Brooklyn Zoo

by Darcy Lockman

  When T. arrived, she picked Mr. Younger and his muffin as her first teaching point. “Doing outpatient therapy is passive. Working in the ER is active. Tell him to wipe his mouth. It’s very primitive to have food all over. When adults need to be told to wipe off their faces, they’re infantile, no ego boundaries. It’s not polite to tell a man to wipe his mouth, but we’re providing structure, not politeness. To get along in the world, he needs to know how to take care of his body, so part of our job is to help him be more aware. One of the ways we’ll know he’s getting better is when we don’t have to tell him anymore. Who do you want to see first?”

  I told her about Glover and his overdose attempt. “Mood disorder or thought disorder?” she asked. It was the same question she’d been posing to the interns each week in the seminar she taught us. Different from the diagnostic paradigm I’d learned in school (developmental level; character organization), the idea here was that you narrowed it down to mood or thought disorder based on a patient’s observable behaviors and reported experiences and then tried to isolate which mood or thought disorder it might be per the DSM’s checklists of symptoms and their durations. I’d come to understand, in our ER seminars, that a DSM mood disorder diagnosis supposed that depression or mania or both were the patient’s primary and debilitating problems, while a thought disorder implied that it was psychosis, schizophrenia being the most serious and organic of these, and with the poorest prognosis.

  These were the categories of symptoms most typically addressed in the ER, but there was also a third DSM category: personality disorder. Glover had become desperate after a threat of abandonment, which I thought put him in this latter group. Thought disorder, mood disorder, personality disorder: they weren’t mutually exclusive. Most of the patients we saw likely had personality problems (or rigid and unhealthy patterns of thought and behavior) along with their psychoses and bipolar depressions, but these were never quite addressed in CPEP, sort of like how you wouldn’t immediately treat a patient’s osteoporosis if he came to a medical ER with a broken arm.

  Dr. T. nodded when I told her my ideas and sent me to the nursing station to get Glover’s chart. On my way, a young, slim guy in a blazer and pompadour motioned me toward him. I went over. He came close enough to whisper. “I’ve got a controlled substance,” he said, flashing a prescription pill bottle in his right hand.

  I became giddy with the opportunity to think quickly. “Can I have it?” I asked.

  “No,” he replied, dropping the bottle back into his pocket.

  I looked around. Kelvin was nearby. I got his attention and pointed at the patient. “Kelvin,” I said, keeping my voice calm. “He’s got a controlled substance.”

  The tech was taller and broader than the patient, who gave the pills to Kelvin without a fuss, muttering something about Adderall. Feeling heroic, I continued toward the nursing station. I retrieved the chart and went back to T.’s office. I wanted to tell her what I’d accomplished, but I couldn’t find the words to give my feat its due. I stayed quiet but must have been swollen with pride. Dr. T. took the chart from me and opened it, reading. ER glory was short-lived.

  She shared information about Glover with me as she scanned. “He took fourteen Tylenol and then called his girlfriend and told her what he’d done. She showed up four hours later”—at this she furrowed her brow—“and brought him to the medical ER, where they treated him and discharged him to us. What do we want to know when we bring him in?”

  “More detail about what set him off. What exactly happened leading up to the attempt. What did he think was going to happen after the fight? Does arguing always upset him? Has he done this before? Does he have mood symptoms like poor sleep or appetite?”

  T. nodded. “What else?”

  “Is he still suicidal? Had he been feeling for some time that he wanted to die, or was this impulsive? What made him call for help?”

  “Good,” she said. “You’re thinking about mood and personality disorders, and you remembered the telescopic lens. I’ll go get him.”

  When Dr. T. returned, she had both Glover and his girlfriend in tow. The girlfriend did not look happy to be there. “Chandra was here to visit, so I thought we’d do a couple’s session,” Dr. T. explained, introducing me. The office was only big enough for three chairs. I gave mine up and perched on the edge of the old metal desk.

  The room fell silent. “This is a difficult time for you two,” said T.

  Chandra glanced at Glover angrily and then back at Dr. T. “There is no ‘us two’ anymore. We broke up a week ago.”

