Weekends at Bellevue

by Julie Holland

  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.

  At the top of the page of the CAF, the Comprehensive Assessment Form which gets filled out on every patient, I must document my own evaluation of the patient’s reliability. Some people are genuine, accurately reporting symptoms and psychiatric histories. Others are ingratiating, evasive, seductive, or hostile. This can tell me a tremendous amount about personality structure, and also what the level of motivation is for seeking treatment or avoiding it. Many have ulterior motives: the patient who wants to be certified as disabled, the abandoned girlfriend who wants her boyfriend to feel guilty, the prisoner who is looking for a hospital bed instead of a jail cell. Mostly, when there’s only one informant, I need to rely on my gut to tell me who’s lying. Sometimes friends, family members, employers, therapists, or probation officers (called collateral contacts) can give me a fuller picture, helping to confirm or refute what the patient is reporting. Occasionally I’ll find myself in the midst of a “he said/she said” situation, but usually it’s easy enough to tease apart the reality from the added layers of lies and drama.

  Funny thing, being a psychiatrist, you’d think I’d be used to drama, to the gnashing and wailing of people in distress, but I’m not. Actually, I can’t stand it. Genuine emotion is one thing. I know it when I see it and I can ease my way around it, working to get to the information I need to make a diagnosis and make a difference. It’s the blatantly manufactured melodrama that nauseates me. But I let that work in my favor. If I’m not feeling sympathetic, chances are it’s my sixth sense telling me I shouldn’t be.

  A taxi driver once asked me what I did for a living. “I’m a psychiatrist,” I answered warily.

  “Oho! So … you know what I’m thinking right now?” he asked. He wasn’t joking. He honestly thought that I was a mind reader. People sometimes clam up when they find out I’m a shrink, afraid I’ll be able to peer into their souls and know their darkest secrets. I wish it were that easy. Once people start to open up, I begin to see where their issues are, but if they don’t talk, I can’t possibly know what’s going on in their minds. Psychiatry isn’t neurosurgery. We have no trick for getting inside someone’s head. You speak, we analyze. You don’t talk, we got nuthin’.

  Scrutinizing a patient’s speech and its structure is crucial to establishing the diagnosis. Answers can be concise and goal-directed, or the words can wander off in various directions. In mania, the speech is pressured, tongue-twistingly fast and difficult to interrupt. The patient will suddenly shift gears, moving from one topic to the next. If I pay close attention to this “flight of ideas,” I can usually see a thread linking the topics, and it is often poetic in its beauty. Schizophrenics can have disorganized speech, a reflection of disordered thoughts. Either the patient will go off on a tangent and never return, or the speech is so muddled it stops making sense and is referred to as “word salad.”

  There is a form of psychosis called catatonia that is so severe, the brain seems to shut down the speech centers entirely. It’s not just the mouth that is paralyzed; the rest of the muscles of the body behave strangely as well. If I move a patient’s limb, it will stay in its new spot, no matter how gravity-defying. This is called waxy flexibility. The first time I met a catatonic schizophrenic, I walked into the interview room, introduced myself, and extended my hand. He stared straight ahead, his frozen face expressionless. Lights on, nobody home. I initially thought the patient rude for not returning my greeting and shaking my hand! It wasn’t until I checked for waxy flexibility that I realized what was going on.

  In CPEP, I learned to allow patients to remain in a catatonic state for a while. As long as their blood pressure, and heart and respiratory rates, remain stable, it is better not to rush them into the next phase. But if necessary, it is usually not difficult to “break a catatonia.” An injection of any member of the benzodiazepine family of medicines (like Valium or Ativan) will loosen up the muscles, the brain, and the mouth. The problem is, underneath that quiet exterior lurks a severe psychosis. Most catatonics break loud, so when the CPEP is noisy enough, the nurses and I typically agree that there’s no reason to go upsetting the applecart. We won’t rush to medicate someone who is mute because, more often than not, we still won’t have any useful information once they start talking.

