I am wearing them everyday, and that makes me feel prepared and ready for whatever the day brings. A nice pair of year round wool slacks, a Hugo Boss or Hanks leather belt, a Bellroy wallet, nice socks from Vermont or (if I’m feeling a little more dressy some mornings) a little mill on the banks of a river in England, and one of my several pairs of Samuel Hubbard shoes. (I am often up and down and on my feet for up to eighteen hours in a day, and I have very unforgiving feet).

So, could I trudge upstairs with a nice fresh Oxford shirt over a pair of khaki shorts and flip flops? Yep, I most certainly could, and no one would ever be the wiser.

Except I don’t. I’m channeling my inner Steve Jobs.

And now, you know.

 

Pushmi-pullyu

It’s a common scenario in emergency room telepsychiatry. 

Sixteen year old female comes in after an argument with her boyfriend or her parents (usually fathers, sorry guys). She decides that she is going to get back at the person she fought with, and show them a thing or two. She rifles through the medicine cabinet. The thing that immediately jumps out at her is a big bottle of acetaminophen, the 500 count. It’s cheaper that way you know. She thinks what the hey, it’s Tylenol. How bad could it be if I take a handful or two of it? It’s headache medicine. She proceeds to do just that. Someone finds her, calls 911, gets her to the local ER. Her acetaminophen levels are through the roof, and rising rapidly. Houston, we have a problem. A big problem. Acetaminophen taken in even larger therapeutic doses over a long time can cause liver damage. Overdoses of it can cause liver failure. These ODs kill livers. And sixteen year olds who didn’t really mean to die. 

He’s a stud, a late twenty something with nice tattoos and even nicer pecs who thinks the world is his oyster and the girls will always fall for him. He works hard in construction during the week, but the weekends he considers his to blow out and party like it’s 1999. (RIP, Prince) He starts with marijuana at nine, alcohol at fifteen, cocaine at seventeen, and now and again a little crystal if he can score it. This time, on this Saturday, he goes a little too far. The cocaine, most likely cut and adulterated with God only knows what, treats his heart like crap. He has an arrhythmia that won’t go away. Hearts need to beat regularly. If they don’t, dirt nap. 

He is one of the most genteel and dignified men I’ve ever seen. His silver hair is still thick and full, his skin is ruddy and healthy looking, and he is dressed in nice khakis and a polo shirt. He smells of alcohol, his other vice (expensive cigars). He saw his family doctor the morning before he was admitted to the ER. He is on a small dose of antidepressant and something for sleep. His alcohol use is escalating, he has isolated himself, and he rarely sees his friends any more. He has stopped reading, and he doesn’t care at all this year about another love of his, presidential politics. Oh, and as for love? His partner, his true love, his wife of sixty five years, finally said goodbye to him when she passed away peacefully in her sleep six months ago. He has felt lost, alone, and abandoned ever since. He can’t shake it, and now he’s not even sure he wants to. “Let me die, Doc. Please just let me die.” 

The sixteen year old wakes up, feels a bit better, eats a little. 

“It was just Tylenol, for God’s sake. I was pissed at my dad. I didn’t mean to kill myself. Can I just go home, please?” (Insert grand eye roll and turn away from Doctor, arms crossed)

Her insight is nil. She damn near died. There are real problems at home, not to mention the fact that she has zero coping skills when normal day to day problems arise. She see none of this-yet. 

“It’s a fluttering, Doc. My heart is all a flutter, I guess, you know. The way I affect the ladies. They see me, and boom! They fall for me. It’s a curse.” 

He winks at me, unshaven, hair mussed, but still brash and arrogant and full of the misdirected passion of youth. He has little insight into the fact that he is a heartbeat away from nonresidency. 

“Oh, c’mon, Doc, give a guy a break. I still got some weekend left before seven AM work time on Monday. There’s beer in the fridge at home, buddies are blowing up my phone. I’m good. I’m really good. Let me out of this prison. Please!”

A single tear runs down his handsome tanned face. He looks up at me, telegraphing quite clearly that if he does not get some help, if he is sent home, that he will die. Oh, did I mention that he is an avid hunter and has a safe full of guns at home?

“May I please be discharged now? I’d like to get home to feed my dogs, and take a nap…” He trails off, head hanging down to his chest, hands clasped limply in his lap. He begins to sob, quietly. 

