(Please note this story was written with permission. All names have been changed, as well as some non important details. The exact location has not been provided, this is to protect the patients identity. This story contains some strong language.)

Today he could tell me his name, a better day for him. Mr. Lucena presented to our emergency room with “acute confusion”, heroin and alcohol were present in his system. Delirium would be a better term. He had already been evaluated by the medical team and cleared. “Mr. Lucena how are you doing today my name is….” He cut off the senior resident suddenly and tried to sit up and reach for me. “Mike, mike please Mike I want to go home.” That is as far as we got in the interview that night. “ Mike, Mike please, where is mike.”

Mike was his son, Mike was dead.

Mr. Lucena was placed on our secure acute psychiatric floor, a government facility. The next 2 days he didn’t speak much as the heroin and alcohol left his system. He vomited and shook, received regular Ativan to prevent seizures. On the third day he emerged from his room to eat, I found him watching TV holding a copy of the Bible.

“Mr. Lucena, how are you doing today?” He looked at me and said “I’m doing ok Mike, decided I need to read the Bible.” He opened to a verse and read, but only gibberish came to his lips. “Mr. Lucena my name is Alex, we met 2 days ago.” He looked at me as if I was speaking Russian. “Mr. Lucena can I ask you a few questions?” He starred down and nodded yes. “Can you tell me the date today?” Ten seconds of silence. “Wednesday.” He continued to stare down, correct answer Friday, the 8th.

“Ok Mr. Lucena how about the month and year?”

With force he said “1984”, It was august 2014.

“Can you tell me who the president is?”

“That mother fucking Nixon” at a near yell. We left it at that for the morning. He watched daytime TV, he was scoring zero on the CIWA scale, he ate lunch.

The ward was set up in a secure work area and secure patient area, tiny windows at the top of the secure area separated the staff from patients. It was just after lunch before group therapy was to begin that a schizophrenic patient made his move, he hadn’t been eating and was very thin. He made it up the 8 foot wall and half way through the tiny window with surprising speed. The janitor, a former marine, pushed him back through, reacting to the screams of the nursing staff sitting below. He told us “Look the CIA is after me, trying to kill me for what I’ve done, and don’t try to tell me it isn’t true because I know that this is a government facility that I’m not allowed to leave” It was hard to argue with his point, he was in a locked government facility.

That afternoon we received records from an outside hospital from across the country that began to paint a picture of man who had lived a hard life. Extended military service, PTSD, divorce, drug and alcohol use…a son lost in military service. Among the myriad of medical problems vascular dementia was prevalent among them.

As the days went on and his acute symptoms went away his mentation settled into a steady state of the mid 1980s. He scored zero on every mental evaluation presented him. He cried at random times, he asked for Mike, he asked for his wife, he asked for narcotics.

Six days in he started attending the group therapy session, led by a long haired hippie type turned doctor. While his confusion persisted, his timeframe jumping around somewhat, he began to share some of his nightmares. He shared a story of watching his friends die from friendly fire in Vietnam. He talked about how proud he was of his sons. He talked about hitting his wife during alcohol and drug induced flashbacks. He loved the Packers and the A’s. He loved Rocky. He loved Chess. Chess with his son Mike was a favorite topic. “But that little shit still ain’t never beat me” he boasted

Speaking of Mike, Mike died during his military service, he was the oldest son and closest friend of Mr. Lucena. Mr. Lucena called me Mike more often than not, I was a young man, but I am a pale Welsh German white, Mr. Lucena and his children were African American. But this delusion persisted on and off the entire time I worked with him.

The attending I was working with at the time was frustrated with Mr. Lucena. “I’m not sure if he is failing the testing we are giving him or he isn’t trying. Day to day I would say his symptoms meet the criteria for dementia, but sometimes I feel like he is being manipulative, but to what end I’m not sure.” That is a paraphrased 45 minute conversation with one of my favorite attendings ever who had the true gift of gab. One of the many reasons she was a great psychiatrist.

It was her that proposed the chess match as a test of his mental ability. At the time I was a decent chess player, also I was, more of than not, Mike.

I brought a chess set and set it up in the central common area.

“Mr. Lucena how about a game of chess?” I asked him, he looked up and toward the board set up on the table beyond the windows of the common area, a smile cracked on his face. He stood up wordless and walked toward the table.

I went ahead of him and sat behind the black pieces and considered my opening. “Alex I always play black, I like seeing how people start.” He called me Alex, not Mike. I switched sides and he sat down across from me. I opened with pawn to B4, he mirrored my opening move. I moved out my Queen’s bishop, he moved his knight, I moved my knight, he moved his bishop, I castled, he castled. The opening volley was done, the board was set. I began to attack trying to make him play a game where he couldn’t simple mirror what I was doing. It was clear he knew the rules, but did he understand the game. He had been silent until now, then I got him into an early check. That’s when the trash talk started. “Shit son do you think you can push that knight down my throat, no, no, no.” He countered and I quickly lost the knight and a castle, he attacked at a rapid pace, taking pieces but also loosing pieces, but mostly pawns. He tapped on the board as I surveyed the scene. Tap tap tap “The board won’t change the longer you stare Mike.” I was Mike again. I changed my strategy and slowed the game down, got him out of his rhythm. A crowd of patients had begun to watch, and talk, when they got to loud Mr. Lucena gave them a polite “Shut the fuck up, we are playing chess here, not checkers, not fucking dice.”

I began to close in, he was hemorrhaging key pieces, he again became silent. The crowd grew. He knew he was loosing, he went on the pure defensive. He attacked pieces away from the main game, he brilliantly maneuvered his king and protection. Soon we were left with pawns and a castle on my side and a knight and pawns on his. I offered him my hand. A draw. One man in the crowd clapped, which slowly faded, he being one of the few that understood what had happened.

Mr. Lucena couldn’t tell me anything that had happened to him in the last 20 years, as far as we could tell in his current state he couldn’t really read or comprehend his situation. He, on and off, thought I was his Son. He had just forced a draw against me in chess.