“Patient denies AH, SI, HI,” I write succinctly, using the standard abbreviations for auditory hallucinations, suicidal ideation, and homicidal ideation. Then I write what I always do when I haven’t gotten anything juicy in a three-minute conversation: “No gross evidence of psychosis currently, though brevity of interview precludes full assessment. Continue current level of care.”
Bor-ing.
Why are the notorious bad guys in the news always so dull when I finally get a crack at them? As the years roll by at Bellevue, this will become a recurring pattern. The more hyped-up they are in the press, the saner they seem when I finally get to sit down with them for an interview. Well, maybe not sane, exactly. They’re deeply troubled, but mostly, when I scratch the surface, there isn’t much underneath. They’re almost always undereducated or borderline retarded, and they’re often quite childlike. Talking to a psychotic killer, I will learn after a few years at the hospital, is a lot like talking to a dumb kid, only it’s more pathetic. With a kid at least you have a sense of optimism about his future.
This prisoner, though he is not one to brag, has left a wake of carnage that the city won’t easily forgive or forget. I appreciate that I have a chance to speak to him, however briefly. Bellevue will always be kind in affording me these opportunities. It is one of the reasons I came here, and one of the reasons I stay.
I leave the prison gates and head for the relative freedom of CPEP to start my shift.
Little Earthquakes
Two nurses and a few psych techs are standing around a stretcher in the shower room. A woman has come in by ambulance from a crack house and is in desperate need of bathing. Her hair is sticky and covered with dirt; she is speckled with mud and feces, and from what we can tell, semen. She has scratches all along her back and buttocks, and bruises on the insides of her thighs.
She is either still high on cocaine or a combination of drugs, or she is out of her mind from trauma—I can’t tell which. While she is being scrubbed clean, she arches her back, and opens her mouth wide toward the head of the stretcher, jutting her chin toward the ceiling. She keeps making these openmouthed sucking motions, and groaning rhythmically. Groaning and gulping, absentmindedly, automatically, as if she’s been doing that for hours already.
“Julie,” says Nancy, in her froggy voice, “I think she been raped.” Nancy is my very favorite nurse. Love Nancy. With her ample bosom and her gap-toothed grin, she is my warm, welcoming, and accepting auntie, and I would do just about anything for her.
“Maybe we shouldn’t be washing the evidence off her?” I wonder aloud. “Should we send her to AES for a rape kit?” It is standard procedure: If someone reports a rape they are sent to the medical ER to be examined. A rape kit is a forensic physical, a way of examining a sexual assault victim with a fine-tooth comb, literally. It can be traumatic for the patient, resonating with the assault itself, but it’s the best way to collect DNA evidence to assist in prosecution. The vagina and anus are swabbed for semen samples, and the pubic hair is combed for the rapist’s pubic hairs. Also, pictures are taken of the bruises, abrasions, and any other physical signs of the attack.
“I don’t think she was in any shape to identify anyone,” Nancy surmises. “Plus, I imagine she did it for the drugs. You know how these things go. It’s best we clean her up, let her sleep. She looks like she been through enough. I say let it be.”
I suppose she’s right. I watch my coworkers, my friends, tend to this woman, lovingly washing away the dirt, the grime, and the evidence of the crime. I am touched by the scene, the symbolism of the water, the baptism. I hope it washes her clean, inside and out. I hope she can’t remember a blessed thing, unlike our other rape patient in the CPEP.
That woman, who is in the EOU, was attacked just a few blocks from here under the FDR, the highway next to the hospital. She was hit on the back of the head and tackled by two guys. They took her wallet and sexually assaulted her, but then the cops drove up. The two guys ran in two different directions. One of them ran across the highway and was hit by a car. The ambulance brought him to Bellevue, where he was rushed into the trauma slot. The other guy was caught by the cops and taken to central booking.
My friend Jude, one of the AES attendings, calls me with an update. I’m always happy to talk to him. He’s fun to flirt with, and usually flirts back even more insistently than I do, even though he knows about Jeremy.
