Brooklyn Zoo (31 page)

The resident looked pained and offered, “She said she got angry at her mother and did it on impulse.”

“Even worse!” said Dr. Cherkesov. “Who is to say what she will do next time there is an impulse? Until you and the patient get to the bottom of how this happened, it can happen again. If she is sent to the G-ER, she will be pushed to process her experience. Again and again people will ask her about the attempt, and she will be forced out of her denial, her assertion that this is no big deal. Discharging her only reinforces that what she did is almost irrelevant.” She paused. “Dr. Malou, you took this too lightly. The crime did not fit its punishment.”

Dr. Cherkesov returned to addressing the rest of us: “A study was done of patients presenting to the medical ER after a suicide attempt. Those who were sent from the medical ER
to the G-ER after their attempt were less likely to attempt a second time.”

Dr. Malou was fighting off tears. I felt for her and with delicious dread anticipated the day when
I
might be on the receiving end of such a grave teaching point, one that I was never likely to forget. Dr. Cherkesov seemed to take pity on the young doctor and smiled gently. Her tone, if not her message, lightened as her smile broadened, and I found her so acutely and charmingly Russian: “Anyway, you discharged her. I hope nothing will happen. I hope it won’t affect your life in horrible ways!”

Dr. Malou got up and gathered her notes and her worry and her shame. Dr. Singer began to fill Dr. Cherkesov in on a case from the day before. The rest of us stopped rubbernecking and turned our attention toward him. He had seen a woman admitted for pregnancy complications. Her obstetrician was worried that the baby was at high risk for cerebral palsy if the mother delivered naturally, but the woman would not agree to a planned C-section. Dr. Singer was called in to determine whether she had decisional capacity: Was she in her right mind to make such a choice? He’d gone to see her and determined that she was confused, in and out of consciousness, and unable to understand the consequences of her decision—apparently, the CL equivalent of unfit to stand trial. I thought about the baby and asked, “What if she
had
been able to understand the consequences of her decision? She would have been allowed to put the baby at risk like that?” Dr. Singer said no, that if she’d been able to reason and understand and had still refused the operation, the hospital would have gone to court to ask a judge to declare her incompetent for the sake of the baby. CL was more serious business than I’d realized.

After the meeting I approached Dr. Singer. He was the head of the department and so—in the absence of any psychologist, the same old song—would oversee my tasks there. Tamar had loved working with him. Like Dr. Cherkesov, he welcomed me warmly. His ID card attested to his M.D. and Ph.D., too. He explained that I would spend some days at Downstate and others at Kings County. Each morning after the meeting I would report to whichever attending or resident was “on the pager” and go with him or her on consults in one hospital or the other. He explained that consults were requested by medical doctors, who were supposed to fill out paperwork where they detailed their rationale for the request: for example, “Patient is not eating and is having difficulty sleeping. He reports feeling sad. Please evaluate for a mood disorder.” Often, though, the details were sketchy. A doctor might just write “not eating” or even nothing other than “psych consult.” Sometimes you could reach the doctor to ask for more information, sometimes not, but the consult had to be done within twenty-four hours either way. Dr. Singer summoned a graying Indian man who’d arrived halfway into Dr. Cherkesov’s lesson. “This is Dr. Kapoor. He’s one of the attendings here. You’ll be working with him today, at Downstate,” he told me, introducing us. I read his ID card: another Mud Phud. Rarely did I have this opportunity to feel so undereducated.

Dr. Kapoor and I rode down in the elevator together and crossed the street. The sun was shining and the air was crisp with the coming spring. I felt my mood improving like the weather as we walked across the drive and away from Kings County Hospital altogether. He told me that both he and Dr. Singer had done their Ph.D.’s in research psychology, “so we have a lot of respect for psychologists.”

“Some of my best friends are psychologists,” I expected him to say next. How much psychiatric disdain was he trying to shore me up against?

Dr. Kapoor told me that his dissertation had examined how doctors talk to their patients about terminal diagnoses. He’d found that the doctors’ own anxiety about mortality affected their behavior. He asked about my dissertation and my background, and I told him. When we reached the elevator bank, he told me I should go up to the seventh floor to see a call that had come in that morning. I was delighted to be given so much independence so fast. Maybe some of his best friends really were psychologists. He gave me the patient’s name, Valerie, and her room number. She’d just had her appendix out, and the reason for the consult was “panic attack.” I should see her, determine what had happened, and then go down to his office on the fifth floor to report my findings. Reflexively, I began to review in my head what I knew about panic—the unconscious emotional states that engender it—but then stopped myself. I had before me only this beautifully uncomplicated task. A panic attack had specific parameters. I would determine whether this Valerie had one, not theorize about its underpinnings or help her place it within the broader context of her life. No wonder psychiatrists often seemed so self-satisfied. Dr. Kapoor said good-bye and headed for the staircase: he always climbed up, he told me, for the exercise.

I rode the elevator until the doors opened onto Downstate’s seventh floor. The floors were shiny and bright, the walls a pale shade of yellow. Doctors in white coats walked back and forth purposefully. Nurses in pastel scrubs worked behind the desk. I wished I had a uniform, some easily identifiable evidence of my role there. Everyone else who worked at the hospital seemed to have that much, from the security
guards to the janitors. I felt so unfortified, wandering around in my street clothes. I found my patient’s room and went in. Valerie was maybe forty, light skinned and overweight. She was lying in bed, looking as if she was recovering from something. I introduced myself as a psychologist in training and told her I was with consultation-liaison psychiatry, that her doctors had called us to come see her. “I’m not crazy,” she said. My appearance by her bedside was obviously an insult.