The common threads here are obvious. 

Some patients are at extremely high risk of self harm, even death. Some are young and naive, some are full of the vigor of young adulthood, and some are old and tired and sad. 

The other common thing about all these types of consults is that each patient, without fail, asks to go home. They have almost succeeded in poisoning themselves to death, they are playing Russian roulette with needles instead of guns, and they have given up on any further happiness in life. Somehow, they get to the ER and seek help. Yet, they can’t see the gravity of the situation, the extreme risks, the pain they would cause the ones left behind. They only want what they want, which is not to be in the emergency room. 

What to do?

Well…

You push me…

I pull you…

…with any luck, back into your own life. 

Don’t remember what a pushmi-pullyu was? Watch the video below and it’ll come back to you. 

https://youtu.be/pmp-ITOI0-I

迷失東京

I take language for granted.

You probably do too.

I go to work every day thinking that the least of my worries is going to be how I communicate with the people who come to me for help. I’ll have to help them deal with alcohol problems, depression, hearing voices and thoughts of suicide, but the common language between us, English, will facilitate this process, not hinder it.

But as Robert Burns said in his 1786 poem To a Mouse,

But, Mousie, thou art no thy lane [you aren’t alone]
In proving foresight may be vain:
The best laid schemes o’ mice an’ men
Gang aft a-gley, [often go awry]
An’ lea’e us nought but grief an’ pain,
For promised joy.

I was tasked with evaluating a patient the other day, a patient with the usual family problems, mood changes, and possible paranoia and delusional thinking that many of my patients have. The history given me by the hospital emergency department staff was pretty straightforward. I needed to see whether or not this person needed to be hospitalized for safety, medicated for psychosis, treated for depression and anxiety, or simply sent home because of a cultural misunderstanding.

The problem? I speak fluent English and absolutely no Mandarin Chinese. He spoke fluent Chinese and very, very little English.

Now, I have written about the positives and negatives of telepsychiatry before. The picture is crystal clear, the sound quality is usually very good, and the ability to assess and intervene from hundreds of miles away is remarkably and surprisingly easy. Except when the two parties involved do not share a common language.

We tried the usual say a few words and use sign language thing. No go.

We tried to find a family member to help, but they had already left the hospital.

We then turned to a translation line out of California, something that most all facilities nowadays must have ready access to in order to provide care for anyone who might walk through their doors, especially if they receive any Federal monies as payment for services at all.

Problem solved, right?

No.

We could not get the translator hooked up through the speaker phone on the hospital’s end so that both the patient and I could hear her.

We tried having her call in to my desktop speaker phone, which would then be picked up through the mic on my Polycom unit and heard by the patient in the ED. No go.

We finally worked out a three-way call that involved her talking to the patient on a corded phone in the ED, on camera, and me on my iPhone in my office at the same time. The patient was on camera and could see me and vice versa. I turned the sound on the telepsych unit all the way down to prevent the double double transmission transmission of of every every word word.

We were then able to proceed, albeit awkwardly and gingerly, through an intimate conversation about marriage, business, and madness with the help of a very patient and very helpful young woman in California who spoke both Mandarin Chinese and English.

Once we were able to communicate, the cultural issues, nuances, and differing manners and cultural protocols became more obvious between us, doctor and patient. This added another layer of richness and frustration to what should have been a fairly easy, fairly straightforward thirty minute conversation and assessment.

Two and one half hours later, I hit send and my consult was on its way to the emergency room doctor and staff.

I was emotionally exhausted. I got up and walked around, got some air, and contemplated what had just happened.

Sometimes we go through our days not even noticing the miracles around us. We take so much for granted. We are sure of what we are going to do and exactly how we are going to do it. We set out schedules and feel that we are in perfect of control of our lives. We think that our way of doing things, our language, our culture and our priorities are the best, the most important and the ones that everyone else in the world espouses and holds dear.

We would be dead wrong there.

Practicing telepsychiatry has taught me many things in the last four years.

I have learned that people are people, with similar problems and hopes and dreams and fears, no matter the color of their skin or the way they dress or the language they speak. I have learned that being patient is absolutely essential to doing my job. I have learned that being flexible saves me, the hospital emergency room staffs, and my patients a lot of heartache.

I have learned that communication is key. Without it, my services are absolutely useless.

