Weekends at Bellevue

by Julie Holland

  The fear instilled by the terrorists that day has insidiously grown and metastasized so that we barely register its presence. It has become the new norm. We are used to being reminded on the subway to “remain alert and have a safe day” and to being informed that our backpacks may be checked for weapons of mass destruction. Armed National Guardsmen are stationed at Grand Central Station in pairs, but we think nothing of it. Maybe that’s partly due to all the antidepressants and antianxiety meds so many New Yorkers are taking now.

  Across the Universe

  Frequent flyers are the patients whom the staff sees over and over again at CPEP. I will sometimes joke about a patient being a gold-card level frequent flyer, or maybe platinum, to differentiate just how often we see them. The most common reason for recidivism is alcoholism or drug addiction. These patients walk into Bellevue, or are brought in by EMS, and they are completely drunk, high, or both, stumbling, disorganized, and occasionally aggressive. There’s no safe place for them in the medical ER. They don’t necessarily have an acute medical problem, and they tend to be belligerent and disruptive, so CPEP takes the transfer, sedating and housing them. I consider it a favor for AES more than anything else.

  Usually, we don’t get to do a full interview until the morning, when they’re hungover and miserable. They typically want to leave the hospital, so they can get out there and do it all over again. Sometimes I will talk them into getting a detox bed upstairs, but more often than not there is no convincing them, no getting between them and their next fix, or their first drink of the day. So I step aside and let them leave. I let it go and move on, knowing they’ll be back if their problems get bad enough.

  Isaac Jackson, a frequent flyer, is a hulking menace of a guy. He’s a meaty, tattooed thug who has taken a liking to PCP over the years. This, in and of itself, is unusual. The average Joe who tries PCP once never goes back for seconds. For most people, it is an unpleasant experience, unless you have a miniscule amount. It is common to become paranoid, thinking everything is a secret message for you to decode, that everyone is speaking a language you are not privy to. If you manage to smoke only a little, you may feel spacey, separated from your body, like you are floating on a cloud. But this is rare. More likely, you will become exquisitely fearful, which can turn on a dime to rage, if your paranoia can find a target.

  Isaac typically comes into Bellevue angry, shouting racial slurs, threatening everyone within earshot with bodily mayhem. He requires heroic amounts of sedation—not for the faint of heart. I’ve had the pleasure of seeing him in these agitated states on more than one occasion, and I’ve learned just what combination of medications are required to tranquilize him. But this time, when he gets to the CPEP, he is all smiles and I barely recognize him. Only his tattoos assure me that it’s the same guy. He’s high on something, that’s for sure. EMS tells me he was picked up after he refused to leave a McDonald’s. The Ambulance Call Report lists Ecstasy as the likely intoxicant. I am intrigued. This is not his drug of choice, and he is out of his league, and in some respects, into mine. My Ecstasy book got published a few months ago; his timing is perfect.

  “Isaac, what have you gotten yourself into now?” I ask, getting closer to him than I ever dared before.

  “I’m high, Doc. I feel good. Don’t mess with my trip.”

  “I wouldn’t dream of it, darlin’,” I assure him. I find myself sounding more like Lucy sometimes. Her Southern drawl always seemed to make everyone feel better.

  Isaac’s pupils are dilated. “Looks like you managed to find some good stuff. Let’s you and me have a little talk.”

  Ecstasy, the popular name for MDMA (methylene-dioxy-methamphetamine), has a fascinating history. Before it became a recreational drug, taken at clubs or all-night underground parties called raves, it was used by psychiatrists and therapists. They would administer MDMA to their patients to help the therapy go deeper, faster. Feeling serene and loving, the patients could open themselves more fully to the process of digging up painful memories of physical and psychic trauma. MDMA gained a reputation among these psychiatrists as a powerful catalyst, helping patients to get to the heart of their problems. I interviewed many therapists for my book and was convinced they were on to something big before it became illegal.

  Now I can see for myself just how well it works. I finally have Isaac where I want him. For the first time, he is actually going to receive some treatment in the CPEP instead of just being tied up and put down for the night. He and I are going to go spelunking inside his dark cave to see if we can’t figure out what is making him tick like a time bomb. I’m excited, as if staring across the Grand Canyon, about to do an Evel Knievel on my motorcycle. I take him into the triage room without a nurse.

