Weekends at Bellevue

by Julie Holland

  “It’d make sense if I die after what I did to him,” he cries. “It’d balance things. So then I can die and he can live.”

  Bingo.

  There’s the psychosis—he thinks he can bring his son back to life by killing himself. He’s tipping some delusional scale of justice. And even if he’s not crazy, he still knows he should die for what he’s done, and he’s prepared to make that happen.

  Either way, he’s not safe to be alone in a cell.

  I let him know we’re going to keep him here in the hospital. “We’re going to try to help you. I’m going to start some medicine so Chance’s voice will get a little softer at least. Maybe it’ll go away entirely. And we’ll keep you on a watch so you can’t hurt yourself. Okay?”

  “Okay,” he says simply, relieved. He sobs quietly in his high-backed wheelchair, his wrist cuffed to its wooden arm.

  He eventually goes up to the forensic psychiatry unit, admitted as an involuntary patient as are all forensic cases, but I can’t get him out of my head for days and days. I finally call up to the prison ward a few days later to find out which doctor got assigned to him. It’s my friend Rose, and I’m glad that she’s open to my need to debrief.

  “I know! That guy totally got to me, too!” she confides. She’s not sure what to make of him either. “I opted to take him at face value, so I continued the Risperdal you started.”

  “Oh, that’s good. That makes me feel better, actually,” I admit.

  “They’re both pretty heavy-duty cocaine addicts, he and his wife. They spend most of their checks early in the month on drugs, and then they don’t have enough left over for diapers and formula.”

  “Lovely.”

  “And here’s the best part, are you ready?” she asks. “The wife is pregnant again. Three months. She wants to keep it.”

  “Oh man, Rose … I honestly don’t know how much more of this I can take.”

  A Hard Day’s Night

  One Sunday night I go to a cocktail party before work. I have a glass of wine, and half of another. By the time I get to the hospital, my cheeks are a bit pink, and I’m all smiley, glassy-eyed.

  When I roll into the triage area, Rita smiles right back at me. “Don’t you look happy? Sorry to tell you, but it’s a disaster in here. If you’re smart, you’ll back away quietly … go home. We never saw you.”

  “You so funny!” I say, laughing as I go in. Big mistake. Shoulda backed away. Worst Night Ever. EMS just keeps bringing ‘em in and bringing ‘em in and each one is crazier than the last. Even the walk-ins have incredibly heartbreaking tales. I can’t discharge anyone, and the bodies keep piling up.

  Doctors talk about the patients on their service in terms of how many they are “carrying,” and what their “patient load” is. This is no misnomer. The more patients you are responsible for, the heavier your burden.

  I thought that I would be able to order in a nice meal and sit down to something tasty around eight or nine p.m. No matter how busy it is, I usually find time to eat some sushi, or Thai food, or at least a coffee shop salad. Tonight, I don’t stop to take a breath, and it’s past one in the morning before I’m finally eating a Bellevue baloney sandwich that I fished out of the fridge.

  The resident is doing the best she can to stay above water, but she doesn’t have as many helpers as usual. There is only one medical student to assist instead of the usual three or four. Also, it’s the medical student’s first time down here and she’s nervous. Normally during their first time in the ER, the medical students just shadow a resident, sitting in on interviews but not asking many questions, and not writing up any charts. Tonight, this cannot be. It’s baptism by fire and I send the medical student on her own to see cases. “I need all hands on deck,” I apologize. “I’m going to have you see a case or two on your own. No one too psychotic or dangerous, though, don’t worry. I’ll try to pick someone with a story to tell.”

  Luckily, there are plenty of patients in need of a shoulder to cry on. They’ll keep her busy and I know she’ll be safe. It’s important to match the medical students up with a patient who will be educational but nonviolent. That way, when they’re done talking, I can do a little teaching. I can explain why someone is acting a certain way, or how their medicines aren’t working, or how their street drugs of choice are working. There won’t be much time for teaching tonight, but I can at least make sure the student gets interesting, talkative patients who won’t try to strangle her.

