Sometimes patients are eager to leave, but other times they mostly want a place to sleep. Occasionally they’ll ask earnestly if they can please just spend the night; other times they’ll manufacture symptoms in order to dupe me. Either way, I utter my well-rehearsed line, “This isn’t a shelter, it’s a hospital; you need to be genuinely sick to stay here.” The Bellevue men’s shelter is just one block north, and many of our discharged patients are referred there, though they are loath to go.
There’s an oddball category of patients with no official status that I call “Waiting for Laces.” This is a T & R whose discharge paperwork is still pending, sitting in the nondetainable area waiting to speak with a social worker about what we call the “dispo plan”—where to go next and how to follow up with outpatient services. It’s a tense, vulnerable position to be in, having been judged sane enough to leave the hospital, but still in limbo while you wait for your walking papers and your belt, shoelaces, and wallet, knowing you need to stay calm and polite in order to be released. Some of these patients are furious at being discharged. They would rather be admitted to Bellevue than sleep on the steaming sidewalk grates or in the subways or shelters. Sometimes they’ll make a scene, threatening the staff and requiring hospital police to escort them off the grounds, perhaps without all of their belongings. (When I see the laceless walking the streets of the city, I wonder if they are people who got tired of waiting for the social worker and just left without picking up their belongings, or if they were never actually deemed safe to be discharged but have somehow managed to escape.)
After I have figured out how many patients are in the CPEP and where they’re likely to end up, I see how the staffing looks. Do I have any medical students rotating through here tonight? How many residents are here, and are they first-years or second-, slackers or stars? Most important is which attending—which doctor in charge—has been working the shift that immediately precedes mine. This will establish whether I have a mess to clean up or whether things have been left in pretty good shape. Sign-out is the changing of the guard between the attendings. It will occur whenever the departing doctor has the time to sit down and run the list, discussing every patient in the area. Often, there are many loose ends to tie up before that can happen.
A busy Saturday night for me is twenty-five or more patients in the CPEP, or more than five on triage. If there are a lot of triages, I won’t wait for sign-out. I will just “glove up and dig in,” as they say in medicine. (This saying is medical jargon for manually dis-impacting a constipated patient, but it has morphed into meaning “suck it up and get to work.”) I will grab a chart and see any patient who has already been triaged by a nurse and looks like he could be a quick T & R, which only involves writing up the interview and a discharge order, considerably less paperwork than the other dispo plans, since there are no legal forms or admission orders to fill out.
When it is less busy, the first order of business is, “When’s dinner and where are we ordering from?” This was especially true during the months at Bellevue when I happened to be pregnant and took “eating for two” very seriously.
The nights tend to progress smoothly. The on-call resident and medical students see the triages, and then present the cases to me. I help them decide who stays and who goes, and I check over all the paperwork to make sure the admissions get packaged for transfer to the upstairs wards. By one a.m., I usually turn in, letting the resident run the show in my absence. I am available for phone calls and consultations, both by the second-year resident in the CPEP and the third-year who is doing consultations upstairs in the rest of the hospital. The attendings in the medical ER often call me as well, to let me know they’re sending someone over to CPEP. I usually sleep about five hours or so, though it is interrupted by multiple phone calls, and occasionally I need to go across the hall to deal with some problem or fill out restraint orders that require an attending’s signature.
I don’t usually eat like a lumberjack, but on Sunday mornings I make an exception. It’s the middle of my Bellevue weekend, and I like to treat myself. Short stack, two eggs over easy on the side, sausage split. I’ve developed little traditions as the years have gone by, and the men behind the counter at the Bellevue coffee shop, with their easy grins and mischievous eyes, have kept up with my preferences. Their pancakes are legendary among the ambulance drivers and police officers, and their prices are so low even the panhandlers can sit down to a good meal.
I bring my breakfast back to the CPEP and give sign-out to the Sunday morning attending and the moonlighting residents hired to work the weekend day shift. By ten, I am out the door for my eight hours off before I drive back into work Sunday night and do it all over again.
