This particular patient has a wealthy family in the art world, and when he’s psychiatrically stable, he is the manager of an art gallery. Because of his long history with psychotic illness, he often can’t work. Once I get on the phone with the family, I get a better understanding of what “water damage” really means: He’s been hoarding his urine and feces in plastic garbage bags throughout his condominium, and it has started to damage some of the fine art he is collecting and storing there. I don’t know why people collect and catalogue their excretions, but it happens. A lot. Maybe the toilet becomes terrifying when you’re psychotic, or maybe the collection business is an indicator of extreme obsessiveness, an irrational unwillingness to let go of anything.
Luckily, the family has intervened in time, and while the “water” did damage some costly pieces, many other works have been salvaged. He is admitted voluntarily so that we can get him back on his medications. My assumption is that he will be transferred to a different, cushier hospital once he calms down a bit.
The other interesting patient of the night, in keeping with the “money can’t buy happiness” theme, is a young woman with what looks to be a $30,000 ring on her hand. The dark mother-of-pearl stone, nearly an inch in diameter, is surrounded by diamonds. She has been heartbroken, she tells the triage nurse, since her mother died aboard one of the planes on 9/11. We are still seeing fallout from the attack, although the three-year mark is next week. Anniversary reactions are very common in trauma. I have been encouraging my patients to try to leave the television off as 9/11 approaches. The people who have been doing better will often have a resurgence of mourning and its attendant melancholia as the media reminds us all of what happened.
Some of the people who took 9/11 the hardest have only gotten worse over time. The reminders of that day are still too prevalent, and terrorism is a potent weapon against mental health. There has been a constant hum of anxiety in the city since the collapse of the twin towers. Our government won’t let us forget we’re in danger; New Yorkers are still on guard against the fear of loss which never fully abated after the attacks. Everyone has been taking psych meds or martinis to cope.
Many people fell off the wagon after 9/11, especially the cops and the firefighters. EMS was not bringing survivors from the towers, they were bringing us drunks. I remember Daniel complaining about it in rounds one morning that September, but I spoke up, since I’m supposed to be the substance abuse expert at CPEP. “These people need our assistance just like any other victims of the attack.”
The gal with the ring has been admitted to our EOU. She’s been depressed and drinking for years since her mom died, and now she’s talking about suicide. She was on the phone with her friend in Florida when she let on that she had cut her wrist. The friend called 911 in New York City and now my new patient—perfectly coiffed, nicely dressed, with an air of supreme entitlement, yet carrying a teddy bear—has every family member and friend calling us on her behalf to get her out of Bellevue. The family arranges for her to go to a private uptown hospital, but her insurance office is closed over the weekend. I call Columbia psych ER, and they are willing to accept the transfer, unbelievably, without insurance verification because of some guarantee made by the family.
Now all I have to do is secure the ambulance transfer from Bellevue to Columbia without an insurance authorization, which means a family member has to give a credit card number. I am on the phone with a friend of hers in New York City, who refers to Bellevue as a “snake pit,” then says, “Nothing personal, I mean you working there and all, but we gotta get her outta there.” The brother in California is on the phone bitching about paying for the ambulance, feeling it’s the hospital’s responsibility, but Bellevue doesn’t typically pay for transfers, unless it’s to another city hospital because we’re full. Usually the patient’s insurance company pays for a transfer. The only other option is that she spend the weekend in CPEP, which nobody wants, except maybe the cheap brother.
The staff wants this gal to go—she is issuing one demand after another—and I want one less patient in the area if Columbia is willing to accept the transfer. Finally, the brother and the ambulance company are connected so he can give them his credit card information, but all he has is American Express, which this ambulance company doesn’t take. I have to call around to find an ambulance company that does, and the staff are cracking jokes left and right.
Rita says, giggling, “When your suicidal sister is stuck at Bellevue, don’t forget your VISA card, ‘cause the transfer won’t go through with American Express.”