  The detainable area is packed with patients who are done being processed, but we have nowhere to send any of them. The up-wards are completely full. The forensic ward, which is hardly ever full, has been backed up all weekend. We have multiple prisoners who need to be admitted, each of them trailing two cops, and the CPEP looks like a precinct. Again.

  Not only are we chock-full of prisoners and their police escorts, but tonight, these particular patients are more medically complicated than usual. Typically, the police cases are healthy at the physical level. They are young sociopaths on minimal medications with few medical problems. But not on the Worst Night Ever.

  The prisoner who just stabbed his wife has a broken leg, which was casted in the medical ER. To further complicate his medical picture, he has a number of fresh cuts on his head, which is shaved because he recently had a brain tumor removed. Oh yeah, and he also has leukemia. Plus, he is totally out of his mind, yelling about the apocalypse, and it’s difficult to sedate him due to the head injury/brain tumor situation. People with neurological disorders tend to get disinhibited when they’re sedated, sort of like a loud drunk. He’s doing his part to add to the noise level in the area, making it feel even more chaotic.

  Another prisoner is a very thin, sick-looking gentleman with longstanding AIDS and hepatitis C. On top of that, he has recently been diagnosed with lung cancer. He told his stepson he was going to kill him and his mother with a revolver, but then he decided to turn the gun on himself instead. No one was shot, thanks to the kid tackling his stepfather, but the patient ended up running into the street as soon as he freed himself. He was eventually caught, subdued, and brought in by EMS, the stepson riding along in the rig to help calm him.

  But he’s far from calm. In the nondetainable area, when our hospital police remove his shoelaces and belt, the patient tries to stab himself in the neck with his belt buckle. This gentleman “isn’t going anywhere but up,” as we say. Because he’s arrested, he must be accepted onto the forensics unit. And the divas running 19 West tell us when they can and cannot accept admissions. This whole weekend, it’s been more on the cannot side of things. So we wait.

  I’ve also got a female prisoner doing anything she can think of to get herself admitted and therefore transferred to Elmhurst. First she threatens, in a general way, that she is going to hurt herself. Then she tells us she’s pregnant. Finally, she goes into the bathroom (her police escort stands outside the door instead of going in with her) and tries to stab herself in the genitals with a pen, saying she’s giving herself an abortion. She comes out of the bathroom to show us her bloody panties. We can’t tell if she is bleeding because she has her period and therefore isn’t pregnant, or if it’s because she has just pierced her own flesh, or if she has actually aborted her fetus. But we’re just too busy tonight. The bar has been set incredibly high for admissions, and she isn’t quite making it over. If she goes to Elmhurst, we still have to keep her for hours to medically clear her. We decide to discharge her via the medical ER so they can have a look and see if she has done any permanent damage to herself or her unborn baby—if there even is a baby.

  We are sending out everybody that we possibly can, but it is busier, crazier, and more jam-packed with patients than I’ve ever seen. I am starting to turn people away at the door.

  “Sorry, but we’re not seeing any walk-ins tonight,” I tell them as they try to come in. I’ve never done that before. It goes against everything Bellevue stands for, and everything I believe in, but tonight my beliefs are changing. Usua
lly, it’s “Give us your sick, your tired, your poor,” but tonight it’s “Go tell it to Beth Israel. We’re full.”

  After a quick evaluation, we even send out a woman brought in by EMS from an apartment building where, according to her boyfriend, she was “swinging out the window like she was on a jungle gym.” She had walked into his apartment and seen him in the shower having sex with another woman. She tried to jump out the window (dramatically, making a scene in front of the naked couple) but the boyfriend pulled her back in. It sounds like total theatrics to me, though, and he agrees that she probably wasn’t really going to hurt herself. The patient is preoccupied with an exam she has to get home and study for, which makes me think she probably isn’t planning on doing herself in anytime soon. Normally, with a story that sounds this dangerous, we’d hold her overnight for observation, but not tonight. Too many people, nowhere to put any of them, and I’m feeling braver about discharging patients than I’ve ever felt, because now I’m counting down the days until I leave this nuthouse.

