The conference room is full of unit chiefs, department directors, and other high-level administrators sitting around a large, rectangular table. I choose my seat carefully, looking for allies. I am afraid for my job and for my reputation, and it’s hard to figure out whom to align myself with. I sit between Daniel and MacKenzie.
Henderson calls the room to order and begins. “This is a very complicated case. And though it seems clear that this patient was marked”—he pauses for dramatic effect—”marked for death, this should not have occurred in our hospital.”
I love that, marked for death. Henderson’s got quite a flair for the dramatic. He asks to hear from the different specialties assembled around the table, and the director of nursing begins.
And we’re off. There is some confusion about how many patients were in the area and how busy we were that night. I look over at Daniel questioningly, with terror on my face, and he does something cryptic but potentially communicative in its symbolism. He begins to draw on my Special Review handout—a schedule of who is to speak and in what order, with Mr. Martinez’s initials and medical record number at the top of the page. Is Daniel writing me a note? No, he draws a tic-tac-toe board and he puts an X in the bottom right-hand corner. He slides the paper toward me.
Tic-tac-toe…. Yeah, okay … Huh?
What the hell is he doing?
Dr. MacKenzie is directly to my left and there is no way I want our boss to see us playing a game at the outset of this meeting. Is Daniel trying to get me in trouble? Like making a sibling laugh while getting chewed out by Dad? Or is he trying to show me it’s all a game? That he doesn’t think this meeting is a big deal and neither should I? Or maybe it’s a message I’m supposed to interpret in a different way: The nurses are playing a game and they’ve put the first X here. They’re setting up the board and now it’s my turn.
Being a shrink can be a real pain in the ass. I can offer up a slew of interpretations, but when the subject is me, I have to choose one all on my own, and sorting through them all is distracting me from the meeting.
People seem to be maneuvering around, trying to dodge the blame ball. Not only are the nurses giving conflicting accounts about how many patients were in the area, but now there is a discrepancy about the staffing. I’m almost positive we had fewer workers that night than they’re reporting. What advantage is it for them to overstate the number of staff? At least overestimating the census makes sense to me. We were busy, we didn’t catch him putting a string around his neck. But to say we were heavily staffed instead of understaffed makes us look like buffoons: We should’ve seen this happen if there were extra staff members tripping over one another on the unit.
The thing that makes the least sense is the nurse’s triage paperwork from that night. She must have panicked. She has written not one, but three different responses in the space on the nursing triage sheet where it asks if the patient is currently suicidal. First she wrote “Vague” and then that is crossed out and it says “Denies,” which is also crossed out. The third response says “I want to die.”
When a patient is asked whether he is suicidal, either he says he is, or he isn’t, or he’s vague. Pick one! The nurse probably never got to ask him point-blank if he was suicidal. That’s why she was at a loss for what to write. If she didn’t get to formally interview him, why not just report that? The nurses are allowed up to two hours before they have to triage a patient, and the doctors are allowed up to six hours. Given the time frame of the events, she could’ve written that she hadn’t asked him yet, and that would’ve been fine.
Luckily, Mr. Martinez hadn’t been interviewed by the doctors yet, so the amount of writing I had to do in the chart was limited. I wrote one quick paragraph summing up the entire events of the night, taking the easy way out—the truth. He had been on the unit less than an hour before the suicide attempt.
Dr. MacKenzie asks me, “Dr. Holland, given what you know about the case now, in hindsight, would you have done anything different that night?”
“With hindsight I would’ve done everything differently, in order to prevent this suicide attempt, yes. But given what I knew prospectively, going into the case, I wouldn’t have done anything differently,” I answer as calmly and confidently as I can. I hope they appreciate my good grammar.
“Did you think this patient was high risk?” Dr. Henderson asks me. “All the patients in the detainable area are high risk,” I answer. I know Daniel likes my answer. We had agreed during our earlier phone call that there was nothing specific about Jesus Martinez that would have separated him out from the other patients we typically see. Nothing that was available to me at the time of his presentation, anyway.
