Weekends at Bellevue (2 page)

But tonight there is no phone conversation with the Silvers. Joshua won’t even acknowledge that they exist, and I have nothing to go on but his manic ramblings. He tells me he’s come to New York City with three dollars in his pocket and nowhere to stay. Knowing no one in the city, he made his way from the Port Authority bus terminal to the K-ROCK radio station at five a.m. in order to spread his message. When I first started my job at Bellevue, I heard the Port Authority referred to as The Port of Atrocities, because EMS brought us such sick people from there. That name stuck with me throughout my tenure at the hospital.

Joshua continues, chronicling the events of his day. After K-ROCK turned him away, he spent the rest of the morning sleeping in Central Park. Later in the afternoon, the police in the park told him to move on, and gave him a tip: Try hanging out around Forty-Second and Broadway. Wandering around Times Square, he happened upon some teens entertaining the tourists by playing drums on overturned white plastic buckets. He danced for them, and the tourists threw him money and took his picture.

“You know how there’s cops there on horses? They let me pet the horses; they seemed cool about me touching the animals, and the tourists took my picture again!” He seems impressed that he’d become a tourist attraction himself.

“Well, weren’t you naked by then?” I remind him.

He admits that he must have been by this point, but then begins to digress into a tirade against photographers, who, instead of living life and immersing themselves in their surroundings, only interact superficially by documenting the scene.

“You may have a point there,” I offer. I think of my boyfriend the photographer whom I confronted with exactly this accusation not so long ago.

My patient perceives me as a friend and ally because I am aligning with him, chatting agreeably rather than asking the standard annoying psychiatrist questions. There’s no need for those as far as I’m concerned—he’s a definite admission. The only uncertainty is whether I can get him to sign in voluntarily or will have to fill out the 9.39 paperwork for commitment.

The criterion for a 9.39 is danger to self or others, or an inability to care for self. If a patient doesn’t fit this narrow definition, he needs to sign in voluntarily. A frustrating situation often develops in a family when a patient clearly needs psychiatric help but is unwilling to agree to a hospitalization. In Joshua’s case, I can probably justify the danger-to-self scenario. He can’t fend for himself while he’s psychotic like this: He’s on the street with three dollars in his pocket—that is, when he’s got his pants on—eating and drinking nearly nothing.

Could severe dehydration and low blood sugar be affecting his behavior? Is he high from LSD or PCP? My money is on mania, the “working diagnosis,” but it’s my job to second-guess myself. If it’s drug-induced, he’ll come down in a day or so, but the mania won’t de-escalate that rapidly. I can ask the nurses to obtain a urine sample to be tested for PCP—phencyclidine—a tranquilizer called Sernyl, once FDA-approved but now illegal. When people are high on PCP, they frequently disrobe and run amok. There is a saying among toxicologists that “naked running is PCP until proven otherwise.” Since Joshua presented to the ER naked and disorganized, I figure I should at least send for the test.

If I could just talk to his parents, I’d get a sense of his history—whether he’s been depressed or manic before, and what meds work best for him. Of course, he won’t offer me any telephone numbers for his family, only for K-ROCK, a number he knows by heart. He still wants Howard Stern to broadcast his manifesto.

I push forward on my chosen tack: schmooze-fest. I tell him I admire his theory that people are art. I share his appreciation for the perfection of all he surveys, of the complexities and magic in the world around us. Like being high on hallucinogens, mania can provide a sense of wonder and awe at the realization of how the universe works. It’s easier to access the macro, to pull back and see the big picture. Often there is a feeling
that “everything is connected,” a realization in common with experiences on psychedelics and with mystical religious epiphanies. There are likely neurochemical similarities between the mystical, psychedelic, and manic states.

At Bellevue, I am repeatedly shown the big picture, taught that there is more than one way to look at just about everything. When I open my ears and mind to the “ravings of a madman,” I’m reminded to pay more attention, to Be Here Now. Everywhere we choose to see it, the world is full of splendor and wonderment. I’ll never forget the manic teenage boy who tapped my shoulder in the detainable area, excited to explain to me that, “We’re part of this huge experiment. All of us are under one microscope, being observed and studied. You know where the eyepiece of the microscope is?” he asked me, his pupils dilated with enlightenment. He pointed to the ceiling, “It’s what
you
call the sun.”