“Psychologists aren’t just for crazy people,” I said. It was by now a well-worn line, delivered each Friday morning by Alisa and me, with utmost discomfort (it rendered such disrespect to the cuckoos) to our fluctuating group of cancer patients. “Your doctor was worried you’d had a panic attack,” I told the woman.

“A panic attack?” She looked confused.

“Did your heart start racing at some point? Maybe you thought you were going to die? Did your palms get sweaty?”

“No,” she said. Did I have the wrong person? Had Dr. Kapoor been confused?

“Do you think your doctor would have any reason to think you’d experienced something like that?”

She reflected. She was an easy talker once she got going. “I did get upset before my operation. I was in so much pain. I’d had it for weeks and figured it was gas. I waited for it to go away on its own. By the time I got here, it had been a month of hurting. So I’m laying there waiting to go into surgery, and they’d been promising me for hours that I’d get some medication. But it never happened. It hurt so badly, and I started to get worked up. I yelled at them. My blood pressure went up. Since I arrived, they’d been constantly prodding and poking me and hooking me up to IVs without any explanation or pain medication. It made me upset and a little nervous.”

“Do you get nervous often?” I wanted to be thorough.

“Once in a while,” she said.

“Tell me about the most recent time besides here.”

“About a year ago my son didn’t come home one night. He’s sixteen. I was worried.”

“When you worry, or even when nothing in particular is worrying you, do you ever have symptoms like the ones I asked you about—racing heart, sweaty palms, numbness in your hands maybe, or chest pains?”

“No,” she said. “That night I just felt scared about what had happened to my son. I went downstairs to a neighbor, and she helped calm me down. He came back in the morning. Teenagers.”

I did a mental status exam and asked about her history. She told me she’d been in the middle of a shoot-out once, twenty years earlier, at a party. “Someone pulled out a gun and started firing. I live in a rough neighborhood. Parties can get dangerous.” She hadn’t attended one since, but she assured me she still had an active social life. I told her it didn’t sound to me as if she’d had a panic attack, just a reaction to pain and the unfortunate difficulties of being in the hospital. That seemed reasonable, but was I missing something? Her surgeon, after all, had been concerned enough to call for the consult.

I reported back to Dr. Kapoor and asked him what he thought had happened. He guessed that the patient’s anger had upset the doctor, who’d responded by calling for psych. “The staff use CL in a lot of different ways. They don’t want to consider that poor treatment or just plain lack of information might be having an impact on a patient. They think that if she’s upset, she must have a diagnosable psychiatric problem. I’ll check in on Valerie later myself.”

The next day Dr. Kapoor told me that he agreed: Valerie
had not had a panic attack. But as we sat in his office, another call about her came in. When he hung up, I looked at him questioningly.

“They want us to see her again,” he said.

“Anxiety?” I asked.

“Yes, but not hers,” he said matter-of-factly. “She’s crying. Doctors often call us when their patients cry.”

Dr. Kapoor let me absorb this and then continued, “And, of course, she has a psych history.” Another phrase I had come to know well, with its undertones of derisiveness.

“No,” I said, shaking my head. “I asked her about that specifically yesterday. She’s never talked to a therapist. She’s never so much as taken a sleeping pill.”

Dr. Kapoor’s face remained straight. I admired his unfailing placidity. He continued in an arch tone, with a smile on his face. “You saw her for fifteen minutes yesterday. Now she has a psych history.” He was still amused, though no longer befuddled, his expression said, by all of these doctors who were not psychiatrists. It was then that I first considered the gulf between psychiatry and the rest of medicine and realized that it might very well be as wide as the one between psychiatry and my own field.

One night a woman showed up in the ER saying she’d ingested antifreeze. She was high on cocaine and alcohol. The next morning at the meeting Dr. Singer speculated that maybe it hadn’t been a suicide attempt. Maybe she was just looking for a better buzz. He seemed excited by the novelty of this idea, and so I felt excited by it, too. “Do people use antifreeze to get high?” he asked. I guessed that he liked having students around: they would know what drugs the kids were
into these days. But nobody would cop to knowing about the recreational pleasures of antifreeze. He made a note to call Poison Control to ask.

Dr. Cherkesov, whose intriguing tidbits, I was noticing, were often delivered like grand proclamations, said, “The combination of cocaine and alcohol is especially toxic! Impulse control becomes poor! As the coke wears off and alcohol stays in the system, painful emotional states become overwhelming! It’s a lethal combination!”

The resident Dr. Malou reported that there had been several calls from obstetrics the day before. “They rely on us too much,” she complained. Psychiatry residents did three months on CL. Dr. Malou was near the end of her tenure there and it showed. Dr. Singer explained that a young woman had come in a couple of years earlier on the verge of delivering an infant. She hadn’t even known she was pregnant and insisted on leaving the hospital in order to go to her own doctor. CL wasn’t called. The woman left the hospital, delivering and then killing her baby.

“Ever since, they overuse consult,” he said apologetically.

Dr. Malou was on the pager, and so she and I left the meeting together. On CL, I was well below the psychiatry residents in the hierarchy. This was correct, I knew, because there was so much going on that was medical, completely unknown to me. But I resented it, too, pervasive as the psychiatry residents’ attitude of superiority to us psychologists was no matter the setting. Dr. Malou told me I could call her Amari, and my outlook on our relationship improved. She was my own age, with a brusque manner but a pretty smile, and being on a first-name basis felt much more natural to me, though the physicians rarely used first names even among themselves. Months of “Doctor” this and “Doctor” that had finally had
the intended effect on me, and any other title had come to sound pedestrian, to the extent that I’d felt an immediate and startling disdain during the recent presidential primary debate when the candidates were addressed simply as Mrs. Clinton and Mr. Obama.