I reply, “Having a MasterCard to get your girl outa that snake pit … priceless.”
It feels so good to be back, I can hardly stand it. I love Chuck and Nancy, and Rita and Vera, and all the other staff at CPEP, and I am home again.
But for how long? And how soon until the burnout creeps back in?
Beautiful Boy
I’m wiped out from the kids at home and was hoping to turn in early tonight, but it is not to be. I’m staying up to wait for a pre-arraignment evaluation that’s being transferred to us. A Bronx hospital called earlier about a psychotic prisoner they thought we should admit to our forensic unit. He’s hearing the voice of a man who he says protects him, a man he calls “Chance.”
I start with my usual—ignore the perp and ask the cop, “What’s the charge?”
“Endangering the welfare of a child,” he answers. “It’ll be Murder One as soon as they take the kid off life support. He beat up his baby. Pretty bad. I doubt the kid’s gonna make it.”
“How old’s the kid?” I ask.
“Ten months,” the cop says.
I try to play it cool, like it doesn’t faze me.
“I don’t know which are worse, the baby-killers or the mother-rapers.” I want him to think I’ve seen it all. And maybe by now I have? When I was a medical student I did see one patient who had raped his mother—totally psychotic, of course—the only thing I can think of as horrific as killing a baby. I have now seen two of each in the seventeen years since I entered medical school, but I toss it off to the cop like this is standard stuff, no big deal.
And then I stop to think: He probably doesn’t see this all the time either. We’re both acting nonchalant, business as usual, and we should know better; it’s a very big deal.
Nancy and I decide to see the patient together. Usually the nurse triages the patient first, and then the doctor does the second evaluation, but it’s a very busy night and we’re both wiped out; we streamline the process to keep things moving.
We sit side by side in the triage room to do the interview, our paperwork in front of us. The patient/prisoner is a surprisingly good-looking guy, with medium-length dreadlocks and light brown skin. He sustains good eye contact and his voice is soft. Nancy asks him why he’s been arrested, and he starts off telling us some obscure detail about his son’s current medical status.
“My boy’s intestines are perforated, or something like that.”
“Well … how’d that happen?” I ask.
“I beat my baby up,” he says, looking stunned. “He wouldn’t stop crying and so I punched him over and over.” His eyes plead with me, and I can see that he is completely unhinged, but he’s working to bury it. Nancy wants to know where the mother was during this time, and he tells her she was in the next room watching TV. “She never helps with the baby. I have to do everything: the Pampers, the bottles. And she won’t tell me how to calm him down. She knows the secret way and she won’t tell me.”
All of this is hitting way too close to home for me, and Nancy knows it. She looks over at me, gauging my response, and I cock my head, shrug my shoulders. I don’t know what I’m trying to communicate to her. I’m okay with proceeding, I guess. I have a nine-and-a-half-month-old baby boy at home and this guy’s son is ten months old. Diapers, bottles, crying, calming … we have everything in common, and I can feel myself getting sucked in. And the mom having a secret magic trick to calm the baby holds true i
n our household because I am nursing.
“Is she nursing? The baby’s mother?” I ask.
“No,” he answers simply, then adds, “She’s my wife. I only married her because she was pregnant.”
He is answering questions clearly, succinctly, but later in the interview, he explains that he’s been hearing voices most of his life. “The cocaine sometimes calms them down,” he tells us. He is smoking a lot of crack, and blunts with pot and crack in them. So is his wife. The prisoner tells me how his own mother used to punish him by locking him in a closet when he was a kid, and how this imaginary friend, “Chance,” used to appear and take care of him, talk to him. Chance has been talking to him ever since.
I can’t figure out if he’s a schizophrenic or not. Maybe his mother’s sadism caused him to fall apart. A severely stressful childhood can put anyone over the edge; their personality structure shatters, and they may develop alternate personalities. Not everyone who hears voices has the full-blown syndrome of schizophrenia. The chronic cocaine use could bring on hallucinations as well, especially in someone with psychotic tendencies.