Enjoy your day. Talk to someone today. Really try to understand what they are saying to you. Take nothing for granted. You will be richer for it.

The title above is Lost in Translation, written in the traditional Chinese.

Tools of the Trade

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I have had some of you ask me what I use day-to-day to get my job done. In other words, what are the tools of the trade for a psychiatrist as he goes about the business of seeing patients in the clinic and the emergency room?

Although the personal interview and personal attention to patients is my stock-in-trade, I could not survive nowadays without technology.

I use a new twenty-one inch iMac in my home office, the machine I use to do most of these posts. I have two 4 TB hard drives attached to it for extra storage of music, video, and other items, as well as to back up my data. Everything is backed up three times, twice on my desktop on two different drives and once in a cloud service off site.

I have a set of harman-kardon speakers as well as a DVD drive attached to this machine for enjoyment of music, as well as for viewing videos, doing continuing medical education and the like.

There is a copier/scanner, a stand alone printer and a Fujitsu ScanSnap iX 500 on another desk adjacent to my main workspace. A shredder lets me securely get rid of paper that needs to be destroyed. I am transitioning to a completely paperless home office, so the last two remaining piles of charts and supporting documents on the floor will find their way into the ScanSnap and from there to my iMac as soon as time permits. 

My iPhone has been my primary go-to computing device on the road since 2007. When I leave home, the iPhone goes with me. Everywhere. Everything that I do on the iMac syncs wirelessly at home and through the cloud without me thinking about it. When I pick up the phone, I can get right back to a post, a project or anything else I was doing on the main machine at home before I walked out the door. Believe me, I have tried more configurations of more machines than you can shake a stick at, including desktops, laptops, phones and tablets. For me, having one main machine at home and one device to take with me just works better overall. 

Of course, you have seen me post about the setup at work, including the Polycom system, an HP laptop, a Dell desktop, fax machine, printers and the like. This is in my telepsychiatry office and is a static configuration that I leave on and operational all the time. As you know, I am an Apple guy, I use PCs and supporting peripherals to do my day job by default, trying not to whine too much about it! Another Dell desktop lives at the clinic office and is tied into the department network, so I can access all databases and notes for either job from either site. 

So tech is cool, but what about analog tools? Is there still a place for them in the twenty-first century? Of course there is! I also love paper, notebooks, pens and other analog tools almost as much as I do my tech toys. In the home office, I always have a couple of Field Notes notebooks and a large cup full of pens around for jotting down ideas as they come to me, later to be captured in my electronic devices for processing. I have a large whiteboard on an easel right behind my desk, so that I can stand up, think about projects on my feet and jot down outlines or notes as I go. On this board I also note books that I’m reading, places I want to visit, and a working budget for my daughter’s upcoming wedding! There’s something about having a large  white space like that that promotes brainstorming and planning for me, which can be very helpful in a way that a blinking cursor or mouse pointer cannot. 

When interviewing patients, especially new patients I meet for the first time, I’m still a clipboard and template sheet kind of dinosaur. I have an interview template that I’ve used on and off, with multiple modifications, for over twenty-five years. It keeps me on track, helps me to remember overall areas that I want to cover, and is sprinkled with mnemonics for various assessment tools that I might want to use. When I get to the bottom of the stack of papers on that clipboard, I make fifty more copies and keep going. 

I also have Field Notes notebooks in my bag for on the go, plus an assortment of charging cables, batteries, pens, paperwork and other goodies that I grab as I go out the door. I keep this bag stocked all the time, so that I never have to remember whether or not I have a USB cable or a uni ball Vision Elite pen or some other equipment that I might need when I’m away from home. 

Prescription pads, printed schedules, paper projects that need to be top-of-mind and various other stuff take up the remainder of the room in my bag. There is always something to send to someone, process, respond to or to read. 

I haven’t covered absolutely everything, but you get the gist of what I grab and go with almost every day as I go about the business of working, writing, reading, seeing patients and living. 

One day soon, I’ll share with you the applications that I use on my iPhone every day. That little device connects me with the world and keeps me organized and productive in ways that I would never have imagined even five years ago. 

What do you use as you go about your day? Are you a digital or analog person, or do you rely on both to keep you productive? 

I’d love to hear from you. 

Tele-Psyched

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A couple of nights ago, our little Telepsych Program that Could reached a major milestone. 