“We see people who have just attempted suicide all the time. He wasn’t particularly special in that way,” I explain.
“In hindsight, everyone is a genius,” Dr. MacKenzie says during the review. Man, you aren’t kidding. I did the best I could in the moment. It was like a war zone; there was no time to mull over my options, no room for error. Now, with the luxury of time and speculation, it’s all twenty-twenty vision.
The Special Review is winding down. Now that everyone who has ever treated this guy has come together, I have learned a bit more about Mr. Martinez. One new piece of information is that he had hidden a razor in his mouth on a prior visit, and a staff member saw him retrieve it from under his tongue and place it in his sock. That was one month ago, when he was admitted involuntarily to the upstairs psych unit, then transferred to the medicine floor for a work-up of a fever. He was eventually discharged home from the medical ward, instead of being transferred back to the psychiatry ward, because the psychiatrist on the consulting service said that he wouldn’t benefit from an inpatient stay.
If I had known that story on Saturday night, I would’ve ordered a one-to-one observation for the guy as soon as he walked in the door. But I have never done that before. This was the crux of the phone conversation I had with Dr. MacKenzie prior to the one I had with Daniel.
“Wouldn’t you have ordered a one-to-one on this patient as soon as he came in?” MacKenzie asked me, genuinely confused.
“Actually, we never do that.” I explained. “One-to-one observations in the CPEP are very unusual. And we certainly wouldn’t do that prior to an evaluation with an M.D. Don’t forget, receiving a patient status-post suicide attempt is not a big deal for us.” “Status-post” is a term mostly used in surgery, but I like to say it. It means “after,” but it also means I went to medical school.
As the Special Review ends, I think about what I have learned. I now know that a man can want to die so badly that he will let no one stand in his way. A man such as this might make good use of a string the thickness of a hoodie tie.
CPEP will now remove the ties from zip-up sweatshirts before patients enter the detainable area. And what was once considered a high-observation area is now deemed a “blind spot.” It turns out, when the nurses are at their desk filling in charts, the place where Jesus tried to end his life is invisible.
I have also learned that Mr. Martinez is still alive, still on a respirator, and will likely be transferred to a nursing home or chronic care facility. He is, for lack of a better word, a vegetable. And yet, in the ultimate rendition of closing the barn door after the horse has escaped, the nurses in the intensive care unit have ordered a one-to-one observation for him. There is a Bellevue staffer sitting by his side twenty-four hours a day to make sure he can’t finish the job he very nearly completed.
No family members have come to see him as far as I know, and no one in the news media catches wind of the story, for which I am supremely thankful. I can just see the headline on the front page of the New York Post: SUICIDE IN THE ER! The outrage over how something like this could happen fuels my own relentless inquisition: How did I let it happen? Surely there was something that could’ve been done differently, that would’ve prevented it. I can’t let it go, even after the Special Review is over.
I’m not in th
erapy anymore, having stopped after Molly was born. I haven’t seen Mary for over a year, but I know I need to talk to someone about the suicide. I can only bend Jeremy’s ear for so long before it becomes clear I need a professional to help me to process this in its entirety. I call Mary and leave a message, asking if we can have a phone session. She has a new office now, in Chelsea. It’s not a convenient location for me at all, compared to her old office ten blocks from my apartment.
I remember how I convinced her I was ready to terminate, a few months after restarting, once the excitement of a new baby had died down. I felt proud of myself, getting confirmation from my therapist that I was strong enough to go on without her assistance. Now that I look back, though, I’m afraid some part of me wonders if it had more to do with her moving offices and wanting to lighten her patient load, and less to do with my readiness.
But how do we know if we’re ever really done, if we’re fixed? How do I know if and when I am okay? I’m married, I have a child, I have a steady job. To an outsider, I probably look pretty healthy, but am I really? I’m afraid I still haven’t found that perfect balance. There has to be a middle ground between the yin and yang, the sappy and the heartless. I need to treat the patients with compassion and dignity, but I’m afraid I’m still falling short of that goal. And now, with this suicide, I’m beating myself up for a million different reasons.