“Hey, Jude,” I coo.
“Hey, bulldog. You know that rape victim you have over there?” he asks.
“You wanna narrow it down for me, lovey? I got more than one in the area.”
“Yeah, lessee … white woman, mid-thirties? What’s her name, Jackson? Johnson? Something like that …”
“Johansen,” I say, exaggerating a Swedish accent. “Jah, she’s still here. What about her?”
“Maybe you want to let her know her attacker didn’t make it. He died in the slot.”
“Ouch. Well, sorry you lost one, pal, but maybe not so sorry it was this one in particular, huh? Okay, I’ll let her know. I guess you really are supposed to look both ways before you cross the street. Even if you’re running from the cops.”
“Turns out … so, uh … maybe I’ll come by later to tuck you in, huh?” he teases.
This is a long-standing joke between us: our mutual attraction, and also the fact that I sleep through a good chunk of my overnight shift, while he works every minute of his. Later that night, when my pager goes off with a callback number of 6969696969, I will assume it is him and roll over, settling back to sleep with a smile.
“Tuck me in … I wish,” I sigh dramatically. “Are you wearing those light blue scrubs that drive me wild?”
“I am, indeed!”
And on it goes. I hang up the phone and go to the EOU where Ms. Johansen is lying in bed, curled up in the fetal position with her back to the door.
I enter her room quietly, not sure if she’s sleeping or not, and lean over her to get a look at her eyes. She is staring at the wall, barely blinking, breathing shallowly. “Hi,” I say softly, tentatively. “How are you feeling?”
She rolls over to see who is addressing her. “Mostly numb,” she answers. “My head hurts, still, but the anti-anxiety medicine is working pretty well. I finally stopped shaking. I can’t stop seeing their faces, though. It doesn’t seem to matter if I close my eyes or if they’re open. I keep replaying what happened.”
“That’s perfectly normal after a trauma,” I explain. “It’s called intrusive recollections. It goes away in a few days, usually.” Can I give her any useful advice? “Don’t try to fight the memories. You really can’t. Just let them play out and know it’s your brain’s way of dealing with what happened. It won’t go on forever.”
She sits up, moves her pillow to behind her back, and motions for me to sit on the edge of the bed.
“I have some news for you, sort of,” I begin. “One of the attackers, the one who got hit by the car on FDR?”
“Yeah?”
“He was brought here to Bellevue, to what is called the trauma slot, where critically injured patients are worked on by the ER doctors.” I pause to give her a minute to process what I have just said, and to brace for what’s coming next. “He died.”
“Okay,” she says easily. “But the other one’s still alive?”
“Right. As far as I know, he got taken by the police to central booking, you know, to get fingerprinted, mug shot taken, all that. They’ll keep him there until he gets arraigned. They call it the tombs, where the prisoners wait to see the judge. I guess it’s kind of a creepy place.”
“I hope it is creepy,” she says. “I hope he’s scared, and can’t breathe and has the same tight chest I have. He should spend the rest of his life behind bars.”
I know this won’t happen. Even if he gets convicted, which is always a huge if, they don’t give rapists life in prison as a rule. The pot dealers get longer sentences half the time. Don’t get me started.
“So,
you try and rest now, okay? Do you want me to send in a nurse with some more medicine so you can sleep?”
“Could you? I’d really appreciate that. I just want to turn my brain off. Do you have anything that would do that?”
“I’ve got just the thing,” I say convincingly, though I’m not sure exactly what I’m going to order when I get to the nurses’ station. I rise off her bed and the door opens.
“Dr. Holland, can you come to my office for a minute?” It’s Rita, who rarely leaves the clerk’s office, and even more rarely enters the patients’ rooms. “Sorry to interrupt, Ms. Johansen,” she says pleasantly.
I follow Rita to the clerk’s office, curious as all hell. “What’s going on? Why didn’t you just overhead page me?” I look around her desk. Hundreds of pennies, nickels, dimes, and quarters have been segregated and organized. Wads of wrinkled bills are stacked according to denomination. She is vouchering property for a recently admitted patient, a panhandler. Her gloves are black from counting the money.