He tells me he’s been diagnosed as schizophrenic in the past. My gut tells me he’s too well-related (he connects easily on an emotional level) and organized, but other psychiatrists have disagreed. He’s been tried on several different antipsychotics, but he never makes it to his follow-up appointments and eventually stops taking his meds.
He says he’s hallucinating now, and the transfer paperwork from the other hospital is making a good case for that as well, though he doesn’t appear to be responding to internal stimuli. Psychosis aside, I need to determine if he’ll be safe when he’s alone in a cell. He doesn’t volunteer anything suicidal-sounding until the last second, when we are done talking, as the cop pulls his wheelchair out of the interview room.
“It shoulda been me,” he says softly.
I know what he’s getting at.
I also know that Nancy wants him out. We’re full to the brim with patients and prisoners, and she doesn’t think he’s going to do it. I usually try to appease Nancy in these situations. She’s the nurse in charge and we usually happily agree on what to do with all the patients. I bite my tongue and start the paperwork to release him back to the police, dancing around any words that might allude to dangerousness necessitating a psychiatric admission.
I try to talk the cop into taking him back to be arraigned. It’s a hard sell, maybe the hardest one I’ve ever had to make for a prisoner T & R. I’m doing my best, but the cop is nervous. I am having very real fantasies of this guy hanging himself with his shirt in a holding cell somewhere, left alone for five minutes too long. I think this officer is having the same fears. The cop sees what I see: Some part of this guy knows how massively he just screwed up. “It shoulda been me.” If he really believes it, I know he’ll have the desire, and quite possibly the means, to carry it out while waiting in a cell.
Obviously the patient has poor impulse control. He beat up his baby. What makes me think he’s not going to turn his rage on himself next? I don’t tell Nancy I’m having second thoughts. I want the night to go smoothly, and it always goes better if I don’t go up against her. The problem is, now I’m going up against my intuition, and I know I shouldn’t do that, either.
Luckily, the cop gives me an out. I can blame it on him. “I really don’t feel comfortable taking this guy back to booking, Doc. I got a funny feeling about this one.”
I walk into the nurses’ station looking defeated. “NYPD won’t take this guy, Nancy. We gotta eat it.”
A few minutes later, the cop asks me to interview him again. “Uh, listen, Doc. I think you better talk with this guy some more. He just told me he’s planning on hanging himself in the cell.”
Just what we were afraid of.
I wheel the prisoner back into the triage room. I was hoping that since he didn’t volunteer any suicidal thoughts during our first superficial, controlled interview, I could document it as such and get on with my night. But now we’re going to get into it. And of course, like rubbing my tongue against a canker sore to see if it still hurts, I can’t stop myself. I decide to go for it whole hog, diving in. I might as well learn as much as I can about what makes a man beat his own son to death. One of the perks of the job, I’ll confess to my friends later. “You read the cover of the Post, about these crazy people committing heinous crimes, and you think, What kind of man could possibly do that? I have the pleasure of meeting these men and trying to answer that question.”
But I am growing weary, as time goes by, of these golden opportunities. It doesn’t feel like such a gift anymore, getting to see the underbelly of humanity. I’m starting to think that maybe I want to live in the sanitized, Upper-East-Side version of New York City, knee-deep in denial, seeing the good in people all around me. I’m afraid that the longer I work at Bellevue, the harder it will be to revert to being oblivious. It’s like cooking an egg: it can never go back to soft-boiled once it’s hard-boiled.
All this exposure to the depravity, to man’s inhumanity to man, I’m frightened that I won’t be able to walk away from it, forget it, and get on with my life. I’ll never again be the person standing at the edge of the subway platform waiting for a train, instead of leaning up against the wall so no one can push me onto the rails just as the train pulls into the station. I’ll never walk by the Empire State Building without thinking about the shooter who took out so many people. I’ll never run around the lake in Central Park without thinking of the “Baby-Faced Butcher,” the young altar boy so incapacitated by the combination of his psych meds and malt liquor that he gutted a man and dumped him in the pond.