  “I see,” said T., addressing Glover now. “You did this because you couldn’t bear to have her leave you.” His shoulders slumped.

  Chandra continued. “I don’t care what he does. I’ve had enough. We’ve been together a year, and he’s still sleeping with other girls.”

  Glover broke in, trying to take her hand. “But, baby …”

  Chandra pulled her hand away. “There’s no more ‘But, baby.’ ” She was visibly shaken, teary.

  Glover began to speak. “I love her,” he told us. “I don’t care about those other girls. I only want her. I took the pills because I got so scared about being without her. And then I call her and she doesn’t even show up for hours.”

  “She was angry,” said T.

  “It’s not my job to take care of you!” Chandra replied, starting to cry. “What am I supposed to do now? Be with him or he kills himself?”

  “What about trying to understand him better? Why does he fool around with other girls if he loves you? With understanding can sometimes come change—and forgiveness,” T. said.

  She turned to address Glover. “Tell me about growing up.”

  “It was good.”

  “Who raised you?”

  “My dad mostly.”

  “That’s unusual.”

  “My mom was in and out. They were never together. She moved around a lot. When she was in New York, I saw her sometimes.”

  “That’s sad.”

  Glover shrugged. T. turned to Chandra.

  “There’s a little boy in him still longing for Mommy. But once he has her, it’s terrifying to be so invested in one person, one person who’s always abandoning him. So he needs to shore up his resources, find other mommies in case the important one leaves. This is what he’s struggling with. It fuels the cheating. The more he starts to feel dependent on you, the more he needs to do it.”

  “And so I’m supposed to put up with that just because he didn’t have a mother?” Chandra seemed angry at the suggestion.

  “No,” said T. “But if he’s serious about being with you, he can really commit to therapy and start looking at those old feelings. Eventually, he won’t need the other women in order to quell his anxiety.”

  Glover tried to take Chandra’s hand again. She pulled it away, crying. “I don’t know,” she said.

  “It’s just a thought,” said Dr. T. “You two need some time alone. We’ll stop for today.”

  “Are you letting me go home?” asked Glover.

  “No. Maybe tomorrow. You and I have more talking to do.”

  Glover and Chandra left T.’s office. She said to me, “What is the real meaning of choice? Does Glover choose to cheat? Yes, sure, but it’s also a behavior that’s overdetermined—a lot of factors influence it. Most of our big decisions are overdetermined. Take my choice to work here. I’ve been here almost twenty years. I grew up in a traumatized household. My parents were raised on the Russian front. They saw family members killed in front of them. In my home it always felt chaotic, like we were waiting for something dire to happen. So this crazy place feels familiar to me, comfortable.

  “The way we work with patients, we are constantly juggling dire situations. The ER is not an outpatient clinic. There you have the luxury of time. Here you do not. There you let the patient set the pace. Here you are direct and provocative. I love working with cases like Glover’s. A patient who’s not psychotic comes in at a point of c
risis in his life. His defenses are down because this just happened. You can really get in there and help him explore his raw spots—same for Chandra. There’s just a brief window while they’re vulnerable. I want her to see the damaged child inside Glover. His behavior isn’t just dumb; it’s motivated by who he was.”

  “I don’t know, Dr. T., she just seemed finished,” I said.

  “But she was crying.”

  As I left T.’s office to go about my afternoon, I glimpsed Chandra and Glover down the hall holding on to each other as if for dear life.

  When Glover timed out, his cousin came to take him home. T. told me that he had asked Chandra to pick him up but she declined. The cousin, only a little bit older than our patient, was understandably nervous. “What if he tries to kill himself again?” he asked Dr. T.

  “You can keep an eye on him, ask how he’s doing, but mostly it’s out of your hands,” she said, always pragmatic. At T.’s suggestion, I had helped Glover set up an appointment with me at the outpatient clinic for the following week. Apparently, if he didn’t see an intern, he’d be assigned to one of the staff psychologists there, and each staff psychologist had 150 patients in her caseload. T. had tried to instill in Glover the value of understanding himself better, even now—especially now—that the crisis had passed. She told me, once he had gone, that she doubted I’d ever see him again. “But I planted the seed,” she said. “Maybe after the next girlfriend leaves him, and he starts feeling desperate again.”

