Weekends at Bellevue (30 page)

I go into morning rounds to report on the patients in the area. When I get to Isaac Jackson, and tell the whole story, I get a little choked up.
Daniel doesn’t let it go, of course. “Doctor Holland, I’ve never seen you get so emotional about a patient. This one really got to you, huh?”

In front of everyone, he is making me feel like a sap. I give a mini-lecture on MDMA-assisted psychotherapy. I try to defend myself, the experience I had last night, but mostly I am worried about my patient. I am worried that in the cold light of morning, with the indifference of a new shift, Isaac will simply be grist for the mill. Packed up and shipped off like any other patient: He was high, he’s cleared, get him out the door and on to the next patient. I explain, in more detail than I probably should, the content of our session the night before. I plead with the staff to spend extra time with him today, to treat him gently, and to follow up on the plan to get him to Texas. At the very least, get him a detox bed. Daniel moves rounds along dismissively, and I seethe.

I find out the next weekend that Mr. Jackson was discharged on Monday morning, hours after I left, with no real assistance from us. I am told that he “didn’t want detox.” It pisses me off that they didn’t do as I asked. The paranoid, neurotic part of me can’t help but think that Daniel personally made sure that Isaac was discharged without getting what I wanted for him, though Daniel assures me that they did spend extra time with him and it went nowhere.

After one more drunken CPEP visit several months later, Valerie does help him to get some bus-fare money wired from his girlfriend, and we never see him at Bellevue again. I like to think he’s a Texan now, down there with his wife and daughter, and he is making up for lost time, making his life better, finally.

I won’t follow up and call him. I learned that lesson years ago. I won’t even do a search on his name in the computer to see if he’s been to the AES. I’d rather just pretend that he’s found a happy ending. It makes my job easier.

T
he night starts out light on December 14, the day after my birthday. There are only a dozen people in the area and no one on triage. I make the mistake of appreciating out loud the low census, and the superstitious nurses shoot me a look. Oops. Sure enough, in the next hour I’ve got four triages and nowhere to put them. There’s a long-standing tradition in medicine of avoiding certain words in the ER. I waver between being superstitious and not, but there are definitely ER staff who deem it bad manners to mention certain words: “calm,” “quiet,” “dead.” They think it’s like baiting the gods to screw with us.

Superstition is akin to something that psychiatry calls “magical thinking,” the belief in talismans, omens. It’s normal in most people, and easy for me to see why. Twice now at Bellevue I have uttered the word “dead” as in, “Man, it’s totally dead in here!” and the crowds came running. Five EMS deliveries in seven minutes once, moments after the evil word was uttered. Now I allow myself the occasional “slow” or “easy” but rarely will I say the word “quiet” and never, ever “dead.” Mostly, it is safer to never comment on the activity level of the ER when you are on shift, though it’s fun to utter a prohibited word as you’re leaving. Then it’s someone else’s problem. Tonight, though, it’s mine.

A pair of EMS guys, two of my favorite clowns, bring in a patient who’s been to Bellevue before. The 911 call came from the Port Authority police reporting an overdose in the bathroom. Jesus Martinez,
at thirty-four, has end-stage AIDS contracted from IV drug abuse. Years ago, he unknowingly infected his wife with the virus, and she has recently died. Somewhere around four-thirty in the afternoon, he shot a big load of heroin and cocaine in a bathroom stall at the bus station, hoping it would kill him. At nine p.m., he was found by a janitor. He had been passed out on the toilet for nearly five hours, and had a temporary sacral neuropathy. Basically, his legs had “fallen asleep” due to the compression on his buttocks, so he was unable to walk after my two EMS pals revived him.

They regale me with the details of their pick-up, telling me there was vomit, urine, and feces at the scene. Mr. Martinez’s colostomy bag had become unhooked, leaking its contents all over the bathroom floor. They make some joke about a trifecta, and we all laugh. “It’s the holy trinity of body fluids,” I add.