  “Do you want some water? Are you thirsty?” I offer. It’s important to stay hydrated with Ecstasy, though excess water retention can cause a lot of medical problems during MDMA intoxication.

  “Yeah, Doc. That’d be great.” The water will feel wonderful to him, which will help to align us. He will have good feelings for me if I help him to feel good.

  “Isaac,” I begin, “I’m glad I can talk to you today. You usually come in here pretty pissed off. You’re all riled up and it’s hard to talk to you much.”

  “I know, Doc. I’m mad as hell most of the time. I’m mad at the world.” He pauses for a minute, looking up at the ceiling. “It’s like I’m stuck.”

  “Why do you think that is? You must know that it makes it hard for us to help you, when you scare us away.”

  “Yeah. I guess so. But I keep ending up back here, don’t I?”

  “I think part of you really is asking for help. Screaming out for help, actually. Does that make sense to you? It reminds me of a little boy trapped in his crib, screaming bloody murder for his mother.”

  He stares at me, blankly. His mouth hangs open, but he says nothing. Am I going down the wrong path already? I’m losing him, and I know I don’t have much time. Ecstasy doesn’t last for more than three or four hours, and I have no idea how long he’s been high. I decide to go for the gold. Most patients with a diagnosis of antisocial personality disorder have had horrendous childhoods. They were abused physically, sexually, psychologically. They weren’t born monsters, they were raised by monsters.

  “What did they do to you, Isaac, when you were younger? Who hurt you? Can you tell me what happened?”

  “They hurt me bad, Doc. They hurt me bad and I’m mad as hell about it. They shouldn’t live with what they done to me!” He is shouting now. Spit is flying out of his mouth, and the hospital police are staring into the windowed triage room to see if I need help. I wave them off, and I make a point of making sure Isaac sees me waving them away. I want him to know I’m not afraid, that I trust him, and hopefully he’ll feel that he can trust me, too.

  “What happened? Can you remember what happened?”

  “They beat me. A lot. They beat me all the damn time!” he yells. Then he locks eyes with me and tells me quietly, “And I got raped. I was just a kid. I got fucked, Doc. I got fucked up the ass by my own family. How fucked up is that?” His face reddens, scrunches up, and he is sobbing. “Why did they do that to me? Why did they hurt me? I didn’t hurt them.”

  I wait. I make myself shut up and wait. I know it is important for him to vent, to have a catharsis, but I also know it will only do half the job. I want to try to have a more complete therapeutic interaction with him, and I try to stay focused. I’m not used to this sort of thing happening in the CPEP. I’m a lot more comfortable with keeping everything surfacey and light. A huge, angry man has broken down and is crying in the triage area. HP has probably never seen anything like this either.

  “I hate that they did that to me. They fucked up my life. And now I hate everyone and everything.”

  “Even yourself?” I ask.

  “Even myself.”

  He is doing a great job, getting exactly to the place where he needs to be. I plow ahead.

  “I know it’s
horrible. They should never have hurt you. You didn’t deserve that. No one deserves to be hurt by anyone, least of all their own family,” I say.

  “I didn’t even do anything!” he yells.

  “I know you didn’t, Isaac. I hear you.” I am trying to let him know that I get it, so we can move on to the next step. “And I see you’re angry, Isaac. Every time I’ve seen you, you’ve always been angry. But I want to tell you something. Listen to me. Look at me.” I pause. He lifts his head up from his arms, folded on top of the triage desk. I wait until his tearstained face is engaged with mine. “They never should have done what they did. We both know that. It’s completely fucked up. But we can’t change what happened, right?”

  “Right,” he answers obediently.

  “The only thing you can change is Now. Right now, you are doing their job for them. You are fucking yourself. You’re finishing what they started. You have to stop it. You show them that you’re better than that. You show them you can have a good life. You deserve better and you need to make sure you live better than you have been. You come in here over and over again, and you’re high on PCP, and you’re drunk out of your mind. And you get arrested, and you hurt people, and they hurt you. It’s like a broken record, Isaac. All the pain, all the anger. You have to take the needle off the record. You need to make this stop. Do you think you can do that? You are fucking yourself, Isaac. You’re taking up where they left off. You’re letting them win. Can you stop it?”

