“What are you talking about?” I ask.
“I’m going to let you in on a little something I haven’t told everyone here. At my last job, before Bellevue, I had breast cancer. Radical mastectomy, chemo, radiation, the whole nine. I was thirty-one.” We are standing in line at the coffee shop, getting breakfast. She tells me how incredibly sick she got, how even now anything orange, the color of the chemotherapy meds in the IV bag, can make her gag. How her white blood cell count got so low, her fevers so high, her oncologist didn’t think she was going to pull through, but she did.
As if she weren’t enough of a mythic figure in my eyes, Lucy Jones has beaten cancer. I call her accountant and get the pricey disability insurance.
Our faculty meetings are a smaller version of the weekly staff meetings: just the attending physicians are included. We meet on Thursday mornings after Lucy’s overnight shift. She is giddy from lack of sleep and even more disinhibited than usual. It’s my favorite time to be with her. She is wearing scrubs and is usually in need of a shower. There are times when I lean into her, seeing if her scent does anything for me, the way Jeremy’s does. I love his smell; I can feel something stir in my pelvis when I breathe it in. I stare at her armpit hair, transfixed as it peeks out from her tank top. She doesn’t shave there, like I do, like a man doesn’t. She smiles at me and I blush. She has caught me, I think, but she lets it go. I am experimenting with an idea here, and I appreciate the latitude. We huddle in the corner, whispering and cracking wise. Dr. Lear has to separate us during the meetings as if we were schoolgirls. On Monday mornings, when I come in for rounds, I often say, “Good morning, Dr. Jones…. Good morning, everyone else.” I do, on some level, separate her (or maybe it’s us?) out from the rest. She rises easily above and beyond the other staff members, the cream above the crop. And I’m not the only one who places her on a pedestal. There are many of us at CPEP who speak of Lucy in blatantly worshipful language. She has a large group of idolizers, but the thing that I love best, that makes me feel special, is that she also admires me.
“Julie, sometimes I lie awake at night afraid you’re smarter than I am,” she says to me one morning. She smiles, and I know she’s teasing me, but not totally. There is truth in her jest, and I lap it up like milk in a saucer. Soon we are a team, a mutual admiration society, and partners in crime.
We double-date with Sadie, her girlfriend, and Jeremy, inviting each other over for dinner to our apartments, or going down to Chinatown for Vietnamese food. Lucy and Sadie eventually buy a house together in the Hamptons, and they go there on the weekends. Jeremy and I can’t hang out with them since that’s when I work, but they generously offer us the use of the house during the week. The light in the late summer afternoons is like nothing I’ve ever seen. We go biking, windsurfing, kayaking. We eat lobsters and corn. We break their hammock with our combined weight, and I replace it, owning up to it when I see Lucy on Monday morning.
In the Bellevue of the Beast
I thought I knew what crazy was. Then I came to Bellevue.
I had already seen plenty of insanity, insinuating myself among the sickest psychiatric patients whenever possible during my eight years of training. I’d interviewed a guy at Temple who was hearing the Devil’s voice while smelling burning flesh and seeing the flames of hell; I’d talked to a man at Mount Sinai with tinfoil under his hat to deflect the messages sent by the aliens; at the VA, I’d convinced a Vietnam veteran wearing a dead rat around his neck that we had better ways to protect him from his enemies.
These patients and their symptoms all pale in comparison to the pathology that parades through Bellevue’s doors. The depth and breadth of madness on display at CPEP is like nothing I’ve ever experienced, and because of that, going to work is fascinating, illuminating, and exhilarating, week after week.
It’s not until I start working at Bellevue that I finally appreciate what sets psychiatry apart from the rest of medicine. Medical illness has an endpoint: death. Psychosis is boundless; the degree to which someone can lose their mind is infinite. Most nights at CPEP, I’ll think I’ve just seen the craziest patient ever, and then inevitably, a week later, a new patient will best the last.