When they bring him to Bellevue, the EMS drivers assume the patient will be accepted at the medical side of the ER since he is an overdose with an inability to walk, not to mention the end-stage AIDS and colostomy bag. But the AES nurse signed off on him and told EMS to bring him to us. When EMS presents the case to me, they encourage me to “bounce him back” to the AES, as if I need encouragement to get rid of this guy; the stench is impressing even my veteran nose. I roll the man down the hall to AES, looking for the attending. I’m hoping he’ll be cool and just accept the triage, do me a favor, but it’s a new attending I’ve never met. She’s Polish, or Russian maybe, and about five months pregnant. She looks cute in her scrubs with her little belly, and it’s hard to hate her, even though she examines the guy a bit, asks him “Where does it hurt?” about half a dozen times, and turfs him back to me.

“The overdose was six hours ago. He’s fine. His feet have good pulses,” she says to me.

The fetid stink from his feet hits me seconds after she takes off his shoes. “Have you had much trouble working in the ER during your first trimester?” I ask her. “I remember when I was pregnant with my daughter, I really had a heightened sense of smell, and also more of a gag reflex than usual. Are you doing okay?”

She smiles, and we have shared a moment; belonging to the same club and all that. Then it passes. We discuss briefly the fact that he can’t walk right now, which is a new symptom for him. I know he’s
got a temporary syndrome from the compression of his sacrum, but I’m playing dumb, asking if he’s paralyzed from a stroke or something, hoping she’ll take him and do a head CT. She minimizes all his physical complaints, findings, and history, and is gently making it plain that she is still not signing the EMS sheet, not accepting the patient to her area.

“You’re getting hit with triages even worse than I am tonight,” I notice. It is a peace offering, my mentioning how busy she is, and she takes it as such. She smiles sweetly as I decide to do her a solid and take a hit for the pregnant doctor.

Back at CPEP, we wheel Mr. Martinez to the high-visibility area, right in front of the nurses’ station. I know a little about this man, because he has been admitted to Bellevue a handful of times in the past. He had a well-known hospital roommate awhile back, maybe a year and a half ago. A man on 12 South—admitted after he cut off his penis and the Bellevue surgeons reattached it—had attempted to escape from the hospital. The man spent days, or perhaps weeks, meticulously cutting strips off his mattress and braiding them together to make a rope. Then, he somehow pried open a window and attempted to rappel himself down the side of the building. Needless to say, the makeshift rope broke, and he fell roughly ten stories to his death on the street outside the hospital.

Mr. Martinez was traumatized by this, as were many other patients on the ward. He somehow felt guilty about his roommate’s death. But the real guilt that was driving his current behavior was that, in his eyes, he had killed his wife. His years of shooting drugs into his veins had left him with AIDS, and he infected the woman he loved before he knew he was ill. Since her death six months ago, he has made several attempts on his life.

Between the overpowering foot smell and his burst colostomy bag, this guy needs a shower in the worst way. He’s being nasty to the nurses, and irritable to the psych techs. He even spits at one of them.

“Go away!” he yells. “You babied me the last time I was in here, I don’t want to be babied. Get away from me!” He lets Magil, the psych tech, change his colostomy bag, but then he starts complaining loudly about the pain he’s having from his herpes zoster, aka shingles. AIDS patients, with their weakened immunity, often have herpes, which is a virus that lies dormant in the body waiting to be reignited when the
patient’s immune system lets its guard down. The virus hides in the nerve cells of the body, and when the herpes infection flourishes anew, it is immensely painful. And this is not a guy who suffers in silence.

I call the pregnant AES attending, wondering if there is any medication she specifically likes for the neuropathic pain of herpes, which is often treated differently from other kinds of pain. She tells me to give him Tylenol with codeine, or morphine. She knows he’s shot heroin earlier today, but I go ahead and give him two Tylenol 3s, because his jaw is grinding away a mile a minute, which tells me the cocktail he shot up this afternoon must have had more cocaine in it than heroin. I write the order at ten thirty.

I’ve got five triages to deal with; I figure I better start in on the pile. As usual, I look for the easy T & Rs, people I can shoo out of the area with a minimum of paperwork. I leave the more complicated admissions for the resident.

The surefire T & R, one hundred percent of the time, is an arrested woman. If she’s calm and not dangerous to herself and others, she goes back with the police to get arraigned. If she’s insane or agitated, she goes to Elmhurst Hospital, which the city has designated for female forensic psych admissions, the counterpart to our 19 West, where the male cases are housed. I talk to the cop to see what the charges are, and why she was brought for psych clearance.

