by Judith Lucci
Several minutes ticked by. It was finally quiet. The only noise in the room was the click, click, click sound of someone clicking their tongue against the roof of their mouth and the squeaking of the two rocking chairs as the patients continued rocking back and forth.
Monique made a decision. She spoke to the patients in a cool, calm voice, glancing at her watch. "Our time is about up. Why don't you all take a break and then report to where you should be at 4 o'clock. Rose, you can go to my office because we have individual therapy at 4:15. The rest of you know your schedules."
The patients left the community room quietly. Only the two rocking patients remained. Alex breathed a sigh of relief. She was impressed with how Monique had handled the situation. Dr. Desmonde's firm tone of voice had waylaid any further patient outbursts. The psychiatrist had taken control of a potentially dangerous scenario by neither acknowledging nor discussing the situation and by redirecting energies of the patient group in a positive manner. Her behavior and poise were highly professional.
Alex glanced around, still uncertain of her surroundings. "Monique, we've gotta talk …." Alex began.
Monique lifted her index finger to silence her. "Yes, but first I've got to make sure Donna got Jim to the quiet room. Wait for me. I'll send some medicine and a psych tech back here to deal with these two." She gestured at the two remaining patients.
Alex left the community room and walked into the central nursing station, behind a door and glass windows, where she felt much safer. She was relieved to see the patients playing board games and watching the soaps on TV. She wondered to herself just how therapeutic watching soap operas could be, but figured it was better than beating up on each other and the staff. She decided to keep her mouth shut about what she thought was therapeutic. She turned and saw Dr. Desmonde in the medication room and followed her. She watched Monique select a 3 mL syringe from the locked cabinet, snap the top off an ampule of Haldol and deftly fill the syringe. Monique continued to draw up Ativan for anti-anxiety and Cogentin to combat the side effects of the Haldol.
"Alex?" Monique intoned as she nodded towards the hall.
Alex and Monique walked deliberately down the hall to the quiet room, where they found Donna and Jim talking quietly. Jim had been crying. As they entered the quiet room, he spoke.
"Donna, I don't know what gets into me. These tempers just come. I don't know what to do. I need help. I'm scared. I never know what I'll do next." Jim was so upset, he began to sob, his voice coming out in great gulps.
Donna patted his shoulder reassuringly. "Jim, we're gonna try to help you. We care about you here in the Pavilion, don't we, Dr. Desmonde?" Donna's acknowledgment of the physician's presence drew Jim's attention to Monique.
He looked at Dr. Desmonde sadly and said, "Sorry, Doc. I just need more help. I don't know what's happened to me. Is there something else you can do to help me? A new pill or something?" Jim's voice was desperate.
"I know, Jim. I know you don't understand your outbursts and, yes, we will continue to help you." Dr. Desmonde looked sad as well. "We'll keep working on it. We've made some headway. I've made you a shot that'll help you rest. Where do you want it?"
"Can I have it in my left arm? Last time it was in my right." Jim pointed towards his left deltoid muscle.
"Well," Monique hesitated, "this needle's a little long. How much muscle do you have in that arm?"
"Doc, I got muscle. I just don't have no brains!" Jim smiled for the first time.
Alex was surprised at how handsome he was. He had a beautiful smile, dark hair, and perfect, brilliant white teeth. She guessed he was in his mid-thirties. He looked to be of Irish descent. The Black Irish, Alex wondered to herself, acknowledging her knowledge of Jim's bad temper. How very sad if he is really one of them.
Dr. Desmonde returned his smile as she injected the needle and said, "You've got plenty of brains, Jim. They're just a little scrambled right now. We'll get them fixed!"
"Thanks, Doc, Donna, and Alex. I'm pretty tired now. I guess I'll sleep awhile. See you soon." Jim turned over in the bed of the quiet room.
Alex was impressed that Jim had remembered her name and said so to Monique and Donna on the way down the hall.
Donna said, "Jim's very bright. I'm not surprised at all. I like him. He wants to get better and I want to help him." Donna's voice was concerned, her interest in helping the patient obvious.