  He thinks about what I am saying. Should I have broken it down into smaller pieces?

  “Can you let us help you to stop it?”

  I have no idea if he’s getting it. He is quiet, exhausted maybe. I sense the Ecstasy is leaving his system, and he is starting to shut down again, to close off the most exposed parts of himself. This is something he needs to do to survive, I know, but it is disheartening to watch it unfold in front of my eyes. I have the sense that he is reassembling his armor right in front of me. I’m not sure I got through to him. I don’t know if it got into his head in time. He needs to rest, to process what has happened.

  “They hurt me bad, Doc. They should die, what they did to me,” he repeats.

  “I know, Isaac. I know they hurt you. But you can’t change that. You can only change Now. And the future, maybe. You can probably change that, too. You have to stop hurting yourself, Isaac. Don’t keep doing their job. Don’t keep fucking yourself.” I’m purposely repeating simple phrases over and over again, hoping it will act like hypnosis, hoping some of it will sink in deeper, subconsciously, and make a difference in his life. But I can’t tell if it’s going to work anymore. I don’t know if the MDMA has totally left his system or not.

  “Do you want to sleep here tonight?” I offer, like he can crash at my pad. “I’ll give you the best room in the house. You can think about what we talked about. Think about how you can make your life better, and in the morning, we’ll talk some more, and you can meet with the social worker. You can come into the detox ward if you want. Let us help you, Isaac. Let us do our job; don’t push us away this time.”

  I admit him to the EOU, to the largest room in the corner, which I like to think of as the VIP digs at CPEP. It is the best room in the house, though that’s not saying much, seeing the rest of the house.

  In the morning, after we’ve both slept, I go into his room to talk to him some more. I have a few minutes before rounds, and I want to see if he is still opened up at all, or if he has completely reverted to his intimidating old self. He is sitting on the floor, his back to the cot. His elbows are resting on bent knees. He looks up at me and smiles as I enter.

  “Good morning, there, chief,” I begin. “How are you feeling?”

  “I feel pretty good.”

  “Do you remember what we talked about last night?”

  “Yeah. I remember. You said I’m finishing the job they started. But they should pay for what they did to me.”

  So it’s a compromise, half my mantra, half his. It’s a start. “Isaac, you’re making everyone pay for what some people did to you. That doesn’t make any sense. Not everyone is the enemy. You can’t go through life scaring everybody, pushing everyone away. We’re not all going to hurt you.”

  “I’m mad at what they did. I’m mad at the world.”

  Great, we’re back to that again. I try a different tack. “Isaac, let me ask you this: Who loves you? Who do you love? Where can you go to get some love?”

  “I got a girl in Texas. We have a daughter together.”

  “You’re kidding me. You’re a daddy?”

  He grins sheepishly at me, and then I know where he belongs. And so does he. “I’m going to talk to the social worker this morning and we’re going to try to figure out a way for you to get down there.”

  “That’d be good, Doc. I think that’d be good for me.”

  “I know that’d be good for you, Isaac. There’s just one thing. There’s a lot of PCP in Texas. It’s called “fry” down there. You gotta stay away from it, you understand? It’s not doing you any favors, that drug. It makes you too scary. No fry, Isaac. Go down to Texas and get yourself some love, but stop with the PCP, will ya? And stop getting loaded all the time. You hear me? Move on! You gotta fix up your life. Try to start over. Be a good daddy, why don’t you?” We shake hands, solid, strong, and I leave his room feeling buoyant.

  I go into morning rounds to report on the patients in the area. When I get to Isaac Jackson, and tell the whole story, I get a little choked up. Daniel doesn’t let it go, of course. “Doctor Holland, I’ve never seen you get so emotional about a patient. This one really got to you, huh?”