Hello Goodbye
My oatmeal with sliced banana and my lousy Bellevue coffee are lined up in front of me on the counter of the nurses’ station. I spend a few minutes opening and sprinkling the sugar packets into the two matching paper cups, one filled with brown liquid, the other with brown solid, waiting for the other doctors, psychology interns, and social workers to arrive. The crowd assembles, the nurses are called over to join us, and it’s a little after 8:30 when the CPEP director instructs me to begin the Monday morning sign-out. It’s time for me to download what I’ve been doing all weekend and who’s still left in the area.
Mostly what I’ve been doing is trying to stem the tide of patients flowing into CPEP. When there’s a slew of patients on triage and no empty beds upstairs, I can call my own 911, the EMS diversion desk, and beg them to take us out of the loop. It’s a number I know by heart already. An EMS is quick to remind me, diversion is a courtesy. They can make an announcement to all the ambulances, telling them we’re full to the brim, but they can’t guarantee compliance. And once an ambulance shows up, I can’t turn them away. And the walk-ins are still going to come regardless of our diversion status, so there’s only so much I can do to relieve the pressure of the incoming patients on the area.
I begin morning report with an announcement. “Listen up. We’re on diversion, confirmed by EMS operator 8758. It’s good till noon, for what it’s worth. Okay, here we go. Starting with the voluntary admissions, on a 9.13 is Mr. R. He’s a fifty-two-year-old African-American male with a history of schizophrenia and alcohol abuse, and he’s hep C positive. He walked in Saturday night saying he’ll kill the person at the shelter who stole his meds and wallet. He’s got a history of aggressive behavior, though nothing recent. Also, he did a stint at the Greenhouse drug rehab program not too long ago. He’s on Zyprexa for his psychotic symptoms and behavioral control, and a Librium taper for the alcohol withdrawal. Keep an eye on his vital signs. Also, rule out malingering. He could be faking it, just looking for a better place to crash, and the homicidal threats are bogus.
“Then there’s Mr. J, thirty-five-year-old Hispanic guy, also with schizophrenia, who was referred from the walk-in clinic on Friday. He’s been noncompliant with his outpatient treatment, showing up sporadically, going on and off his meds. He’s getting delusional, says he’s going to confront people with tattoos and piercings because they are in league with Satan. That should keep him busy for a while. He’s on Risperdal one milligram twice a day.
“Moving on to the involuntaries, Ms. D is a fifty-three-year-old black female brought in by EMS from the Port of Atrocities Bus Terminal on Saturday morning, where she threw a fit because she felt that someone had touched her. She was almost arrested, but once the cops got a sense of her, they decided to make her an EDP so they could just drop her off here instead of taking her downtown and booking her. They made the right choice, actually. She’s pretty intense, irritable, paranoid, disorganized. She came with a notebook full of stuff about the Devil and God doing battle inside her, that sort of thing. She denies a psych history, but she looks like a street schiz. Also, she’s got a history of cardiac issues, hypertension, chest pain. She needs blood pressure meds written before she goes upstairs.
“Mr. S is a thirty-six-year-old Hispanic man with a h
istory of depression who currently lives with his sister and is unemployed. He recently returned from Puerto Rico with worsening depression. He banged his head repeatedly against a wall in a suicide attempt on Saturday, got bandaged up in the AES Saturday night, and then started head-banging here, too. Head CT is clear; he’s neurologically intact. His utox is positive for cocaine. His ex-wife says he’s been depressed for years and he acts out whenever they have a fight, which they did recently in PR. He seemed calmer on Sunday, but he was pretty agitated on Saturday. He’s on Lexapro for the depression, and prn Librium as needed. He’s a drinker. No signs of withdrawal so far, so we haven’t given him any, but keep an eye on his vitals.