  “What are they gonna do, fire me?” is a well-worn refrain by now. It is late winter, and I’ve made my decision. I aim to be out of here by July first. The medical new year can be rung in without me; I am moving on, saving what’s left of myself. Head for the lifeboats! Women and children first!

  The night is crammed full of dismal stories and dejected people. One twentysomething gal called 911 saying she was afraid she was having a nervous breakdown. Her boyfriend of eighteen months had taken her to some man’s apartment in Queens to have sex with the guy for money. They all hung out and smoked crack and then the trick paid her boyfriend $150, so he split with the money. Later, when she finally tracked the boyfriend down, he broke up with her because she was a whore. She didn’t know whether she wanted to kill him or herself. Then she tells us the only thing that’s keeping her from ending her life is that she’s pregnant … again. Okay, so she couldn’t stop smoking crack during her last pregnancy and she lost the twins at five months, but this time she is planning on stopping before her second trimester. Only she’s already sixteen weeks.

  The medical student is recounting her past history. “She was gang-raped at twelve and has been prostituting herself ever since. She overdosed on pills after the trauma at age twelve and again at age seventeen.”

  Her life story sounds horrendous. She has two children from two different fathers. One is staying with the baby’s father and the other is with the baby’s paternal grandmother. She has become addicted to crack somewhere along the way, and at this point she mostly prostitutes herself to support her habit, which means she isn’t really saving up any of her earnings. She is a “crack whore,” for lack of better words, though this is a pejorative term that doesn’t begin to convey the misery it should, and she’s had a miserable existence since puberty. The weird thing is, she looks pretty well put together and is actually sort of charming. She is very, very smiley—telling us her horrible life story and smiling, smiling, smiling.

  “Maybe I can just stay for a few days to get my shit together?” she asks sweetly. We decide she is in complete denial, in total disconnect with how intensely miserable her life is, and it’s probably healthier that way. We let her stay.

  I’ve just finished hearing about another case and I tell the resident he needs to discharge the patient. He looks at me as if I am a monster.

  “I don’t know if you’ve ever heard me say this before,” I tell him, “but all of it is sad, so none of it is sad.” This is a line I often use with the medical students and residents when they try to convince me how pitiable a patient’s situation is. “What I mean is, I have to set the bar high—my threshold for what will get to me, what reaches me—because all I hear is horribly sad stories every shift I work.”

  I’ve been working at Bellevue for nearly nine years now. Because it takes more to break through and touch me, I will discharge patients that other doctors would surely keep. This frequently offends the medical students I am working with, and the residents as well. I know they think I am too harsh, unfeeling. I have a reputation for being callous and uncaring. It’s all a front, of course, and one that I’m having a harder and harder time maintaining, but they don’t seem to get that. Lousy shrinks, I guess.

  “The first casualty of life at CPEP is a sympathetic ear,” I continue. “You stay down here long enough and you’ll learn that you need to look beyond the story to the question of danger.” I try to soften my tone. I am here to teach, not to be defensive about my hardened demeanor. “The bottom line is, is it safe to release the patient? Will they kill themselves, or take out someone else? I factor their miserable childhood into the equation, yes, but usually that’s extraneous. And every single patient that walks through that door has had a miserable childhood. I guarantee it. But usually, the backstory has no bearing on the outcome of the case. The dispo of the patient rests on our predicting the future.”

  The resident is still looking at me like I am an ogre. I stammer to add more, to make him understand me. “It’s ridiculous, really, but that’s my job. I need to step back and look at the big picture. I can’t get bogged down in the ‘oh-the-humanity’ response.”

  “I get it. You’ve got to hide your love away.” He smiles.

  “Pretty much, yeah.” Maybe he does understand. We do speak the same language, at least.

  When I’m in more of a hurry, I care less what my underlings think of me. Tonight would typically be one of those nights, but I want this guy to like me, or at least not to hate me, especially if he’s a Beatles fan. I want him to understand that I’m not really heartless. I do care, more than anyone seems to know. I just also care about getting the job done.