  T. and I were settling in to discuss the morning’s group when Dr. Amony, the debonair Haitian head of CPEP, swept into her office. He needed her immediately. He began to tell a story that sounded like the opening line of a joke. Lady calls 911 to get a squirrel out of her apartment. When 911 had failed to materialize some hours later, the lady called back. “How do I get you here?” she asked them. “Do I have to say I want to kill myself? Fine! I want to kill myself!” The police arrived quickly. They brought the lady to CPEP, leaving the squirrel behind to have its way in her pantry.

  “We’ve got to see her and get her out of here,” Dr. Amony told Dr. T., making it clear he feared litigation if she wasn’t quickly evaluated and released. I imagined Dr. Amony as a dodgeball player, lithely avoiding hurtled lawsuits like so many light red air-filled balls. When they left, I retrieved the charts for my group patients from the nursing station and wrote notes in each, as T. had instructed: “Mr. so-and-so attended morning therapy group.”

  Group had been almost full that morning, five patients, three of them new to me. Mr. Bonture was still there, as was Mr. Younger, the man with the crumbs. “Would you each like to introduce yourselves?” I asked my group. They agreed that they would not.

  “I shouldn’t even be here,” said a toothless older man in pajamas. “My old lady threw a plate of food at me yesterday, and I’m the one who gets locked up. Women are the source of all problems.”

  “Not true, it’s men,” responded a young woman wearing a backpack. Her face had more acne than I’d ever seen on one person. “I just went out with a guy who was so cheap. All he bought me was a cup of coffee and pack of cigarettes, and he told me I owed him. Do I owe him?” she wondered aloud.

  “No,” said the middle-aged man. “He only wants sex.”

  “I don’t do that,” said the girl.

  “Relationships don’t work, because God isn’t in a relationship. Can I leave now?” asked a young guy with eyes too wide who had been reluctant to come in the first place.

  “I’d rather you stay. You obviously have things to contribute,” I said encouragingly.

  “I shouldn’t even be here,” he responded, walking out. Mr. Younger followed him. He did not have crumbs on his face today, but his button-down shirt was wide open, yet another indication, I thought, that he was not ready to go out into the world.

  As I sat in Dr. T.’s office working on my notes, Rhoda came in looking for her. T. was still with the woman who should’ve just called animal control, so Rhoda sat down to wait, eager to chat. I felt amused and vaguely flattered. Staff did not generally go out of their way to speak to interns at any length. We were so temporary and uncomfortable.

  She seemed poised to tell me about herself. “How long have you worked here?” I asked. She smelled like cigarettes, and I guessed that it had been a very long time.

  “Sixteen years,” she said proudly.

  “Do you enjoy it?” I asked.

  “I hate it, but the benefits are great. I get free dental,” she said.

  We both fell silent. She thought some more. “But it’s an interesting place. World famous. People in South America know about it. When they need treatment, they fly into JFK and take a cab straight here. They give fake Brooklyn addresses. It’s a city hospital. We can’t turn anybody away. Doctors all over the country know about G Building. A lot of them rotated through here. They all hated it, too,” she declared, her face brightening.

  T. returned and was cross with her. “You’re distracting my intern from her notes,” she said.

  “I’m done,” I said.

  T. picked up a chart and read it, then another. “These have no substance,” she declared. “You cannot simply write that a patient attended and said x, y, or z. Talk about what they are managing to do interpersonally. Note changes in functioning from the last group. In Mr. Younger’s chart you write that he left the group after five minutes, but I don’t know how long he stayed the day before—maybe five minutes is an improvement. Also, I saw him in the hallway. His face was clean. Say that today he was adequately groomed. We’re always keeping discharge in mind, and our notes show whether patients are progressing toward it.

  “And what I’m saying doesn’t just apply to the charts. Bring these things up with your patients. Once they’ve been to group a couple times, you can ask them to reflect on how they’re getting better. Tell Mr. Younger that you’re happy to see his face is clean, and highlight that as a sign of improvement. Then you can ask other patients if they know what ‘getting better’ looks like for them. Most of them have been here before, and they should start to observe this stuff in themselves.”