He shoots me a smile, and tells me, “You’re gonna love this one, Doc. Assault with a deadly weapon. She attacked her husband with a huge plastic Santa Claus lawn ornament.”

“‘Tis the season!” I quip.

I speak to the arrested woman briefly, enough to establish that while she is schizophrenic and mad at her husband, she is not acutely psychotic, dangerous, hallucinating, or agitated. I send her out with the cop, who is impressed at how quickly his Bellevue detour has been resolved. He heads back to the station to book this woman, and I head back to the rack to pick up another case. I’m on a roll, so I pick up another chart, hoping for a second T & R. It is a woman brought in by EMS, accompanied by her brother, who tells me that he’ll take her home with him after my evaluation, which is music to my ears. A family member willing to take responsibility for a patient means I don’t have to fret so much about her disposition. The EMS sheet reports that her neighbor called 911. The patient
was drunk, complaining on the phone to her neighbor about her children, making some veiled references to suicide, wishing she were dead.

I opt to interview her at what I call the picnic table, a sturdy metal version set up by the EOU rooms, under a TV to glance at in case I get bored during the interview. I strategically place her back to the television;
Saturday Night Live
is on. I spend about five minutes trying to cajole this woman into telling me what she said to her neighbor so I can document just how suicidal she sounded.

She is still a bit drunk, coyly skirting her exact words, and I feel myself getting frustrated because she wants to tell me the backstory. She tries repeatedly to unload her sorrows on me, about her children, her loneliness. What I really need is a direct quote for the chart: Exactly what did she threaten on the phone? Just as she’s finally giving me the goods, I hear a frantic shout from one of the psych techs for me to come quickly. “Doctor Holland!”

“Julie. You better get over here,” the resident adds, nervously.

Mr. Martinez is on the floor, and they’re cutting away what looks like a long black shoelace from the stretcher, unwrapping it from around his neck. Once the string is removed, I can see its braided pattern embedded in his swollen neck. His face is mottled, purple and gray, and he is lying in an awkward position on the floor, his arms and legs arranged around his body at odd angles.

Bill, one of the psych techs, tells me, “He took off his hoodie tie and wrapped it around his neck.”

With the other end tied to the railing of his stretcher, he has thrown himself off the edge of the gurney, hanging off the ground just enough to choke himself. I squat down to feel his wrist while Bill feels his neck for a pulse. I feel nothing, but Bill says, “I’ve got a pulse!”

Jesus is unresponsive—not talking, not breathing, as I rub his sternum and call his name. His colostomy bag has burst onto the floor, the maroon liquid spilling out into an ever-widening circle as the hospital police and techs put on some gloves and lift him onto his stretcher. I stand there frozen for a moment, then quickly decide to bring this guy to the medical ER.

“Let’s get him to AES!” I yell. There is no way in hell I am running a code in the CPEP. It is such a rare event, and the staff, including me, is ill-prepared for it. He’ll surely die that way. There is no time to
second-guess myself, but it is a decision I will have to defend repeatedly in the days to come.

Bill and I push the stretcher out the door, as I yell at the patients to clear the way. We maneuver the stretcher out the CPEP doors, making sharp turns, right, then left, then left, then right, until we reach the straightaway down the long hallway to AES. There are multiple sets of double doors. Why are there so many doors? Dangling off the edge of the stretcher, his right foot hits one door jamb and then another, as we do our best to steer the less-than-agile gurney. We pull into the ambulance bay of the AES, as if we have a new EMS case for them.

“We need a doctor here!” I yell. (A
real doctor
, I think to myself.
Not a shrink. Someone who can save a life, like they do on television.)

The chief resident runs over and directs us to wheel our patient into a spot by the door.

“He tried to hang himself from the stretcher,” I tell him. “He has AIDS, a colostomy. He overdosed on heroin and cocaine earlier today.”

The chief establishes that the patient isn’t breathing and requires oxygen. While he bags the patient, putting an oxygen mask over his face, he asks me, “How long has he been down?” By this he means without oxygen, and it will be the question that runs through my mind repeatedly as the code progresses:
Why didn’t I bag him while we were transporting him here?
I estimate a minute or two, taking into account the time it took us to speed him along the interminable corridor, but I can see the resident is skeptical.