Walking into my workplace is a bit like taking a hit of acid. I know all kinds of weird shit is going to go down, and I steel myself to handle it, because I also know that fifteen hours later I’m going to walk out the “other side.” I just have to hold on tight and trust that it’ll end with me still in one piece. One night I arrive at CPEP, and two patients in the observation area are both sweating and grunting. We have not one, but two women who believe they are giving birth. One of them swears it is the baby Jesus who will soon be delivered unto us. Those are the good nights, when the lunacy is funny, and going with the flow is painless. The nurses and psych techs (the staff in the nondetainable area, who have the most patient contact) strive to keep things light as we go about our business. All of us have chosen this line of work because we want to help others, but we learn over time that we have to set some limits. Most of us cauterize our bleeding hearts by using humor as a shield, so there is plenty of laughter erupting behind the scenes.
After just a few weekends at my new job, I see it’s not going to be quite that easy. Treating everything as a joke will only get me so far. The problem is, I have a hair-trigger empathy switch, and because I am emotionally incontinent, my tear ducts leak with little provocation. If I see war, disasters, or orphans on the evening news or in the paper, my gut tightens and a lump forms in my throat. I can’t abide the unfairness of it all. If I’m going to make it at CPEP, I have to find a way to tolerate hearing about the experiences of the mentally ill, the addicted, the unwanted. Maybe most people’s lives are equal parts hope and despair, but at Bellevue, grief trumps optimism every time. There are sad stories everywhere. Pretty much every shift, if I let it get to me, there’s at least one patient’s story that will tear me up inside.
So I start to toughen up. I can’t allow myself to get bogged down in the darkness, so I choose to have a little bit of a negative charge around me to keep it at bay. I adjust my filter a bit, tweaking the EQ so the sympathy frequency is turned way down. I pretend I don’t care, and after a while, I start to believe it. I pretend nothing fazes me, and pretty soon, it seems like nothing does.
To prevent the misery from overwhelming me, I strip away the pitiful details and focus on the bottom line. Where does this patient need to go? Is he a keeper? Will he survive if I send him back out to the city streets? Or will someone else be in danger if I release him?
To the outside observer, I appear hardened, uncaring. Maybe other people would play it a different way, but this is my game plan. I am all business, except that I go for the cheap laugh whenever I can, whether with the ambulance drivers and cops or the Bellevue police, nurses, and psych techs. But on the inside, if you could hear my interior monologue, it is pure Kurtz … “The horror.” I am aghast at the indignities these patients endure, and there are occasionally times I am afraid for my own safety.
I can laugh all I want, just like a teenager on acid, but I’m kidding myself if I think I’m going to walk out of here unchanged.
By the time I leave, nine years later, my suit of armor will have become dented and worn through with rust. A working mother of two with a heart of mush, I will be unable to harden myself any longer to the atrocities to which I bear witness.
I’d love to tell you that it was a gradual, step-by-step progression, from hard-ass to maternal, that it was a smooth narrative arc. I know that’s how a good screenplay would read; but in truth, my growth came in fits and starts, and I had to learn the same lessons repeatedly before they’d sink in. One step forward, a couple back, a couple more forward: Eventually I inched my way along the path, growing and changing, but the process wasn’t pretty.
To Protect and Serve
I usually start off my Saturday night shifts by cleaning up the trash, throwing away all the used coffee cups, pen caps, and progress note
s. Once the area seems a bit neater, I get to work on “clearing the rack.” Tonight, there is a backlog of patients who have been seen and put on Hold. This means the doctor on the shift before mine couldn’t make up his mind about what to do with them, or else the patients were too drunk or high to be released. Most Holds get discharged once they’re sober (they’ve “cleared” in medical terms), but other times we admit them to a detox bed, or, if they look psychiatrically sick enough, to the dual diagnosis ward upstairs for the MICA patients—mentally ill, chemical-abusing—an acronym that efficiently describes most of our patients.
I grab the first chart from the Hold bin: a guy who was wandering the hospital’s hallways last night, high on cocaine. When HP tried to escort him out, he made only enough sense to convey that he felt suicidal. Now, nearly twenty-four hours later, he says he feels better; he’s come down off his high and is eager to put his Bellevue detour behind him. That makes two of us, but he won’t let me call anyone to confirm that he isn’t a suicide risk or an axe-murderer.
