Weekends at Bellevue (8 page)

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.

I
usually start off my Saturday night shifts by cleaning up the trash, throwing away all the used coffee cups, pen caps, and progress notes. 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 class: 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.

P
sychiatrists 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.

Another thing I need to gauge is a patient’s psychomotor activity. If he is pacing, fidgeting, or wringing his hands, it will be documented in the chart that he is psychomotor agitated. Conversely, when someone reaches a significant level of depression, his movements can become labored and sluggish, called psychomotor retardation. If a patient is paranoid, he may appear hyper-vigilant, repeatedly looking over his shoulders, or he may place his back to the wall, unwilling to have anyone stand behind him.

I pride myself on intuiting what drugs a patient took just by looking at him. Someone who is strung out on speed (methamphetamine) is typically wiry, jumpy, pale, and thin. Sweaty black concert T-shirts, acne, and tribal tattoos are the norm. Crack intoxication is all about twitching, jawing, and grimacing. These movements are called dyskinesias and are the result of too much dopamine flooding the brain. Someone who is high on opiates (heroin, methadone, or prescription painkillers like Oxycontin) has an ultrarelaxed face with slack cheek muscles, the eyes at half-mast. It is called “on the nod” because the head, often with a pleasant half-smile, will jerk up after the chin dips down to the chest.

Pupils are important to pay attention to; I’m always reminding the residents who work with me, “The pupils don’t lie.” They will dilate under the influence of many drugs that act as stimulants, like cocaine, speed, and hallucinogens. If someone comes into CPEP high on opiates the pupils will be constricted to pinpoints. Because all drugs derived from the poppy can slow down the respiratory rate, I need to count breaths per minute. Any fewer than ten and the patient needs to be quickly shuttled to the medical ER to be treated for an overdose with an opioid antagonist called Narcan.

Once I’ve given a patient the visual once-over, the rest of the mental
status exam involves having a conversation. Initially, I need to assess his level of attention and concentration. I’ll ask, “What’s your name? Do you know where you are? Can you tell me what day it is?” while I’m also ascertaining if he’s intoxicated, sedated, stimulated, or distracted. If a patient is alert, or even hyper-alert, I can proceed with the interview, but many times at Bellevue patients are simply too drunk or high to have a meaningful conversation, and I need to let them sleep it off on a stretcher before I can do a good exam.

Typically, I start with questions that won’t be considered too invasive or personal. Orienting questions like “Where are we now? What’s the name of this place?” establish if the patient is firmly rooted in the here and now, and are an easy way to break the ice. They help set the tone for the rest of the interview as well, reminding the patient that I am a psychiatrist and this won’t be a normal, everyday conversation.

It is crucial for me to make sure the patient is medically stable as early as possible, so I ask questions about current medications, drug allergies, and a history of medical illness. Some acute medical conditions can masquerade as psychiatric ones, and the consequences can be deadly if I miss this. I may also ask, “Are you supposed to be taking any medicines you’ve decided not to take?” Plenty of people come to Bellevue off of their lithium or antipsychotics, and this is a useful piece of data to gather early in the game.