“I did page you. I guess you didn’t hear me. Too busy having your little heart-to-heart in there.”
“Well, did you hear? One of the rapists died in the slot.”
“I know. Everybody knows. The AES clerk called me and I told Nancy. But you are not going to believe this.”
“What?”
“The cops just brought in a pre-arraignment. I was going through his wallet to look for a health insurance card. You’ll never guess what I found. Are you ready?”
She is milking it a little, adding to the suspense. She is holding a driver’s license in her hand, but it’s turned around so I can’t see the picture and name. She flips it over and hands it to me.
“Leah Johansen,” I read. Why does this guy have my patient’s driver’s license? Was her wallet stolen? “Wait a minute. You can’t be serious. This is the other rapist?” my voice is loud. Rita shushes me. “You’re kidding me! They brought this guy here? What for? Why?”
“He’s on Prozac and needs to be cleared,” explains Rita.
“This is too much! Jesus, what are the chances?”
“Well, he’s arrested in our borough and he’s on psych meds. So here he is,” she says. “Nancy’s trying to keep him in the nondetainable area so Johansen can’t see him.”
“Oh, shit! I didn’t even think of that! She can’t see him. She’ll go nuts. And he can’t see her either! I mean, who knows what he’ll do if he sees her? Do you think he knows she’s here? I mean, does he know where she is? You think he has any idea?”
“How the hell should I know? Get a load of you! Why are you getting so worked up?”
“I don’t know, Rita. It’s just … this is crazy, don’t you think? I mean, it’s another one of those ‘you can’t make this shit up,’ you know?”
“I know. She gets mauled by two guys. She’s brought to Bellevue, a basket case. Thug number one runs into traffic and is brought to the nearest hospital, us. Criminal number two gets caught by the cops, and needs to be cleared by a shrink. Bring him to Bellevue! Why not? Everyone else is here?!” She’s laughing, but her eyes are wet. It’s sweet. She knows: It’s funny, but it’s not so funny.
I go see the criminal and give him about two minutes of my time. He is shifting his weight from leg to leg, probably in withdrawal from opiates, but his greasy hair and pimpled complexion suggest meth. “Are you hearing voices? Are you suicidal? Do you feel like hurting anyone?”
No, no, and no.
I take the cop aside and explain the situation. I give him the two forms he needs from me, and he is happily out the door. I can fill in the rest of the paperwork later.
Don’t Let It Bring You Down
I got the letter two days ago informing me that I have failed my oral exams to become board-certified in psychiatry. I passed the written exam a year earlier, soon after I got to Bellevue, but the oral portion with a live patient, usually taken a year after residency, is notoriously difficult to pass, with nearly a fifty-percent fail rate. This information does nothing to make me feel better. I am devastated and I can’t stop crying for one solid day. Other people fail exams, not me, I think to myself. How could this possibly happen? Here’s how:
I walk into this small office in an outpatient clinic, and there are two male examiners in the corner behind a desk. The patient to be examined is in a chair in front of the desk, and there’s an empty chair for me. I sit down and introduce myself and right off, I’m transfixed by her appearance. It really throws me off. She’s got very close-cropped jet-black hair, dark eye makeup on the lid above and also circled underneath, and she’s very pale. Maybe it’s her makeup, or maybe she only eats white food, who the hell knows, but she is ashen. With multiple piercings and tattoos and this vicious glare, her whole look is totally goth and dramatic. I should’ve been tipped off right there, but I was laser-focused on doing my job—and not getting thrown—so I didn’t stop and tune in to her, and think, How should I play this?
I keep to my game plan and start with all my usual background questions, trying to keep it superficial: Do you have any medical problems? Are you allergic to anything? What meds are you taking? I’m not getting into her symptoms at all. This isn’t the way most people start the interview. It certainly isn’t the recommended way, which is that you let the patient free-float and tell you all their problems for the first five minutes.
No, siree, I had a format I wanted to follow, my way of efficiently building a database, and I wanted her to go along with it.