“Mr. A is a twenty-four-year-old black male brought in by EMS on Sunday afternoon. He approached the MTA police asking to be placed in a witness protection program. He’s got elaborate paranoid delusions involving kidnapping, murder, being followed…. He’s denying all psych history and all psych symptoms; the only thing he’ll cop to is that he hasn’t slept in three nights. He’s been pretty wired in here. He thinks the TV is sending him messages and that the news has to do with him. We have him on Risperdal one milligram twice a day.”
I detail the arrival, diagnosis, and management of another dozen involuntary admissions, before adding, “One more admission: Mr. H is a twenty-three-year-old Hispanic male with a history of bipolar disorder. His mom is too, by the way, so easy when you talk to her on the phone—she sounds pretty manic herself; she’s talking a mile a minute and it’s pretty hard to follow. The patient was brought in by EMS on Sunday afternoon after he approached NYPD on the street, asking to go to the hospital. He was complaining of anxiety, suicidal thoughts, and paranoia to the cops, but here he’s denying everything. He looks intense, guarded, and he may be responding to internal stimuli. He denies alcohol and drugs. Anyway, last week he took a handful of his mood stabilizer Depakote in a suicide attempt, but he never sought any medical attention. His friend says he was talking about throwing himself in front of a bus for the past couple of days. We’re waiting on Tylenol and aspirin levels just to make sure, but he looks okay medically. He should be on Risperdal and Depakote once the labs come back. Can somebody check those and write the orders?
“Okay, in the EOU we have three admissions. I left some room in there for you guys. Bachelor number one is a thirty-eight-year-old black male … well, she’s a transsexual actually. Okay, bachelorette number one walked in claiming she was raped but was really disorganized and out of it, and at one point she told AES she lied about the rape to get a place to sleep. She was grossly psychotic and definitely high on cocaine. That was Saturday night. On Sunday, she was irritable, still pretty disorganized, and insisting we give her housing. The plan is to discharge today if she’s cleared. If she’s not, give her a bed upstairs. A single if possible.
“EOU bed two is a forty-two-year-old black male with schizophrenia and AIDS. He was brought in by EMS from his adult home, saying the voices were telling him to hurt someone and he didn’t want to. He’s compliant with Zyprexa, and a second antipsychotic, Geodon, and his HIV meds. We’re hoping a short stay in the bed and breakfast suite will take the voices down a notch. He just came in last night so give him some time to pull it together. He’s a nice guy, actually—genuinely ill and pretty mild-mannered. Wouldn’t hurt a flea, I bet.
“EOU bed three is Mr. G. He’s a twenty-year-old Hispanic man brought in by EMS Saturday morning. He came here by bus from Massachusetts to meet Wu Tang Clan. He says he’s a famous rapper himself and he has four jobs. Totally grandiose, bizarre, tangential, poor boundaries. He’ll need a bed upstairs for sure, but we’re keeping him in the EOU because he’s all over the place and needs his own room. Also, we’re pretty backed up; the admissions aren’t going anywhere soon, so he’ll need to have his status changed to 9.39 sometime today or tomorrow, when his EOU time runs out. Spoke to mom who says he was doing okay on Risperdal and Depakote, but he’s probably gone off his meds, so we restarted them.
“On Hold is Mr. W, a seventeen-year-old white male with a history of bipolar. He was brought in by EMS Sunday night from home after throwing some furniture around and getting pretty violent. He’s got a solid history given his age, multiple med trials, multiple psych hospitalizations. He just got out of Saint Vinnie’s a couple of weeks ago. He was pretty combative when he first got here, tore up the peds ER pretty good last night, but once we got some prn’s in him, he calmed down. He’s been pacing up a storm, can’t really sit still. He may have akathisia from recent med switches so we’re holding the antipsychotics for right now. Child psych is supposed to see him this morning.
“But wait! There’s more!” I say like I’m selling something on TV. “There’s a few on triage. I’m sorry. They just rolled in this morning. One guy, a prisoner, Mr. K, forty-eight-year-old guy arrested for robbery, just got out of Rikers a week ago. He says he takes Risperdal and Sinequan for sleep. He’s asking for a few sandwiches and then he says he can go to arraignment. He’s an easy T & R.
