As we continue to talk, he demands further connection with me, now insisting that I look into his eyes consistently. I struggle to focus my gaze on him, increasingly aware of my own eyes, drying from lack of blinking. He senses my discomfort as I approach the ultimate topic.
“Joshua … dude … I have to admit you to the hospital,” I say as gently as I can.
“Can’t you just be cool?” he begs.
“I can’t send a naked growling guy back out onto the streets,” I tell him lightly, jokingly. “People would make fun of me. My boss would kill me.”
“Let me talk to your boss,” he argues. “What’s his number? We can call him right now!”
“Joshua, it’s two in the morning on a Saturday night. I am not calling my boss at home. Forget my boss. I know. You need to be admitted.” I have to switch gears. It’s lame of me to blame my boss; I have to be the grown-up, be the doctor, and take responsibility for admitting him myself. Being cool cannot be the priority just now.
“You need some help. You need to hang out here and get your head together. It won’t be for too long, but you need to check into the hospital for a little break.” I point out to him that he is not taking care of himself, and he is endangering himself. His physical health is deteriorating, despite his insistence that he can survive on the streets by eating the free peanuts that the vendors toss him. He is putting himself at risk by arguing with large men on the city streets and parading naked up Broadway. Surely he can see that?
He glares at me, resentful that I have taken this stance. I have crossed back over to the other side, separating and drawing a firm line between us. There is no longer a blurring of boundaries or a flexibility in our roles, and we are no longer confidants. He is the patient, I am the doctor, and I am admitting him involuntarily to the Bellevue psych ward. I am the one with the keys to the unit; he is the one already locked into the detainable area, whether he knows it or not.
“So, you just sit there in judgment of me. You think you can decide who is crazy and who isn’t,” he says.
I picture myself standing on the corner of Sane and Insane directing traffic. You’re in, you’re out. Step over the invisible line and see what happens.
“Actually, that is exactly what I do here.”
I get up to leave the room. I have more patients to see. I face him and try to smile apologetically as I slowly back out of the door. I assume he won’t attack me, but it’s always best to err on the side of caution.
Ticket to Ride
When I start my job at Bellevue, in July of 1996, I am a single, thirty-year-old, five-foot-four, pear-shaped gal with long brown hair, freckles, and green eyes. I am smart—more than that, a smart-ass. Growing up in the suburbs of Boston, I got good grades and had plenty of friends. I sported a cool, tough-girl act which served me well over the years. I swore a lot, wore jeans, boots, and a leather vest, and smoked cigarettes. I also played guitar and sang in a rock band.
In high school, I became fascinated by the brain, and by drugs and how they can acutely alter reality, which I discovered via my own travels through the looking glass. I knew I wanted to be a “brain doctor,” either a psychiatrist or a neurosurgeon. A premed at Penn, I majored in the Biological Basis of Behavior, devouring coursework in psychology, neurobiology, and psychopharmacology, great training for my eventual career in psychiatry. My cousin was going to Penn Med at the time, and I would run into him around campus. He introduced me to a friend of his who was doing his psychiatry rotation, who was surprised to learn that there was not much emphasis on psychotherapy anymore. “Psychiatry’s all pretty much done with medication now,” he told me, disheartened, but I was thrilled, looking forward to immersing myself in a prescription-driven field. I was enraptured by the brain and how it could misfire, but it wasn’t just the hardware that intrigued me, it was the software with the bugs. And if I was interested in how drugs affected the mind, psychiatry made a lot more sense than neurosurgery.
All through college and medical school, it wasn’t enough for me to ace my exams, I had to be the one who turned in the test first, and gave the teacher attitude to boot. Ultracompetitive but trying to look like a slacker, I thought it wouldn’t seem cool to try too hard. I studied in the back corner of the library, never letting on that I had to work for my successes.