We saw our 16,000th consult patient in the state of South Carolina. 

The Telepsychiatry Program in the SC Department of Mental Health has been going strong for almost six years now, and things just get busier and busier. Some days I come to work and there are ten consults queued up to be seen in various emergency departments around the state. Other days there have been as many as thirty. As I have mentioned previously, each consult, much like a “real” consult on the floor of a hospital, might take anywhere from one hour to two hours or more to complete, from record review to on-camera interview to typing the actual report to be sent to the requesting hospital. 

This milestone gives me pause and makes me think, again, about several very real issues. 

1) Mental illness is very common in the state of South Carolina, and in the rest of the country.

2) Many people have access to mental health services only through their local emergency rooms.

3) Telepsychiatry is filling a need in my state, and is expanding around the country

I have worked in the mental health field for twenty seven years, and I hope to be actively involved in the provision of mental health services to those who need them most for many years to come.

The illness is real.

The sheer volume of work is sometimes overwhelming. 

The rewards for a job well done are many.

Congratulations to my colleagues in telepsychiatry for reaching this major milestone in our program. I am honored to work with you as we try to provide the best mental health care possible for the citizens of South Carolina. 

 

Sixth Sense

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People often ask me if I can really connect with patients via telepsychiatry.

What they mean, I think, is this:

Are you able to really listen to and see and evaluate someone when you’re sitting hundreds of miles away from them in another room and only seeing them on a screen, albeit a large, high definition one? 

The answer of course is yes, but there are drawbacks. 

The use of my Spidey Sense is dramatically decreased when I’m in my Virtual Shrink superhero role as opposed to sitting with patients in the clinic consulting room as a Dr. Peter Parker wannabe. 

There is something to be said for face-to-face, real-time, in-the-same-room discourse. When you’re in the same room with a patient, you can smell last night’s alcohol binge as surely as if you were there with them for every shot at the bar. You can pick up on tiny physical fasciculations or tremors that might be missed on camera. You see the writhing, circular gyrations of the foot of one crossed leg that might not be picked up if the camera is focused in too tightly on the patient’s face. You can see a patient’s nervousness, twitchiness, and physical desire to move about when they are uncomfortable being in the same room with you. 

The thing that is hard to replicate on camera is that sixth sense that stands every good shrink in good stead. 

The feeling that someone is not really telling you the truth. The sense that the mild paranoia that a patient presented with is about to dramatically increase, and the decision to back off and not ask just one more question. The feelings of tension between therapist and patient that have been described as transference and countertransference in the psychodynamic literature. The feeling that you are about to be assaulted in some very real way. (Yes, I have been hit three times in my psychiatric career, and it’s never a fun thing to go through)

Telemedicine allows us to see patients hundreds of miles away in a timely fashion, providing needed evaluation and treatment services to those who might otherwise go without. it is a wonderful advance in modern technology, but it is not perfect. 

Until we can plug completely into someone’s world in a virtual sense, we may miss bits and pieces of their story that would help us provide the care they need. 

Through a Glass Darkly

For now we see through a glass, darkly, but then face to face…

1 Corinthians 13:12

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I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the Criminal Domestic Violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.

Do You Hear What I Hear?

It was just another night in the center.

I was sitting in my office working away. We had had a baker’s dozen more consults come in at least and it had already been a long day. I had six hours to go in my usual sixteen hour Monday shift. I was tired, but I could see the light at the end of the tunnel. I could blow the joint at midnight.

Now, working alone in a big building at night has its advantages. Like working night shift in a hospital, evenings at the center bring a kind of calm that only health care workers know. The phones don’t ring quite as much. Nobody stops by your office door to chat. You can even leave your door open while you work, because nobody is there to overhear your conversations with patients on screen. It’s nice and still and conducive to thought and productivity.

But, there are also things that go bump in the night.

Like any building, my mental health center has its own special creaks and groans and shifts and settling during the quiet hours that no 8:30 to 5:00 worker even notices. The vacuum shift when the air conditioning clicks on, causing a door to be sucked shut on its own. The little air freshener canister holder in the bathroom next to my office, that decides to just unhinge itself and drop down with a loud boiiiiing at odd times on weekends. You know, the noises that a building makes when it stretches at night, thinking that none of its people are there to hear it adjust itself on its foundations.