“Also on triage is Mr. U, a thirty-eight-year-old Indian man who walked in this morning. Looks very well groomed and also very tense. Complains of feeling electric shocks in his head. Somebody make sure he’s not going through Effexor withdrawal. He’s preoccupied with religion, changing from Jewish to Muslim to Christian in the course of a quick conversation with the clerk during registration.
“And, last but not least, Unknown Black Male, looks to be in his thirties, sent from Coney Island Hospital, arrested for assaulting an MTA worker with a cane. Whose cane I do not know. Not his. He got IM’d with all kinds of sedation at Coney and is totally shlogged. Apparently he was very combative there, and was also spitting at the staff. They called me about the transfer last night but he hadn’t been medically cleared yet. They have very little info on him and NYPD is going to run a missing persons. He was pretty violent at Coney; he needed four cops to escort him here, so be careful when he wakes up.
“Okay, that’s all I got. I’m outta here. Have a good week, you guys.” I gather my folder and water bottle and leave the nurses’ station. “Enjoy!”
In the nondetainable area, EMS is bringing in another case as I walk out.
“We’re on diversion,” I say as I head for the exit.
“Oh, really? No one told us that,” answers the driver.
But I keep right on walking, because my shift is done. It’s someone else’s problem now.
My life at Bellevue happens in spurts, in weekly installments like episodes of a dramatic series. I have all week off to recover and to process whatever’s gone down. Like a woman after childbirth, I forget the pain. I come home Monday morning wired and fried, but by Saturday evening, I’m showered in a freshly laundered scrub top, ready to take sign-out.
Girl
(Temple Medical School, Philadelphia, 1988)
Looking back on it, I remember the first year of medical school as cycles of filling and then emptying my head: reading, memorizing, cramming for tests, regurgitating all I had learned, and then, in most cases, immediately forgetting it. It was, in many ways, like being brainwashed. I learned a completely new language, and it insidiously changed my perception. One day I was in the library studying, gazing at the signs on the shelves, and I was so immersed in that new language that I misread the sign that said “periodicals” as “pericardial”—that being the word for the sac that surrounds the heart. I walked around Philadelphia looking at its inhabitants not as citizens, but as patients. That guy with the limp and the drooping face must’ve had a stroke. This one with the tremor and the stooped posture’s got Parkinson’s disease. Everywhere, instead of people, I saw pathology. I was learning to think like a doctor.
I would study so much, I’d feel like the information was going to leak out of my ears. By the summer between my first and second years, I felt I needed a break from studying. I wanted to be around patients, preferably crazy ones. My search for a job brought me to a hallway outside the locked psych ward of Temple
Hospital, where I sat waiting to meet with a psychologist who was doing research on auditory hallucinations. I had my motorcycle helmet with me, and my backpack. A slave to eighties fashion, I wore a green-flowered jumper with black leggings and black wrestling boots. My hair was styled in a spiky crew cut with a foot-long braided tail, tied at the end with a white bow. I must’ve looked like a freak to the psychologist, but after a short chat, he hired me to help him interview one hundred hallucinating patients—a dream job for me, though it paid nothing.
I wandered the psych wards for the next several months, making friends with the psychotic patients so we could get our data. It was great fun, a true pleasure to be learning more about my chosen field well ahead of schedule, and a welcome respite from reading. I hung out in the patient’s lounge, smoking cigarettes with the patients in an effort to ingratiate myself into their cliques. There was one tall, thin man who stayed for months, waiting for a state hospital bed. He had tried to cut off his penis, explaining to me that he felt it was the root of all evil; he joked with me that he would call his memoir Woody. There were many afternoons when he’d wander the hallways singing the lyrics to “Right Here Waiting”: “Oceans apart, day after day, and I slowly go insane.” I’d join him on the chorus, adding harmony to his plaintive voice. “Wherever you go, whatever you do, I will be right here waiting for you,” as if assuring him he’d always be able to come back to me on the inpatient ward if he couldn’t make it on the outside.
Weekends at Bellevue Page 3