  There are other times, however, when there is nothing more irritating, nor more challenging for me to handle, than a patient’s silence. Catatonia is an involuntary mutism; the patient is physiologically unable to speak. A patient who remains mute voluntarily is another story. It is a simple thing to do, requiring a modest amount of persistence and will, but it is a cunning ploy and its effects are potent: The case cannot be closed if the patient will not participate in the interview. It’s a great stalling tactic, frustrating as hell for the attending psychiatrist who is trying to keep things moving in a busy ER. When confronted with a prisoner who won’t talk, I m
arvel at how easily I am thwarted and placed in a powerless position. It is genius in its simplicity. I will surely do the same if I am ever arrested, I think to myself. But I doubt I could pull it off. I am a huge talker. This is likely the reason why I find myself almost in awe of the mute patient. I’d have to be in a coma to keep quiet.

  After gathering information on appearance, behavior, and speech, I need to delve deeper, appraising a patient’s thoughts and perceptions. Sometimes it’s obvious the patient is hearing voices. From my years as a medical student doing research on auditory hallucinations, I know how to recognize when I am speaking with people who are actively hallucinating. There are a few tip-offs to look for: They will dart their eyes or head toward the perceived source of the voices, and their speech will be fragmented. This is because if someone is speaking to you while you’re speaking, it is impossible to be fluid in your speech. The brain cannot both listen to incoming words and create coherent conversation. (Have a friend whisper in your ear while you try to talk and you’ll see.)

  A crucial piece of information to extract during the mental status exam is whether the patient is suicidal. There is a continuum of suicidality: a spectrum that spans from having passive thoughts (“It’d just be easier if I didn’t exist”), to suicidal fantasies (“I wish I were dead”), to intention (“I’m going to kill myself”). In the same way that it is customary to sneeze if you have a cold, it is common to have suicidal fantasies if you are depressed. Suicidal thoughts, especially if they feel foreign and upsetting to the patient, are less worrisome than specific plans, actions, or intent. If a patient has developed a blueprint for ending his life, if he has started to act on this plan and has the intention of carrying it out, it is obviously much more dangerous than someone who is simply musing about how all his troubles would go away if he were to go to sleep and never wake up.

  Statistically, people who have a history of suicide attempts are more likely to try again. I don’t beat around the bush when asking questions about suicidal thoughts and histories. A lot of people are relieved to finally share them with someone. In the CPEP, we err on the side of caution and keep a patient for observation or a short admission if there is any threat of suicide or self-harm.

  The last part of the mental status exam is about insight and judgment. Does the patient think anything is wrong with him or that everything is fine? Does he accept recommendations for treatment, or is he chronically noncompliant? Schizophrenia is often characterized by poor insight into the presence of the illness, and patients in a manic state frequently make foolhardy decisions. In either case, this can accentuate the dangerousness of their situation. Impaired insight typically worsens a prognosis, and having poor judgment in New York City puts you at risk in a million different ways.

  Psychiatrists assess judgment by asking standard questions, such as, “If you found a stamped, addressed letter, what would you do with it?” I prefer to get a gestalt from the patient’s retelling of recent events. Someone who explains that he cut off his right hand because the Bible says to do so “if it offends thee,” I can easily deem to have poor judgment. Ditto the man asking to be injected with Perrier to quiet his voices.

  But then there are the cases that could go either way. My passing judgment on the quality of someone else’s can be influenced by all sorts of information. One of my earliest patients at Bellevue was a man who asked me, “Do you think I’m nuts, or just bananas, because my brother is a total meatball!”

  I told him, with a wink, “I doubt your diagnosis is nuts; I think it’s overused, actually. However, I can’t rule out bananas, or even partial meatball, but I haven’t yet seen a case of total meatball. I’d like to meet your brother sometime.”

  The patient smiled at my response, which I took to be a good sign, but later he asked me to marry him. I didn’t hold that against him, but I did admit him.

  I Don’t Want to Spoil the Party

  It’s my first Christmas at Bellevue, December 1996, and I volunteer to cover the CPEP. Ever since medical school, being a nice Jewish doctor, I’ve gone out of my way to volunteer to work Christmas Day, or Christmas Eve, or both. I have no family obligations, plus it’s always fun to work holidays in the hospital, because people are in a good mood, there’s lots of home-cooked food around, and sometimes a little spiked eggnog or tasty coquito when no one’s looking. Working the holiday also gives me a chance to reminisce about my fourth year of medical school, the time I volunteered to work on Christmas because I knew I’d be paired up with the dreamy surgeon, and we ended up having sex in the call-room most of the day, because there were no surgeries booked.