It’s hard to know if I should go back into therapy or if I just need a little “booster shot,” a small inoculation from Mary, a phone session to help me weather this particular storm. Whenever a patient dies in psychiatry, or in any branch of medicine, it’s a big deal. But when a patient commits suicide right under your nose, practically, it’s particularly unnerving, unsettling. I need help. I have to tell Mary the whole story, to unburden myself. I need her to tell me that it’s all going to be okay. I feel tremendously guilty, even though there was nothing I could have done to stop it. Maybe “regret” is a better word? I relay the night’s events to Mary, the phone crooked in my shoulder.
“There was nothing you could have done to stop it,” Mary assures me. “You did everything you could, Julie.”
Now I’m getting my money’s worth.
I tell Mary how I didn’t go on the offensive at the Special Review. I didn’t sabotage myself. I didn’t overcompensate for my guilt by making everyone else feel as bad as I did.
“Good for you,” she says.
Maybe I don’t need this anymore, her encouraging words. I’m spoon-feeding her everything I know she needs so she’ll spoon me back what I need. Actually, I think I can probably do this for myself, finally: sidestepping the pitfalls of self-sabotage, giving myself positive feedback.
I guess I really can ride my bike without help. I just needed to be reminded of it.
Gone Daddy Gone
Daniel is leaving CPEP. He’s been offered a job elsewhere at Bellevue and he’s taking it. I can’t imagine he’s switching jobs just to get away from me, but it’s certainly possible that being rid of me factored into the equation. Actually, I’m surprised he’s staying at Bellevue. I thought the administration wasn’t too keen on him, but I guess I was wrong. He seems pretty happy about the move, and I am dancing a jig. He is leaving and I get to stay. I can’t help but feel like I’ve won a battle of the wills. I guess I just had to wait him out.
His gal, Michelle, is staying on, which is fine by me. They’ve been dating ever since that Fourth of July weekend, as far as I can tell. She’s a good doctor, efficient and kind to the patients. Also, she’s the new person who’s organizing the moonlighter schedule. After I took my pay cut, Daniel asked her if she would take it over from me. I remember feeling unburdened as I passed along my red folder with everyone’s contact information. When we sat down in her office so I could show her the ropes, I thought I’d further unburden myself. I tried to talk to her about how the whole thing played out.
“I didn’t accuse Daniel of sexual harassment. I just want you to know that.”
“I know,” she said, staring at her computer screen. She wouldn’t look at my face, and I realized we weren’t going to bond over this, exactly. We would never be friends, because of all that had transpired between me and her boyfriend.
“I’m sorry you got roped into doing the scheduling. I didn’t want it to go to you. I just didn’t want to be the one doing it anymore,” I try again, even more sincere.
“I know,” she said again, still averting her gaze.
“Okay, then,” I sighed heavily, giving up. “Let me show you what I have on my list.”
I’m sure Michelle will eventually look for another job. She probably doesn’t want to stay at CPEP under the new acting director, Maxwell. He’s said some very inappropriate things about her and Daniel in the last few months, and she has absolutely no patience for him. He is quite young, probably thirty-three or thirty-four, the youngest director we’ve ever had. When I started at Bellevue he was a first-year resident, and not a particularly well-liked one. To fill the CPEP director vacancy, the administration went through the motions and interviewed a few people for the position, but they’re not offering enough salary to entice anyone halfway decent, and Maxwell would do the job for half of what they’re paying. He’s just dying to be in charge.
When Daniel’s secretary throws a going-away party to wish him well, she makes sure it’s open bar for the first two hours. Everyone arrives on time to start drinking as much free booze as they possibly can. I sit with Julia, the social worker, and Vera and some of the other nurses. We are ordering two drinks at a time, girly drinks with straws, like daiquiris and piña coladas, tying one on in a hurry.