She interrupts my rapid-fire style. “I’m done answering your questions.” She looks me right in the eye, and says, “I don’t know where I am right now. I don’t really know what I am. I mean, I don’t even know if I’m a human being!”
I respond calmly, matching her intimidating gaze, staring her down. “You are in the outpatient clinic, you are a human being, and I have a lot more questions to ask you, so let’s just continue.”
It’s the worst thing in the world to say, I know now. She handed me a bunch of symptoms on a silver platter and I tossed the tray, toppling them all. I was just trying to keep her on track, on my schedule. I had only thirty minutes to get her whole story. This was my exam. I didn’t feel like this was about her. I figured she volunteered for this because she wanted to be part of the process, she wanted to help me pass.
I’m an idiot.
It just goes downhill from there. I should’ve realized the only way to win the examiners over was to win her over, but I guess I thought I could be a star in their eyes and still afford to be an asshole in hers.
A big part of what you are judged on in the boards is the ability to establish rapport with the patient. You need those points to pass. But somehow, when faced with a bad situation, I just imploded. I tried to out-macho the patient. Bad idea.
I see that I’m going to have to work on all of this with Mary before I take the exam again. We’ve got to soften me up somehow, and fast. This steamroller cowboy thing isn’t getting me anywhere. Except …
After hearing about my failure, Jeremy makes me a card to cheer me up. He has Photoshopped an old picture of me from my rock-and-roll days, onstage with my band in tight jeans and a white tank top, my nipples clearly visible. I am wearing dark sunglasses, microphone in hand, and my mouth is wide open.
Below the picture, he has written a caption:
Julie, you pass your orals with me every time.
Piggies
When the weather turns frigid, the homeless head indoors, crowding the CPEP beds and perfuming the area with the piercing stench of fungus. People assume the odor would be worse in the summer, but it is always considerably more unbearable in the winter. Patients who live on the street wear multiple layers, sweatshirts and coats that trap the aromas of the body. As they peel each layer off, the smell intensifies, sometimes becoming overpowering enough to make my eyes water, or even to make me gag. When all I want to do is run in the other direction, it gets a lot harder to be therapeutic and caring toward the patients.
Still, when I greet a new patient in the nondetainable area who has matted-down hair, and bugs in his clothing, smelling of urine, sweat, and feces, even if I can’t help but turn my head away, stifling a “PHEW!” I am careful not to say anything. It’s not his fault. There is nowhere to shower in the city but the shelters, and most of the street people avoid the shelter system like a bear avoids a trap. There are too many rules, addicts, alcoholics, scammers, and lunatics. Things get stolen constantly and people get assaulted at random hours, so no one can ever truly relax or sleep.
This weekend at CPEP has been hell, and it has taught me a valuable lesson: Take time off in January. That’s when the census starts to creep up through the twenties, day after day. Tonight, not only are there nearly thirty people in the area, but they are impressively sick. Many of the patients need wrist and ankle restraints. The process of restraining a patient requires anywhere from four to eight staff members: usually CPEP psych techs and nurses, who are big women, and hospital police, who are smaller men. (Sometimes the sizes and genders are reversed; it depends who’s on shift.) Each staffer takes a limb, and one person stands near the head to oversee the procedure. A doctor is supposed to be present at all restrainings, trying to get the patient to calm down, explaining, “This is only a temporary procedure, until you have better control over yourself. We’re just trying to keep everyone safe.” It’s usually a bit of a mess, with a lot of swearing, grunting, and threatening.
On Sunday, the flurry of aggression that necessitates one man to be restrained sets off another patient who is escalating. Angry that he is being admitted involuntarily, he is screaming at me and kicking the wall. I try to get him to calm down, encouraging him, “Please, try to keep it together so you don’t get tied up,” but he is unable to contain himself. Like a ripple effect in a Rockette line of dancers, five people end up getting restrained over the course of one Sunday afternoon. I wish I were home watching football, instead of at work watching wrestling.
Weekends at Bellevue Page 10