This is why I keep working here.

As the interview progresses, Joshua allows me to see more of his world. He tells me that he can make his dreams become real—he simply thinks of something and so makes it happen. He is convinced that he can conjure up reality out of thin air, and he spends considerable time explaining this to me. At one point in the interview he accuses me of making him crazy; the next second he considerately asks if he is making
me
crazy. He drags me deeper into our discussion as the lines between reality and fantasy blur and blend. The shifting definitions seem to include where he stops and I start. He embroiders on this theme, how there are no barriers, no boundaries between us. He explains to me how we are molecules connected, how the space between us is an illusion, not empty space but vibrating balls of energy. He touches my calf for a moment to make this point. It is rare to be touched like that by a patient; he bends down at the waist to reach the lower leg of my jeans and I wonder why he has chosen that particular part of my body to make physical contact.

As we continue to talk, he demands further connection with me, now insisting that I look into his eyes consistently. I struggle to focus my gaze on him, increasingly aware of my own eyes, drying from lack of blinking. He senses my discomfort as I approach the ultimate topic.

“Joshua … dude … I have to admit you to the hospital,” I say as gently as I can.

“Can’t you just be cool?” he begs.

“I can’t send a naked growling guy back out onto the streets,” I tell him lightly, jokingly. “People would make fun of me. My boss would kill me.”

“Let me talk to your boss,” he argues. “What’s his number? We can call him right now!”

“Joshua, it’s two in the morning on a Saturday night. I am not calling my boss at home. Forget my boss.
I
know. You need to be admitted.” I have to switch gears. It’s lame of me to blame my boss; I have to be the grown-up, be the doctor, and take responsibility for admitting him myself. Being cool cannot be the priority just now.

“You need some help. You need to hang out here and get your head together. It won’t be for too long, but you need to check into the hospital for a little break.” I point out to him that he is not taking care of himself, and he is endangering himself. His physical health is deteriorating, despite his insistence that he can survive on the streets by eating the free peanuts that the vendors toss him. He is putting himself at risk by arguing with large men on the city streets and parading naked up Broadway. Surely he can see that?

He glares at me, resentful that I have taken this stance. I have crossed back over to the other side, separating and drawing a firm line between us. There is no longer a blurring of boundaries or a flexibility in our roles, and we are no longer confidants. He is the patient, I am the doctor, and I am admitting him involuntarily to the Bellevue psych ward. I am the one with the keys to the unit; he is the one already locked into the detainable area, whether he knows it or not.

“So, you just sit there in judgment of me. You think you can decide who is crazy and who isn’t,” he says.

I picture myself standing on the corner of Sane and Insane directing traffic. You’re in, you’re out. Step over the invisible line and see what happens.

“Actually, that is exactly what I do here.”

I get up to leave the room. I have more patients to see. I face him and try to smile apologetically as I slowly back out of the door. I assume he won’t attack me, but it’s always best to err on the side of caution.

W
hen I start my job at Bellevue, in July of 1996, I am a single, thirty-year-old, five-foot-four, pear-shaped gal with long brown hair, freckles, and green eyes. I am smart—more than that, a smart-ass. Growing up in the suburbs of Boston, I got good grades and had plenty of friends. I sported a cool, tough-girl act which served me well over the years. I swore a lot, wore jeans, boots, and a leather vest, and smoked cigarettes. I also played guitar and sang in a rock band.

In high school, I became fascinated by the brain, and by drugs and how they can acutely alter reality, which I discovered via my own travels through the looking glass. I knew I wanted to be a “brain doctor,” either a psychiatrist or a neurosurgeon. A premed at Penn, I majored in the Biological Basis of Behavior, devouring coursework in psychology, neurobiology, and psychopharmacology, great training for my eventual career in psychiatry. My cousin was going to Penn Med at the time, and I would run into him around campus. He introduced me to a friend of his who was doing his psychiatry rotation, who was surprised to learn that there was not much emphasis on psychotherapy anymore. “Psychiatry’s all pretty much done with medication now,” he told me, disheartened, but I was thrilled, looking forward to immersing myself in a prescription-driven field. I was enraptured by the brain and how it could misfire, but it wasn’t just the hardware that intrigued me, it was the software with the bugs. And if I was interested in how drugs affected the mind, psychiatry made a lot more sense than neurosurgery.