I’m also never going to be able to stop worrying that one of my children will end up with a debilitating psychiatric disorder. I’ve shared that pain with too many parents, and I am now terrified that this will eventually become my pain as well.
I have a growing sense that I need to do something before I become irreversibly hard-boiled, in a last-ditch effort to protect my newly expanding rich, warm, liquid center. Like the body walling off an abscess with layers of scar tissue, my callous demeanor protects and defends my tender interior. But I don’t want to lose touch completely with my softer parts, which help to make me a better doctor and an emotionally attuned mother.
I think I’m going to have to get out of Bellevue. Soon.
It should’ve been me.” This is known in psychiatry as the doorknob statement. Named for the timing of its delivery, it is the baited hook dangled at the end of the therapeutic hour, just as the patient is leaving the office with his hand on the door. Seasoned shrinks know that those things mentioned as the patient is leaving the room are often the most important things they will ever say, the things they don’t really want to give up. On the other hand, doorknob statements can be a well-timed manipulative ploy. The patient knows his time is up but wants more, wants to create drama, to test you to see if you’ll continue to be his audience or shoo him out the door for the next patient. But somehow, I’m thinking this isn’t one of those times. He isn’t one of those people. He’s breaking down and needs somewhere to land.
This man, this baby-killer, is still somehow a sympathetic character to me. On some level, I am drawn to him. Perhaps it is as simple as a physical attraction—his charisma, his pheromones—but mostly I think what’s going on is he’s playing into my rescue fantasies. I want to help him, to catch him as he’s falling. If nothing else, we are both parents; at least I can connect with him on that level. From his perspective, he has no reason to align with me, a psychiatrist. He’s been psychotic since childhood with inadequate psychiatric care. No one’s rescued him yet, why trust me now?
Maybe he knows that I decide whether he goes to prison or upstairs. Maybe he knows that it’s cushier in the forensic unit, and if he can convince the doctor he’s in danger, he’ll be admitted instead of sent to arraignment. Maybe, but I doubt it. Not this time. This guy’s for real.
He tells me his w
ife is using just as much cocaine as he is, and he complains, the way my girlfriends complain about their husbands, that she is not pulling her weight in the child-care department. He has to do everything when he gets home—change the baby, wash the bottles. He keeps mentioning how he had just gotten home from doing his taxes. I wish he would stop saying that. Normal people have meetings with accountants and figure out how much they owe the government. Why is this baby-killer saying that? And why is he speaking my language of housewifery, child care, and martyrdom? When he again mentions the secret mommy way of calming the baby, he makes me feel guilty, like I am his wife, and I should’ve shown him how to calm down our son. It’s my fault for pulling that power play.
“I’m the one who has to get up in the morning with him and give him a bottle and put him down in front of the TV.” Great. Now I’ve got a visual. Why does he have to give me an image of a little boy in a diaper plopped in front of Barney or Teletubbies? An innocent little boy who is as good as dead, beaten to death by his father, who was once an innocent little boy abused by his mother, who was once …
“He just wouldn’t stop whining. I hit him and yelled at him to stop crying, and he still wouldn’t stop crying.”
I know about the exquisite frustration at the whining, or when you can’t make the crying stop. When Jojo had colic, and the crying was ceaseless, I marveled at how any parent could cope with it, why more children weren’t hurt by their caretakers. Sometimes parenting seems like the most difficult job there is. Because I’ve come to see firsthand how abusing a child causes a lifetime of psychic pain and psychiatric illness, I’m able to sympathize with this patient. He has failed his obligations as a parent, obviously, in the most extreme way imaginable, but what he has done is not beyond my imagining.
Weekends at Bellevue Page 30