Dr. Desmonde looked narrowly at Donna. "Don't let personal feelings get in the way of professional judgment, Donna. Jim's very ill, psychotic. Don't set Jim and yourself up for disappointment. Don't get too involved in this case." Monique's voice was sharp and a little accusatory.
Donna's face turned red and she replied hotly, "I hope you're not suggesting I have feelings for Jim that are other than professional! There are no boundary issues here for you to be concerned with." Her voice was cold and defensive. "It's just that most of our patients are chronic and we never really help them. Besides, most of 'em don't want help. Many are so manipulative, they can't be trusted. I doubt many of them even want to get well. Jim does. That is the impetus driving my 'involvement' in this case." Donna was enraged and felt attacked.
Monique was quiet for a moment and then spoke. Her voice was repentant and reassuring. She'd accepted Donna's rebuke with grace. She shook her head and said, "I'm sorry, I apologize. I know how you feel, Donna. I have a special place for Jim myself. But, we have to keep it all in perspective. I am sorry if you think I suggested that your involvement is anything other than professional," Dr. Desmonde's voice was pensive and apologetic. She hugged Donna around the shoulders and added, "Nice job in there, gal."
Donna hugged her back. "Thanks Monique. But, you and I both know we've gotta do something about this place and the staffing. That situation could have gotten completely out of hand -- the one last night did! My nurses are scared. Several are terrified and are planning to leave the Pavilion." Donna stopped for a minute and then admitted, "I'm scared too, and that's not even factoring in what happened to Angie. The patients are getting sicker and sicker and more and more violent, especially since we started taking the ones from the state hospital that Lester Whitset contracted for. We're not staffed for those types of admissions."
Dr. Desmonde sighed. "Yes, yes. I know, Donna. I'm trying to get more positions allocated, even if they are only muscle positions. I'd be thankful to have strong bodies to help us in emergencies like this one today. Since we've been under this contract management, it's next to impossible. We need more behavioral health techs to help us out when we have these outbursts of violence."
Alex nodded in agreement with Monique and said to Donna, "I'm concerned about your staffing, too. You don't have enough staff to handle such severely ill patients and control these kinds of situations. What's your typical census?"
Donna responded quickly. "We've got 22 general psychiatry beds and average about 18 or 19 patients. Usually, 8 or so of them are overtly psychotic and have histories of violence or acting out behavior. The rest are acutely depressed or have organic brain syndrome and/or Alzheimer's disease."
Alex nodded in understanding. "How long have we been mixing the elderly and the adolescents with the others? I thought they used to be separated." Alex asked, looking questioningly at Monique and Donna.
Donna shook her head and answered, "We started mixing them at the time the contract manager started. Whitset cut our staff 20%, making it impossible to run an age differentiated behavioral health unit. He maintains that a therapeutic milieu can occur with all ages together, so everyone can ‘learn from each other'! Isn't that some crap? We've even had to eliminate geriatric and adolescent tract therapies. We couldn't staff them!" Donna's voice reflected her dismay.
"How's it working?" Alex asked.
"Not well, not well at all I'm afraid," Donna said. "The patients just don't identify with each other because of their ages. Mrs. Smithson, the elderly patient with the apple cheeks, is appalled when the adolescent female patients talk about
their sex lives and how they have to have "it" every day. The way they talk about sex is disgusting to Mrs. Smithson and I know it horrifies her. In fact, her son told Angie last night that he thought she was worse. He said he was gonna transfer her to Ochsner's private geriatric program. I don't blame him. She could get better care there, at least more care directed towards her age group. I'd move my mother over there, as opposed to here, so she could get better care. No question about it." Donna shrugged her shoulders.
"Is Mrs. Smithson the little lady who looks like Mrs. Santa Claus?"
Monique and Donna nodded.
"Why's she here?"
"She's in for a reactive depression. Her husband died in April and her only daughter, her caregiver, has rheumatoid arthritis and breast cancer. It's very sad, but also very typical for people in her age group. Her son is correct when he says we haven't helped her. Older patients need a different kind of care that is more structured to their place in life and their late life losses. Do you think we have been effective with her, Monique?" Donna looked carefully at Dr. Desmonde.