Daniel gets up to make a speech and everyone around me is rolling their eyes and giggling. As soon as the cake is cut, I make some excuses about having to be home early for Molly and Jeremy, and I hightail it out of there.
I make my rounds, kissing people good-bye. I am a cheek kisser or a hugger, or maybe a little bit of both. When Maxwell kisses me goodbye, I don’t know if he is drunk with the power of his new position or if he is just plain trashed, but he kisses me full on the lips. I am caught off guard and wigged out. Between his saliva and one too many, I’m nauseated as I leave the restaurant, wiping my face. Julia is with me, and I complain to her about what I have just gone through.
“Eww!” she squeals like a schoolgirl.
“I know, it is eww!” I agree. We are waiting for our cabs; she’s going downtown and I’m going up. I let her take the first taxi, then I climb in the back of mine. It hurls uptown, accelerating in between the stop lights and then lurching to a dead stop at the last possible minute. I feel like I’m going to hurl myself, and I have to ask the driver to chill.
“I’m not in any sort of a hurry, sir,” I say as politely as I can. I lean back in the seat and remember going up this same way with Lucy back in the day, when we used to share a cab home from the faculty meetings.
I think about how different things could be now, if I had said yes instead of no. “You know I’d love you to be my assistant director, but I know you don’t want it,” she had said. She was right: I didn’t. I was very happy working my weekend gig and had no interest in anything administrative at Bellevue. I told her Daniel was a perfectly good pick. I thought he’d be fine. But if I had taken it, Lucy and I could’ve rocked the house during our time together. We would’ve been an amazing team, with me taking care of everything at CPEP while she was sick, assuring her that it was all done to her satisfaction. And if I had said yes, I would be the director now. Me, the big boss, five days a week, running the whole show. Did I make a mistake?
It would’ve been the ultimate tough transition though, ascending to Lucy’s throne. I know Daniel felt tortured about taking it over once Lucy was gone. When she was out sick more and more, Daniel had confided that the other division heads were talking about when he’d be the CPEP director. He hated what they intimated. He would’ve gladly traded Lucy’s life for his promotion. It was obvious in his hesitancy. After she
died, he couldn’t move into her office for months. I saw all of this happening, but said nothing. Why did we never connect in our grief, in our feelings of abandonment? We could’ve helped each other through it, bonding over our loss instead of taking it out on each other, but neither of us extended that olive branch.
Sometimes, after I would have a fight with Daniel, I would pass by Lucy’s empty office so enraged, I would give the closed door the finger. Fuck you for leaving me here with him, I would think. I was so angry at Lucy for leaving her post, disappearing from CPEP like an apparition. The director’s office stood like a mausoleum, her name still on the door, her belongings untouched, until Sadie finally came in one weekend a few months later to clear it out. And yet even then Daniel did not move into Lucy’s office.
But now, Daniel is moving on, and Maxwell will likely move into the director’s office as soon as he can. Dave, Daniel’s right-hand man, is leaving too. With both the director and assistant director stepping down, pickings are slim to fill the administrative positions. When MacKenzie calls me at home to get my take on whether Maxwell can do the job, I specifically mention the pie charts and graphs that Maxwell will be able to whip up for the boys upstairs. Oh, how they love their numbers. Maxwell is a computer geek extraordinaire, and he’s got the social skills to go with it. I tell MacKenzie I’m okay with Maxwell in charge; he’ll be fine. I know I can get away with murder with him as my boss. I’ve got so much seniority over him, I’m practically his mama.
Before he hangs up, MacKenzie makes a point of casually offering it to me, “Are you sure you don’t want to take the position?”
“Only if I can do it working weekends,” I answer breezily. It’s become my stock answer every time someone asks me if I want the director’s job. I know it isn’t a realistic option and it’s fine with me. I’ve been happy doing my two shifts a week and I have no desire for more. When I’m there, I’m in charge, and that’s enough for me.
Weekends at Bellevue Page 25