There was a brief detour in my senior year at Penn, when I decided that I didn’t want to become a doctor after all. It was the late 1980s, and I deluded myself into thinking I was the next Madonna, or maybe Chrissie Hynde from the Pretenders. I took a year off after graduation, singing in my band, playing the electric guitar, and riding a motorcycle through the streets of Philadelphia. Even though I had taken my med school exams, filled out all the forms and written the essays, I ended up throwing it all away, literally. I tossed the sealed, addressed envelope containing my application into the garbage the day after my new band formed, sure we were going to make it big, and even more convinced that I had to try. I didn’t want to spend the rest of my life wondering about what could have been. My parents were understandably furious.
After a year of playing in the band and working in a Philly hospital doing neurology research, I got bored and decided to get back on track and go to med school, but I didn’t quit the band. I spent a good chunk of my first two years at Temple Med going to rehearsals and gigs while studying anatomy and physiology. I crammed for exams in between takes in the recording studio, or sat in my car in the parking lot of a nightclub catching up with my textbooks between the sets of a Saturday night concert.
Eventually I quit the band. Once I started my clinical rotations, there was no time for anything but the hospital and sleep. After graduating from med school, I landed a psychiatric residency at Mount Sinai Hospital in New York City. After that, I ended up at Bellevue. Where all the other crazy people end up.
Psychotic people come to our psych ER from all over the world, as if Bellevue were a beacon, lighting the way. Patients will explain, “I started to hear voices, so I figured I should be at Bellevue.” They’ll walk from New Jersey, take buses from Missouri, hop flights from Cairo. One woman walked across the George Washington Bridge carrying two large bags full of her own feces, because she somehow knew she needed to be here. (The feces are hard to explain. Some patients, when they become psychotic, collect all sorts of things that take on special meaning for them.)
Bellevue is a full-service hospital in Manhattan, but many assume it is primarily a psychiatric hospital. The police in New York City are guilty of this as well. They will pull people off of the bridges, out of the subway tunnels, or in from the tarmacs of the airports and deliver them straight to us. Even though the public hospitals throughout the city are divided by catchment areas, the cops bring us psychiatric cases from all five boroughs, knowing that we can handle the patients no one else can.
So why am I so attracted to this patient population? I’ve always been enthralled by insanity. When I was a kid and my parents would take me into Boston, I’d immediately notice the homeless schizophrenics, how they would walk around pelvis-first, talking to themselves. I was fascinated by the idea of hearing voices, of paranoia and disorganized speech. I wanted to understand and help them, but I also think my desire was about wanting to play with fire, to swim in the deep end.
So now I am the doctor in charge of Bellevue’s psychiatric emergency room, also known as CPEP (pronounced “See-Pep,” the Comprehensive Psychiatric Emergency Program). I run two fifteen-hour overnight shifts on Saturday and Sunday nights. They call me “the weekend attending.” It feels just like rock-and-roll psychiatry to me. This is my Saturday night gig.
My work week starts on Saturday evening at six thirty. As I drive south from my apartment near Mount Sinai on the Upper East Side, the East River is on my left, the UN on my right, and I make it to the hospital in about twelve minutes. There is a great view of the Empire State Building as I walk toward the hospital from the back parking lot. I pass the older buildings, the storied repositories for
the disenfranchised, which now house the shelters. There are broken statues on the lawn, the grass overgrown behind the wrought iron fences that surround the decrepit buildings. Faded signs point to destinations no longer in existence.
Bellevue is the oldest public hospital in the United States, with a long tradition of “serving the underserved.” Its origins date back to a six-bed infirmary which opened in 1736. Bellevue has been an almshouse, a penal institution, and most infamously, an asylum: In 1878, a dedicated pavilion for the insane was christened. The world’s first hospital ambulance service, maternity ward, pediatric clinic, and emergency room all got their start right here, but it’s the asylum that gets remembered, the ultimate symbol of bedlam that is most strongly yoked to Bellevue’s name.
“Take him to Bellevue,” is the line I remember best from the old TV cop show Barney Miller. It was Hal Linden’s answer for any arrestee who was off his rocker. I remember watching that show and wondering, Where is this magical place?