"Perhaps the meds have helped some, but basically we haven't helped her much. You're right, Donna. What we are doing isn't helping. I'm philosophically opposed to mixing these patients, but in view of managed care and reimbursement, we have no choice. I guess some concentrated care is better than none at all. At least we can watch her for suicide attempts -- at least, most of the time." Monique looked sheepishly at Alex and Donna.
"What do you mean, most of the time?" Alex asked, her voice anxious.
"Face it, Alex. I usually have two RNs and two psych techs on the day shift. There is even less staff on evenings and nights. We have no security and not a lot of muscle to wrestle these people down if they have outbursts. My RNs have to assess each patient, do paperwork, run groups, give meds, handle emergencies, and participate in community meetings. The psych techs supervise the daily care of the male patients and, together with the RNs, monitor the five-step patient responsibility level." Maybe it will get better when the new health reform act goes into effect. I heard that it may."
"Five step what?" Alex asked.
Donna explained, "Well, it's really not five steps anymore, not since the length of stay decreased to three to four days, sometimes even less. It is a system of patient responsibility level used as a gauge to grant individual patient privileges. As patients improve, they're given more responsibility and freedom. On level I, patients are restricted to the floor. On level V, they may leave the floor unescorted and take unaccompanied trips off hospital grounds."
Alex's legal mind was racing. Her thoughts scared her. She interrupted Donna. "Are you suggesting that we could have possibly sanctioned an activity where one of the psychotic patients could have left the hospital last night and attacked Angie, with CCMC's blessing?" Her eyes were wide with worry.
Dr. Desmonde intervened. "No, we haven't had a patient on level V for several years, mainly because insurance won't pay. They figure if the patient can be off hospital grounds, he can be out of the hospital. Most of our patients reach level III, meaning that they can leave the unit in a group, escorted by a staff member. They go to the coffee shop for meals, the gift shop, and so on. Right, Donna?"
Donna looked pleased. "Good, Monique. Very good. You are the first attending shrink that ever understood the system! I'm proud of you." Donna grinned at Dr. Desmonde.
Alex smiled as the nurse and physician high-fived each other.
"I don't know if admissions will ever return to the pre-HMO days when a psychiatric admission actually changed behavior. According to news reports, mental health services are supposed to get better under the new health care system. Supposedly, 32 million additional mentally ill people will receive psych benefits and the benefits of the 30 million Americans who already have them will improve. I just don't see how that is going to happen, but it surely sounds good," Monique added. "Of course, I am totally clueless on how we are going to care for them. We have no space for more admissions now and I am pretty sure we have more than our fair share in Louisiana," she added.
"Yes," Alex agreed. "It sounds good in theory, but it's all determined on how states interpret the "rules" set forth by the President. Some states could make as many as 500 drugs available for the mentally ill, while other states may only allow access to 250 drugs. Benefits will occur on a state by state basis. The same will be true for inpatient care for the acutely mentally ill and for substance abuse treatment. Some states may allow longer acute care stays or better rehab programs than others. It remains to be seen how all of that will settle out, particularly in Louisiana."
Monique looked at Alex and repeated, "Yes, particularly in Louisiana. I think we already know and shouldn't look for much to improve. There will be no silver linings for us," she added regretfully. "We'll just have many, many more patients with no place to put them. I am not looking for any great fixes to occur in the next few years."
"Anyway," Donna continued, "getting back to your question about patients leaving the unit, each staff member is allowed to take five patients off the unit at one time. And, believe me, the patients raise hell if they've earned level III and they don't get to go. It goes back to basic trust in the building of the therapeutic environment. If our psych techs are out with patients, it's hard for the few who are left caring for the others to monitor everything else. There are just not enough of us. We usually do monitor the seclusion, suicide, and quiet rooms, though. We’re pretty good at that, unless there's a patient or staff emergency on the floor!" Donna looked a little sheepish.
"I'm happy to hear that," Alex said wryly to Donna. "I'll do my best to get you some more help."