  In front of everyone, he is making me feel like a sap. I give a mini-lecture on MDMA-assisted psychotherapy. I try to defend myself, the experience I had last night, but mostly I am worried about my patient. I am worried that in the cold light of morning, with the indifference of a new shift, Isaac will simply be grist for the mill. Packed up and shipped off like any other patient: He was high, he’s cleared, get him out the door and on to the next patient. I explain, in more detail than I probably should, the content of our session the night before. I plead with the staff to spend extra time with him today, to treat him gently, and to follow up on the plan to get him to Texas. At the very least, get him a detox bed. Daniel moves rounds along dismissively, and I seethe.

  I find out the next weekend that Mr. Jackson was discharged on Monday morning, hours after I left, with no real assistance from us. I am told that he “didn’t want detox.” It pisses me off that they didn’t do as I asked. The paranoid, neurotic part of me can’t help but think that Daniel personally made sure that Isaac was discharged without getting what I wanted for him, though Daniel assures me that they did spend extra time with him and it went nowhere.

  After one more drunken CPEP visit several months later, Valerie does help him to get some bus-fare money wired from his girlfriend, and we never see him at Bellevue again. I like to think he’s a Texan now, down there with his wife and daughter, and he is making up for lost time, making his life better, finally.

  I won’t follow up and call him. I learned that lesson years ago. I won’t even do a search on his name in the computer to see if he’s been to the AES. I’d rather just pretend that he’s found a happy ending. It makes my job easier.

  Don’t Panic

  The night starts out light on December 14, the day after my birthday. There are only a dozen people in the area and no one on triage. I make the mistake of appreciating out loud the low census, and the superstitious nurses shoot me a look. Oops. Sure enough, in the next hour I’ve got four triages and nowhere to put them. There’s a long-standing tradition in medicine of avoiding certain words in the ER. I waver between being superstitious and not, but there are definitely ER staff who deem it bad manners to mention certain words: “calm,” “quiet,” “dead.” They think it’s like baiting the gods to screw with us.

  Superstition is akin to something that psychiatry calls “magical thin
king,” the belief in talismans, omens. It’s normal in most people, and easy for me to see why. Twice now at Bellevue I have uttered the word “dead” as in, “Man, it’s totally dead in here!” and the crowds came running. Five EMS deliveries in seven minutes once, moments after the evil word was uttered. Now I allow myself the occasional “slow” or “easy” but rarely will I say the word “quiet” and never, ever “dead.” Mostly, it is safer to never comment on the activity level of the ER when you are on shift, though it’s fun to utter a prohibited word as you’re leaving. Then it’s someone else’s problem. Tonight, though, it’s mine.

  A pair of EMS guys, two of my favorite clowns, bring in a patient who’s been to Bellevue before. The 911 call came from the Port Authority police reporting an overdose in the bathroom. Jesus Martinez, at thirty-four, has end-stage AIDS contracted from IV drug abuse. Years ago, he unknowingly infected his wife with the virus, and she has recently died. Somewhere around four-thirty in the afternoon, he shot a big load of heroin and cocaine in a bathroom stall at the bus station, hoping it would kill him. At nine p.m., he was found by a janitor. He had been passed out on the toilet for nearly five hours, and had a temporary sacral neuropathy. Basically, his legs had “fallen asleep” due to the compression on his buttocks, so he was unable to walk after my two EMS pals revived him.

  They regale me with the details of their pick-up, telling me there was vomit, urine, and feces at the scene. Mr. Martinez’s colostomy bag had become unhooked, leaking its contents all over the bathroom floor. They make some joke about a trifecta, and we all laugh. “It’s the holy trinity of body fluids,” I add.

  When they bring him to Bellevue, the EMS drivers assume the patient will be accepted at the medical side of the ER since he is an overdose with an inability to walk, not to mention the end-stage AIDS and colostomy bag. But the AES nurse signed off on him and told EMS to bring him to us. When EMS presents the case to me, they encourage me to “bounce him back” to the AES, as if I need encouragement to get rid of this guy; the stench is impressing even my veteran nose. I roll the man down the hall to AES, looking for the attending. I’m hoping he’ll be cool and just accept the triage, do me a favor, but it’s a new attending I’ve never met. She’s Polish, or Russian maybe, and about five months pregnant. She looks cute in her scrubs with her little belly, and it’s hard to hate her, even though she examines the guy a bit, asks him “Where does it hurt?” about half a dozen times, and turfs him back to me.