  On my regular weekends, I have to go upstairs to the inpatient wards and write notes on the new patients before I start my work in the ER. Responsibility for these notes is divided between me and one of the moonlighters—the doctors-for-hire who work in the CPEP and upstairs during the weekends and holidays. But on weekday holidays, the attending isn’t supposed to leave the CPEP to go upstairs to write notes; the moonlighter must write all of them himself. Since I’m in charge of the CPEP today, it’s my job to assign the up-wards note-writing to another doctor. I pick Martin, the up-wards moonlighter for the day.

  I’m not looking forward to telling him the news. He hates taking orders from me, and we’ve clashed before on cases where I had to pull rank. He may be older than I am, and he may come from a culture where women are not usually in charge, but right now I am his boss and I have to give this task to one of my underlings.

  “Hey, Martin … I’m sorry to tell you, but you’ve got some extra notes to do this afternoon.” I take a deep breath to explain. “It’s a holiday. I know that the attending does the up-wards notes on the weekends, but it’s a weekday today, and it needs to be assigned to another doctor.”

  “But you’re the weekend attending and you’re here,” he argues.

  “On the weekends, I come in early to do the notes. It’s Monday morning and I have to stay in the ER all day. I can’t leave to go upstairs for that long. I need to assign a moonlighter to do it,” I explain.

  “I’m not going to do your work,” he informs me.

  “Martin, just write the notes. It’s not that big a deal.”

  “It’s not right,” he complains. “I’m going to call Dr. Lear.”

  I am incredulous as he dials the phone. How he knows our boss’s home number is beyond me, and I am flabbergasted that he thinks this is important enough to warrant disturbing him on Christmas Day.

  I can hear Dr. Lear’s voice through the receiver as he talks to Martin.

  Dr. Lear is succinct and unambiguous: Dr. Holland is in charge. My colleague has no choice but to do what he is told. Only he doesn’t.

  When Dr. Lear comes back from Christmas vacation and learns that Martin’s work was not done, he fires him from the moonlighting pool. I think nothing more about it. I’ve got bigger fish to fry.

  The hospital police officer who is frequently assigned to the CPEP on the weekend nights always seems to be sleeping. If Rocky isn’t leafing through his inevitable bodybuilding magazines or chatting me up, he’s got his head craned back, his chin pointed to the ceiling and his mouth agape. Sometimes I stand in front of him while he snores to see how soundly he’s asleep. Other times, I will startle him awake and give him a withering look. This guy is supposed to be protecting me so I can sleep! Dr. Lear has made it clear that the attendings can sleep overnight if the residents have things under control. But I don’t feel very safe with my call-room down the hall from the detainable area if there’s no one guarding the hallway.

  I decide to write a letter to the head of the hospital police, complaining about Rocky.

  A few weeks later, Chuck is attacked by a female patient who is trying to escape. She charges out the door, makes it to the clerk’s desk and grabs a heavy black metal three-hole-punch. When Chuck chases her and attempts to get her to return to CPEP, she whacks him in the face with the three-hole-punch. Rocky wrestles her down and brings her back to
her chair, dragging her in with another HP. Chuck ends up in the medical ER getting sutures across the bridge of his nose.

  Several weeks after the attack, I am summoned to a meeting involving Rocky. I assume it is about the letter I wrote. I walk cautiously into a room reserved for the hospital police, on the other side of the hospital. Rocky is sitting behind a desk, his wide chest wrapped in a suit and tie, flanked by a union representative. I am nervous that I’m getting him fired. I just wanted his boss to tell him not to sleep on the job. A simple reprimand. Why is this office set up like a courtroom? I am asked to approach the table and state my name. There is someone acting like a judge, a mediator I assume. I feel like I’ve been shanghaied.

  “Doctor Holland, can you tell us what happened on the night when Chuck, the nurse on duty, was attacked?” asks the mediator.

  “W-well,” I stammer, licking my lips. This is about Chuck? “I was sleeping at the time of the incident, so I could only tell you what I’ve heard.”

  “Can you tell me if you witnessed this hospital police officer assaulting a patient?” the mediator asks as he points at Rocky. “What?” I yelp. “Assaulting who?”

  “The patient who allegedly assaulted the nurse on duty, did you see any altercation between her and any hospital police officer?”

  “No. I didn’t see anything. I was sleeping.” Rocky smiles at me, thanking me with his eyes. What the hell is going on? What did he do? “Excuse me, but can you tell me what this is about? Is Rocky being accused of something?”