Donna smiled, looked grateful, and said, "Alex, I don't mean to kick a gift horse in the mouth or anything, but Sarah Chassion, the nurse manager who heads the prison unit, is in worse shape than I am. Her patient population is much worse and more violent. Many of them have medical needs also. Lots are HIV-positive and/ or recovering dopers. That's not even mentioning the serial killers, rapists, and murderers they care for over there. As a matter of fact, Sarah swears there is a dope line coming into the prison unit. She has the same staffing ratios I do, and although my job is hard, hers is even worse." Donna looked at her watch. "I gotta go. It's almost 5 o'clock and the daycare gets ugly when you're late picking up your kids. Thanks for your time." Donna waved at them on her way out.
Monique turned to Alex. "I've got to go also. Rose is waiting for me in my office. Do you have time to catch a bite to eat with me in the cafeteria around 6 o'clock? I'd like to talk about things."
Alex nodded. "Sure. By the way, Don refused to meet with us today. Big surprise, huh! He says he has little authority on psych because of the contract management."
"Yeah, gee, what a surprise," Monique agreed sarcastically.
"Sure, I'll meet you. Is it okay with you if I review some of the charts up here? I'd like to know a little about the patients."
Monique smiled at her and laughed, "Alex, you know darn well you don't need my authority to review charts. Help yourself. But, thanks for asking! See you at 6 o'clock!" Monique flashed her a smile as she dashed off.
"Pick me up in the nurse's station," Alex said, watching the elegant Monique Desmonde rush off. She again found herself admiring the psychiatrist and her commitment to the deranged and mentally ill. It's a heck of a job, Alex thought to herself. I'd never do it.
Chapter 14
There was no one that Alex recognized on the evening shift. She introduced herself to the RN in charge who was supervising level II patients in the day room. The nurse identified herself as Joanne Waters, an agency nurse, who was helping out. Joanne laughingly asked Alex to fill her in on the patients after her review of the patient charts. She admitted she hadn't had a chance to look at any of them. Joanne also reported that one psych tech had taken five patients to dinner in the hospital cafeteria and that the other tech was making rounds. Further questioning by Alex confirmed that Joanne had never worked ps
ych at CCMC. Joanne also admitted she knew little about psychiatric nursing and was pretty scared to be up there after what had happened "last night".
Alex shook her head as she entered the nurse's station, taking several records with her into the staff lounge. She hated temporary agency help. Why not pay their own nurses more and not spend $150 an hour for temporary nurses. This type of care is unsafe, she thought to herself. This place is a catastrophe waiting to happen. At least Favre could hire agency nurses with a background in psychiatric nursing! Of course, as Alex remembered, Favre was a believer in the warm body theory. As Favre saw it, if you had a warm body and a nursing license, you could practice anywhere in the hospital. Alex continued to reflect on the unsafe, risky environment in the Pavilion, imagining how catastrophic things could become. Her imagination in no way prepared her for the reality that was to set in a few short hours later. Psychiatric services at Crescent City were explosive, to say the very least.
Alex had reviewed about three charts and was looking at Jim McMurdie's chart when a voice behind her asked coldly, "Who, may I ask, are you?"
Alex turned around in her seat and saw a tall, cold-faced man, who was obviously furious. His face had the appearance of cold granite, his dark eyes looked like chipped, black ice. She stood up to meet his stare. She felt a bit unnerved, but her voice was strong. "My name is Alexandra Destephano. I'm the lawyer for the hospital. Who are you?" Alex's voice was equally cold and formal.
The man had soft features. His black hair was thick and curly, with abundant grey at the temples. His nose was sharp, and his lips were thick and pouty. He had a high forehead. All in all, his appearance was effeminate and Alex didn't like him. She didn't like him at all.
Alex squirmed under the man’s scrutiny. His cold black eyes canvassed her tall, graceful body. Alex suppressed a shudder as his eyes stopped and surveyed her breasts, then continued down to stare at her hips and her long legs. The man was positively undressing her before her very eyes. She was totally humiliated and furious at the same time.