“Mr. DiCarlo, I can’t let you go until I can speak with someone who can vouch for you. I need a phone number of a friend, a cousin … anyone.”
He sits and stews for a while, not willing to give up a number. After a couple of hours of waiting, he realizes I’m not kidding. The number is his only ticket out.
“Okay. You can call my mother, but she doesn’t speak much English.”
I approximate Italian using my meager Spanish, and she manages to communicate two things to me:
1) Don’t send him here.
2) He beats his girlfriend.
She gives me the girlfriend’s phone number slowly in her native tongue.
I know I have to call the girlfriend. Somehow, I sense I can’t release him unless she gives the go-ahead. He’s in a hurry to get discharged and is pressuring me to let him go, and if there’s one thing I’ve learned in my few months at CPEP it’s this: If they want to stay, they need to leave; if they want to leave, they need to stay. It seems to hold true ninety-five percent of the time. If someone walks in saying, “I am hearing voices telling me to kill myself and others,” or “I am a danger to myself and others,” then I know he is relaying verbatim what he’s learned on the street, in the shelters, or in jail. He believes this will get him “three hots and a cot” in the hospital for a few days. If a patient is trying his hardest to be released, but won’t give up any phone numbers that can make it happen, then I have to assume something is amiss.
“Mr. DiCarlo, I need to talk to your girlfriend.”
“I want out of here,” he grimaces. “I’m done with your phone calls.”
“You cannot leave here until I talk to your girlfriend.”
“That isn’t going to happen.”
He doesn’t know I have her phone number already. “Fine,” I reply. “You can rot here all weekend for all I care.” I’m being a bully, and for some reason, he is eating it up. He doesn’t bolt for the door, he doesn’t escalate to the point of being restrained. He wants the conflict to be drawn out.
Eventually I get in touch with his girlfriend and ask her if she will feel safe if he is discharged.
“Don’t let him out!” she begs me.
She tells me she has an order of protection against him which he’s violated continually for the past two weeks, and the police are looking for him. Two weeks ago, he busted down her door, pulled the phone out of the wall while she was trying to call the cops, beat her up, and choked her until she was blue, all the while telling her that he was going to kill her because he loved her. She explains how all of this happened because she went out with some other guy and told my patient they were through. Her father had to pull him off of her and hold him down until the police came and arrested him. He was eventually released from custody, and by then she had gotten the order of protection. She thinks this will protect her, but here’s another thing I’ve learned at Bellevue: An order of protection does not actually protect you. It’s a court order, not a magical shield around your apartment. (I always abbreviate it as OOPs! when I take notes during a sign-out.)
She goes on to explain that he’s been harassing her by phone and threatening her life every time he contacts her, so … no, she does not feel safe if he is discharged. As a matter of fact, he’s been calling her from our ER, telling her that he’s on his way over there to finish the job as soon as he’s released.
I document his exact words in the chart: “You’re dead. You are dead when I get there, do you hear me? I am coming over there to kill you. I don’t care: I’ll do the twenty-five to life.”
Honestly, I marvel at this guy’s balls. He’s in a hospital ER, talking on the patient phone in a public area, steps away from the hospital policeman sitting at his desk, and he’s threatening his ex-girlfriend’s life. The HP on tonight, Rocky, is collapsed in the corner as usual, reading his body-building magazine, oblivious. I call the local police precinct and explain the situation, and they ask me to detain the patient until they can arrive. It is a felony to violate an order of protection.
I call the girlfriend back and let her know that the patient will be locked up, first at Bellevue in our ER, and then downtown at central booking, so she is safe for now. She is crying and thanking me and telling me I have saved her life, which is very sweet. And possibly true.
I sit at the desk in the nurses’ station for a moment, feeling relieved that this story will have a happy ending, sort of. (There’s no white knight and swooning princess, but at least no one gets killed.) I came pretty close to discharging this guy without calling anyone. He was initially held because he told someone he was suicidal. Once the drugs left his system, he denied suicidal ideation, and typically that would be enough to get the ball rolling on a discharge.