All through college and medical school, it wasn’t enough for me to ace my exams, I had to be the one who turned in the test first, and gave the teacher attitude to boot. Ultracompetitive but trying to look like a slacker, I thought it wouldn’t seem cool to try too hard. I studied in the back corner of the library, never letting on that I had to work for my successes.

There was a brief detour in my senior year at Penn, when I decided that I didn’t want to become a doctor after all. It was the late 1980s, and I deluded myself into thinking I was the next Madonna, or maybe Chrissie Hynde from the Pretenders. I took a year off after graduation, singing in my band, playing the electric guitar, and riding a motorcycle through the streets of Philadelphia. Even though I had taken my med school exams, filled out all the forms and written the essays, I ended up throwing it all away, literally. I tossed the sealed, addressed envelope containing my application into the garbage the day after my new band formed, sure we were going to make it big, and even more convinced that I had to try. I didn’t want to spend the rest of my life wondering about what could have been. My parents were understandably furious.

After a year of playing in the band and working in a Philly hospital doing neurology research, I got bored and decided to get back on track and go to med school, but I didn’t quit the band. I spent a good chunk of my first two years at Temple Med going to rehearsals and gigs while studying anatomy and physiology. I crammed for exams in between takes in the recording studio, or sat in my car in the parking lot of a nightclub catching up with my textbooks between the sets of a Saturday night concert.

Eventually I quit the band. Once I started my clinical rotations, there was no time for anything but the hospital and sleep. After graduating from med school, I landed a psychiatric residency at Mount Sinai Hospital in New York City. After that, I ended up at Bellevue. Where all the other crazy people end up.

Psychotic people come to our psych ER from all over the world, as if Bellevue were a beacon, lighting the way. Patients will explain, “I started to hear voices, so I figured I should be at Bellevue.” They’ll walk from New Jersey, take buses from Missouri, hop flights from Cairo. One woman walked across the George Washington Bridge carrying two large bags full of her own feces, because she somehow knew she needed to be here. (The feces are hard to explain. Some patients, when they
become psychotic, collect all sorts of things that take on special meaning for them.)

Bellevue is a full-service hospital in Manhattan, but many assume it is primarily a psychiatric hospital. The police in New York City are guilty of this as well. They will pull people off of the bridges, out of the subway tunnels, or in from the tarmacs of the airports and deliver them straight to us. Even though the public hospitals throughout the city are divided by catchment areas, the cops bring us psychiatric cases from all five boroughs, knowing that we can handle the patients no one else can.

So why am I so attracted to this patient population? I’ve always been enthralled by insanity. When I was a kid and my parents would take me into Boston, I’d immediately notice the homeless schizophrenics, how they would walk around pelvis-first, talking to themselves. I was fascinated by the idea of hearing voices, of paranoia and disorganized speech. I wanted to understand and help them, but I also think my desire was about wanting to play with fire, to swim in the deep end.

So now I am the doctor in charge of Bellevue’s psychiatric emergency room, also known as CPEP (pronounced “See-Pep,” the Comprehensive Psychiatric Emergency Program). I run two fifteen-hour overnight shifts on Saturday and Sunday nights. They call me “the weekend attending.” It feels just like rock-and-roll psychiatry to me. This is my Saturday night gig.

My work week starts on Saturday evening at six thirty. As I drive south from my apartment near Mount Sinai on the Upper East Side, the East River is on my left, the UN on my right, and I make it to the hospital in about twelve minutes. There is a great view of the Empire State Building as I walk toward the hospital from the back parking lot. I pass the older buildings, the storied repositories for the disenfranchised, which now house the shelters. There are broken statues on the lawn, the grass overgrown behind the wrought iron fences that surround the decrepit buildings. Faded signs point to destinations no longer in existence.