I’m used to these eerie little noises, having done this telepsychiatry job for three and a half years now and being quite comfortable with the psychiatrist-as-monk role.

Sometimes I’m startled by something new. Like last night. (shudder)

Like I said, there I was, another night in the old cockpit, staring at a high def screen and typing my fingers to the bone when I heard it. Conversation. Two, maybe three people. Funny, that, as I had heard no one come in from the back entrance and nobody had stopped by my hallway to announce their presence, our long-established weekend and holiday tradition when folks came in to do chart work or make phone calls and they knew I was working that day.

But there is was, loud enough to hear but not loud enough to be distinct. A conversation between what sounded like two women. (shudder) I get chills just thinking about it even as I type this.

Who the heck can that be? Why didn’t they come to tell me they were there?

I got up out of my chair, went to the doorway, stuck my head out the door into the hallway, and listened.

“Hello?”

Scenes from Ghostbusters flashed through my head. Yes, it was clearly, but not clearly, a conversation. Mumble, mumble, drone, drone, ha ha ha, mumble mumble mumble ha ha ha.

And then, just as quickly as it had come, it stopped. Just stopped. They were gone. No people. No talking. No conversation. No ha ha ha. No sound of doors opening or closing. I ventured out into the hallway, timidly putting one foot in front of the other and thinking at the same time how silly I was being.

“I’m alone in this building. I’ve been alone in this building all day long.”

Are you now?

“It’s Memorial Day weekend. No self-respecting state worker in their right mind is going to set foot in a state office on Memorial Day holiday.”

That’s the point, isn’t it, Old Sport?

“Oh, stop it with the Gatsby references, already.”

I can do whatever I want. 

I shook my head and cleared the 1920s cobwebs and flapper dust. There was nobody here. Empty conference room. Empty hallway. Empty outer hallway. Back exit securely closed and electronically locked.

Who you gonna call?

“Oh, stop it.”

I went back to my desk, sat down, and got back to work.

Thirty minutes later, they were back. Mumble mumble HA HA HA mumble buzz buzz mumble HA HA HA. 

Okay, this was creeping me out. Maybe this working by yourself for sixteen hours at a time is not such a good idea after all. What was that William Hurt movie? The one about being in a tank and sensory deprivation?

HA HA HA HA HA HA HA

“I’m glad you think it’s funny. I don’t think it’s so funny.”

Welcome to the Hotel California, where you can check out but you can never leave.

“Okay. Get a grip, cowboy. You’re a doctor. There are no people here with you. There must be a rational explanation for this. No one came in. You didn’t hear the familiar loud crash of the self-closing door in the outer hallway. Get up and investigate this and put your mind at ease. You’ve got five hours more to work.”

I got up, stepped back into the hallway, turned to my right and gingerly, quietly, stealthily tiptoed down the carpeted tunnel to the corner, peered around it to the left, and saw…

Nothing. No green slime. No Stay Puft marshmallow man.

I went back into the outer hallway, looking to my left, then to my right into the semi-darkness. Straining to see the exit way down the hall to my right, the sodium-lit parking lot beyond.

Nothing.

I turned, re-entered the Executive Wing, and retraced my steps. Then, I heard it. Muffled, but there. Voices. At least two. Female.

Ha ha ha mumble mumble mumble.

Were they in my office? I would not be ambushed. I would not go down without a fight. I would stand for timid psychiatrists everywhere. I would fight bravely if it came to that.

I passed by my colleague’s office, a little glass-walled fishbowl of a place on the corner, with its own separate setup of dual high def monitors and computers. Inside, the monitors glowed. And inside, the voices laughed again.

That’s it!

I went back to my own office, sat down in front of the monitor, and waited. My heart rate was rapidly descending from the 140 range. In two minutes, the call came.

“Dr. Smith? Hi! We thought we’d never get you. We tried to call in twice, but we kept getting Aiken 2 instead of Aiken 1 and it was just a dark, empty office. We couldn’t figure out how to get to yours. We were just chatting away, laughing about how we couldn’t figure this thing out and get it to turn off. Ha ha ha ha.”

“I know,” I said. “I know. No problem. I wondered when I was going to hear from you.”

I settled back in my chair for the rest of my shift.

Just another night in the center.

Across the hall, an air freshener can dropped down spontaneously from its holder.