I spent my adult life insatiably educating myself on insanity and its treatment, and as soon as I could get a job there, I did.
A Day in the Life
The doors whoosh open automatically as I walk into the ambulance bay by the medical ER, called the AES (for Adult Emergency Services). I say hello to the hospital police officers who are stationed here. Bellevue employs nearly eighty of their own cops, and I get to know all of them over the years as their positions rotate through the various security desks and entrances of the buildings. When there is a ruckus in the psych ER and the staff needs more hands on deck, “HP!” is our SOS. The hospital police hear “HP to CPEP” over their walkie-talkies and come running, stopping briefly to put on a pair of gloves before jumping in to restrain an agitated patient.
The back hallways leading from the AES to the CPEP are interrupted by multiple sets of double doors. Off the hall to the right is the radiology suite, where chest X-rays and CT scans are performed. On the left is “the blue room,” the holding area for prisoners who have been treated and released and are waiting for the bus to take them back to Rikers Island. When the prison guards amass a busload on Monday mornings, the prisoners, dressed in orange jumpsuits, their hands and legs shackled, will make their way through these back hallways toward the rear exit, where a bus is idling. It is the most abject, sorrowful group of men you will ever see. They are captive and sick, suffering physically as well as mentally. Many are in withdrawal from whatever was keeping them going on the outside. Others have swallowed taped-up razor blades or lightbulbs in an effort to leave the prison and be admitted to the hospital.
While the procession slowly makes its way toward the back door, two corrections officers at either end hold up the traffic, forcing all the Bellevue staff in the corridor to wait until the prisoners have left. The Rikers inmates march right by the entrance to CPEP. When I first started at Bellevue, I was callous, posturing with bravado while I stood there watching them pass. Sometimes I’d even whistle “I Love a Parade” as they went by. Over the years, my demeanor has softened; now, when the prisoners troop by, I am silent and respectful, offering a sympathetic smile, saying “Hey” if I catch anyone’s eye.
Across the hall from the CPEP entrance, there is a suite of offices and call-rooms. Call-rooms are places where doctors can theoretically sleep during the nights they spend “on-call,” in the hospital. My first call-room at Bellevue was small and cold, with a rock-hard, narrow bed. When the CPEP moved to its new location, one year after I arrived, I got a larger office. When I got pregnant a few years later, I splurged for a queen-sized bed. It is the largest in the hospital, as far as I know.
As I walk into my call-room, all the way in the back corner of the suite, I throw my things on the bed and check my voice mail before gathering my belongings for the shift. CPEP keys go in the tiny front-right pocket of my jeans; I call this the drug pocket, because it’s where patients tend to stash their favorite pills, baggies of dope, or crack vials. My Bellevue ID gets clipped to my scrub top, as does one black pen. My beeper clips to the waistband of my jeans. I grab a water bottle, and my clipboard and folder (stuffed with reference material, like how long cocaine metabolites stay positive in urine samples and how many milligrams of Xanax equal a similar dose of Valium), and head for the door.
My hair is still wet from the shower I took before I left my apartment as I walk through the patient waiting area. On one side of the room, six green leather bucket seats are connected by a metal bar. Above the chairs, pictures of flowers framed in plastic are bolted to the wall.
The hospital police officer assigned to this area sits at a desk with a patient log book. If he’s not writing an entry, he may be reading a magazine or watching a portable DVD player, but more likely he is shooting the breeze with a real cop from the NYPD. These guys love to tell war stories, trying to outdo each other with the most outrageous or horrifying narratives.
Once a patient has been logged in by HP and then registered by the clerk, who sits like a bank teller behind Plexiglas, he is sent to see a nurse in the triage room, a windowed cell that separates the patient waiting area from the nurses’ station. My own progress through CPEP mirrors the journey the patients take, and I greet the hospital police officer, the clerk, and the triage nurse as I pass each one. I use my key to enter the main area of the psych ER, the locked detainable area, noting the noise, the smell, and the level of activity that will surround me for the next dozen hours or so.