  “Listen.” I search for the right lyric. “I know that it’s a fool who plays it cool by making his world a little colder. But that’s what works for me. This is how I’m choosing to deal with this war zone, y’know? It’s the only way I can manage working down here year after year.”

  He’s nodding. We’re good. Now I can move along, admitting, discharging, going about my business, walking my tightrope.

  When we’re even busier, and I don’t care how I’m perceived, it goes more like this: “I’ve got no time for trivialities; I don’t want to hear the pitiful backstory. Cut to the chase. Are they suicidal?”

  “No.”

  “Homicidal?”

  “No.”

  “Unable to care for themselves due to psychosis? Presence of severe medical illness exacerbated by psychiatric issues?”

  “Nope.”

  “Then you gotta let ‘em go. There’s no room at the inn. Tonight is one of those “No Vacancy” nights. If Mary and Joseph end up on triage, they’re gonna get T-and-R’d.”

  Waiting for Laces

  By the time the HBO documentary on Bellevue is completed, Lucy is long gone. They dedicate it to her, which I appreciate. She is a central character in the film, just as she was in my life. I miss her terribly, and it is comforting to watch the documentary and see her again, to remember her before she got sick, and bald, and thin and frail.

  At the screening, Sheila Nevins of HBO introduces the film. She says something that sticks with me for days afterwards: “There is not much difference between any one of us here today and the patients at Bellevue. We just know enough to put away our imaginary friends if someone knocks on our door.”

  I admire Sheila, a powerful woman heading up a potent network. Could she be correct in her assessment of what differentiates “us” and “them”? Is it merely that some of us know how to keep our mouths shut? If any of us shared with a psychiatrist every intimate thought we had, our darkest secrets, is it possible we would still be judged safe and sane? There are plenty of times we feel murderous rage, or we think it would be easier if we didn’t exist anymore. It’s a common fantasy to see ourselves driving the car over the edge of the embankment or into oncoming traffic. Using the criteria of danger to self or others for involuntary commitment, any of these impulses and fantasies is enough to buy
you a short stay in the hospital’s inpatient psych ward. On the other hand, as long as you keep them to yourself, you can walk around the city freely.

  There are many nights at Bellevue when I will listen to a patient strenuously explain to me, “I don’t belong here. I’m not crazy. This is all a misunderstanding.” Plenty of times, that is indeed the case. Things are said in the heat of the moment, or while drunk or high, that the patient isn’t planning to carry out. People are brought to the Bellevue psych ER to be evaluated, and, hopefully, a thorough assessment will reveal the truth.

  On one Saturday evening, a man shares a cigarette with a stranger in a bar and ends up dancing naked on top of a car. The cigarette has PCP in it, which luckily shows up in his urine tox screen, helping to explain his behavior. The man has no psychiatric history and I speak to the couple he babysits for to prove it. No matter how psychologically healthy you think you are, circumstances can transpire that will bring you to Bellevue. Hopefully, the doctor in charge will know what to do with you when you get there.

  EMS brings in a patient who is on a street corner preaching to passersby about how they should divest themselves of their worldly possessions. He gives away his wallet and watch in the process. When I triage him, I learn that he has eaten several “magic mushrooms” that contain the hallucinogen psilocybin. He has taken them prior to going into a Chelsea art gallery, the Chapel of Sacred Mirrors. The psychedelic artwork within, by Alex Grey, is intense, spiritual, and inspirational, and the combination of the art and the drugs has pulled him onto another plane.

  Transformed by the mystical experience, he ends up proselytizing enthusiastically in public. He wants to share with others what he has learned, and that is where he gets himself into trouble. A different psychiatrist might have misdiagnosed him as manic, restraining, medicating, and admitting him, but I have been to the Chapel more than once. I know how moving an experience it can be, never mind the psilocybin. I speak with him gently as his trip slowly ebbs, helping him to navigate his reentry, alighting in a city hospital with no money or identification. He stays in touch with me for months afterwards, grateful that I was there to protect him when he soared beyond the bounds of proscribed public behavior.