The thing is … it isn’t just the issue of danger to self, it is also the possibility of danger to others that allows me—and compels me, even as I’m trying to “clean up the area”—to retain a patient against his will. I need to cover all the bases. He denies suicidality, fine, but what else? If I had let this guy go, I have no doubt he would have gone back over to her apartment and killed his girlfriend, or attempted to. And it would have been because I thought he was fine to leave, and was in too much of a hurry to bother with due diligence.
I go into the holding area to tell the patient that the police are coming to get him.
“How can you believe her over me?” he whines. “I just love her so much.”
To which I reply, “You’ve got a funny way of showing your love, pal.” I spin around, thus ending our conversation with a bit of dramatic flair. I am a couple of steps away from the nurses’ station when I hear a WHUMP!
I turn to see Chuck, the large male nurse who is a dead ringer for Kenny Rogers. He is kneeling on the floor with his elbow poised over Mr. DiCarlo’s Adam’s apple.
“I told you I had a bad feeling about this guy,” Chuck grunts. Seeing the patient following me into the doorway of the nurses’ station and assuming he was about to attack me, Chuck put his arm around the guy’s torso and flipped him onto the ground quick as a flash.
“Chuck, you are my hero, ya big tattooed thug!” I squeal. He is the closest thing I have to a big brother in the ER; his protective stance helps to reinforce the feelings of family that pervade my shifts at the hospital. Chuck has my back, literally. Rocky, on the other hand, is nowhere to be seen.
A few weeks later, I call the girlfriend to make sure she is okay, still safe, maybe getting some counseling, and … you guessed it. She’s back with our bad boy.
I hang up the phone feeling exactly the way I used to when I worked at Filene’s Basement. I’d spend an hour meticulously folding a bin full of tangled button-down shirts, only to come back later in my shift to find the bin as sloppy as it was when I started, all because someone was searching for a seventeen-inch neck. It was like I’d never been there, organizing the mess. Like I hadn’t done my job.
I remember learning about entropy in college physics clas
s: The natural order of things is disorder. Chaos reigns supreme throughout the universe, especially at Bellevue. I can’t beat it, so I may as well join it.
Most important, I learn not to call patients for follow-up. I’d rather pretend the shirts remain neatly folded and organized.
I’m Looking Through You
Psychiatrists don’t typically use stethoscopes and tongue depressors, conducting a physical exam the way other doctors do. We don’t need to lay a hand on our patients to make a diagnosis. We perform a mental status exam, a noninvasive way of seeing how the patient’s mind is functioning.
Some of the mental status exam can be done from across the room, for instance evaluating appearance and behavior. Being an ER shrink means that I am allowed to judge a book by its cover. I can unabashedly make conclusions about someone’s mood based on their fashion sense, for instance. In a manic state, with excessive energy and inflated self-esteem, a patient may be wearing bright, clashing colors, garish makeup, or an elaborate Carmen Miranda headdress. (I have a saying at CPEP: “Headdress equals mania until proven otherwise.”) Manic patients tend to over-groom, sometimes shaving their bodies or plucking out all their eyebrows, other times overdoing lipstick and liner, straying far beyond the lip’s natural contour.
Conversely, depressed patients may under-groom. Their clothes are disheveled and dirty, their hair may be greasy or in need of a new dye-job. Fingernails are the windows into the soul, if you ask me. I always make a point of checking nails and cuticles, looking for outward manifestations of internal anxiety states. These are signs of what could be considered “neurotic self-mutilation.” Many patients called “cutters” have arrays of symmetrical cuts on their arms, for example. Psychotic self-mutilation is more extreme and dangerous: I remember a woman at Temple who’d tried to give herself a homemade Cesarean when she heard her unborn baby crying to be let out. As I chat with a patient, I try to look surreptitiously for scars on wrists, alerting me to past suicide attempts, or track-marks on arms, betraying a history of intravenous drug abuse. Although New York City is full of people who have pierced and tattooed themselves beyond recognition, I still take note. Tattoos on the face and neck in particular get my attention, warning me I may be dealing with an antisocial personality.
Weekends at Bellevue Page 6