Once I’m in the nurses’ station within the locked area, the first thing I need to know to get the ball rolling is the census. How many patients are on hold, admitted, or waiting to be seen? How many of the admissions have been assigned to a bed upstairs and how many will remain in CPEP because the inpatient units have filled up? My biggest concern is back-up on either end. Is the waiting area full of patients yet to be seen, or is the locked detainable area crowded with stalled admissions? Priority one is to keep the census down.
Priority two is to get NYPD out of our waiting area. They have brought their prisoners to be evaluated prior to arraignment, and we need to help make it as brief a detour as possible. Bellevue has a job to do for the city, assisting NYPD in keeping their prisoners safe. Any arrested person who has a psychiatric history or is taking psych meds (this includes the Upper West Side mom on Prozac caught shoplifting) needs to be screened by us. If the police suspect that their prisoner is suicidal, they’ll bring him to Bellevue for screening, because it’s not safe to leave a potential suicide alone in a cell. Sometimes, a prisoner is so grossly psychotic that it is inappropriate for him to be held in police custody. Ever since one deranged man at central booking—who was never referred for a psych evaluation—stepped on another’s neck and killed him, we have been screening more prisoners than ever.
Whenever an arrested person is brought to Bellevue, the job of the psychiatrist is well circumscribed. It is only to ascertain if the patient is calm enough to stand in front of a judge and be arraigned, and whether there is an acute risk of self-harm or danger to others while in police custody. This is called a pre-arraignment evaluation. It is not my responsibility to determine the patient’s capacity to stand trial, and it is certainly not my place to judge guilt or innocence.
If a prisoner requires an admission, he is sent to 19 West, the forensic unit. The other inpatient units occupy multiple floors and wings. 20 South is the unlocked detox ward for voluntary patients only. All the other psych wards are locked, even though they house a mixture of voluntary and involuntary patients. 20 East is a dual diagnosis ward for psychiatric patients with alcoholism or drug addiction, the bulk of our clientele. 20 North is the geriatric unit. 18 South has Mandarin-and Cantonese-speaking staff for our Asian immigrant patients. 19 North is the teaching unit for particularly interesting or complicated cases. 12 South is the med/psych unit for those in need of intravenous medication or other intensive medical treatments.
Many of the patients are eligible for more than one unit, but I can only send them up if I k
now there are empty beds waiting for them. The nurses upstairs don’t like new patients coming in over the weekend, so they play games with their own census data, making it seem as though they couldn’t possibly take one more patient. Then on Sunday night, sure as the 60 Minutes clock will tick on CBS, the “mystery beds” miraculously open up, and there is a merciful drainage of our area. The problem is, this relief valve is usually nowhere in sight when I arrive on Saturday night.
But there are other options: I don’t have to admit all the patients upstairs. We have our own six-bed ward, the EOU (Extended Observation Unit), where we can place a patient for up to seventy-two hours on a 9.40, an involuntary admission that gives us up to three days to figure out what’s going on with the patient, which ideally involves speaking to family members, employers, and therapists. During their stay, we can see if there’s any change in presenting symptoms. Once the time is up, we need to either discharge or admit. We can admit by using either a 9.39, an involuntary admission, or if the patient is willing to sign in voluntarily, a 9.13. All the “9 point something”s require a set of New York State legal papers to be placed in the chart.
If I’m not sure where to place a patient, I have an easy out—a twenty-four-hour Hold requires no legal status, no justification for detainment. Patients spend the night and are reinterviewed in the morning when they’re less drunk, high, or sedated. The Hold is the disposition of last resort. It is better for patients to have a definitive status, but sometimes, when they can’t give any coherent information, that’s impossible. The patients who are safe to be discharged from the CPEP are the T & R’s: They are treated and released. They’re not sick or dangerous enough to keep hospitalized, so we patch them up and send them back to the front, just like they did on M*A*S*H, only our war zone is the mean streets of New York.
Weekends at Bellevue Page 2