  By Friday, I was like a summer marathoner in her final mile. I also felt back to square one. There were five patients in EOB, and three of them declined my offer of group. A slow-looking woman named Sylvia was alert but unresponsive, and feeling uninterested, I quickly moved on. The two men in the EOB room refused to get out of bed. I let them both know that their refusal would impact their discharge, but they were unmoved. There was an old lady in the private room reserved for the elderly and others unable to protect themselves. When I asked her to come to the dayroom for group, she moved so slowly I decided we’d be better off having the two-person group in her room. After consulting Kelvin to make sure I wasn’t breaking rules, I invited my other new charge, Marcus—yet another strapping, young, apparently lucid man—to come into Miss Old Lady’s room. He obliged. She was incensed.

  “It’s not proper to enter a female’s room,” she said to him. He looked at me.

  “It’s okay if you have a chaperone,” I said.

  She looked down her nose at me, over her glasses. “In black culture, this is not appropriate.” I felt chastised for my whiteness, but I couldn’t get around it, as glaring and obvious as my inexperience. Maybe they were one and the same. Marcus, whose skin was a good two shades darker than Miss Old Lady’s, got up a little irritated with her and stood in the doorway. Group was brisk.

  I wrote notes in the two charts and sat to wait for T. Then I got restless and wandered into the hallway, where there was more clamor than usual. The door to Dr. Brink’s office was open, and she was seated at her desk. I walked over and inserted myself in her doorjamb. An announcement came over the PA system: “Code Orange on G-51, Code Orange on G-51.” Code Orange was an encrypted cry for help, and when it was called, the hospital police and the techs were supposed to drop what they were doing to dash to the offending unit, but the announcements came often, and the staff t
ended to saunter more than scurry.

  “It feels a little crazier here today,” I said to Dr. Brink.

  She nodded her head with a grave look on her face. “It’s the weather,” she said. “Changes in barometric pressure make people irritable and explosive. They’ve done studies.”

  Dr. T. arrived as if on cue and saw me talking to her nemesis. “What are you doing standing around chatting?” she barked. “There’s work to be done.” She moved in a huff to her office, and I followed her. My supervisor’s quick temper had little effect on me, and this was a delightful surprise, a reminder of one accomplishment of my own therapy: I did not imagine her bad mood any fault of mine. In the parlance of my field, I was not using her crankiness neurotically.

  “You should be calling the families after group. Tell them they have to come in and see us. We need to get a sense of each patient’s baseline functioning in order to know how much better we can expect them to get here.” She took a chart from the stack on her desk. It belonged to Sylvia, the female patient who had not responded to my lukewarm group request that morning. “She lives in an adult home. She went to the hospital for swollen feet, didn’t get her Ativan, and became extremely anxious. Call her caseworker and ask her to come in.”

  Feeling self-conscious under Dr. T.’s gaze, I picked up the phone and called the group home. Sylvia’s caseworker would come right over. Sylvia sat with us in T.’s office to wait, still alert but unresponsive. Dull. But when the worker appeared at T.’s door, Sylvia beamed and jumped to her feet. The tall, pretty caseworker smiled broadly as Sylvia threw her arms around her. Suddenly my own lack of interest in this woman who was, if only briefly, my patient made me feel regretful and uncompassionate. The ER was filled with nothing if not raw emotion, which seemed to either hit me too hard or escape me entirely. “Sylvia’s always quiet and keeps to herself,” the caseworker confirmed for us. T. took the woman’s word that Sylvia was ready for discharge. Her caseworker would wait for the paperwork to be complete and then take her home. After they left, T. told me: “Being sent upstairs can be traumatic, so we want to avoid it if the patient really doesn’t need it. The psychiatrist wanted to admit Sylvia yesterday afternoon, but Nurse Higgins knows her and thought she’d be okay after she got her meds. This is how it goes here when everything’s working as it should. A lot of the patients are familiar to us, and that can be so helpful. We begin to be effective as a community.” She paused to let me absorb this information. “Who would you like to see next?”