Weekends at Bellevue (40 page)

“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.”

B
y 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.

There is a diaphanous membrane between sane and insane. It is the flimsiest of barriers, and because any one of us can break through at any given time, it scares all of us. We all lie somewhere on the spectrum,
and our position can shift gradually or suddenly. There is no predicting which of us will be afflicted with dementia or schizophrenia, who will become incapacitated with depression or panic attacks, or become suicidal, manic, or addicted. None of these states of mind are uncommon, and all of us have friends and family who are suffering with some degree of psychiatric illness. Many of us should be grateful for our relative mental health.

The reality is this: All of us, to some degree, are mentally ill. We get paranoid, anxious, depressed, and insomniac. We alternate between delusions of grandeur and crippling self-doubt, we suffer from paralyzing fears and embarrassing neuroses. We all have compulsions to do things we know we shouldn’t, and there are millions of us with addictions, whether to gambling, drinking, dieting, or playing Second Life. Every one of us has psychiatric symptoms, many of them serious enough to warrant attention, even if they are not incapacitating. But few of us are willing to let on that we are suffering. This secrecy and shame compounds our avoidance of those who have been officially diagnosed as mentally ill. (In family therapy, where the whole family is considered dysfunctional, there is typically one member considered the “identified patient,” who may have a diagnosis or be taking medication, but everyone else in the family is seen as a participant in the dysfunction, too. As in family therapy, so too in the world. Some people may be the “identified patients,” but we should understand that we are all dysfunctional, to some extent, individually and collectively.)

We avoid dealing with psychiatric patients because we hate to see things in others that we don’t want to see in ourselves: weakness, need, despair, aggression. Our experiences with the psychiatrically ill often fill us with dread; they confront us with our own terror of reaching a catastrophically altered state from which there is no return. We should be compassionate to those who stumble out of our lockstep. Yet in our culture, the mentally ill are demonized and shunned. They are ostracized and marginalized as a by-product of our primal fear of going crazy ourselves. It is the nightmare of our own “shadow self,” as Jung called it, that allows us to treat others so harshly.

Families who would typically care for their own turn their backs on children or siblings who have lost their grip on reality. It is too frightening and emotionally draining to tend to their needs. These persistently, chronically ill patients are then left to fend for themselves, relying on
the shelters, hospitals, and soup kitchens to become their caretakers—their new makeshift families. This is how America does it. The hospitals and outpatient clinics substitute for the parents, who are unable or unwilling to tend to their own psychiatric casualties. And it is painful, first and foremost for the patients. I learned this simple fact in my first year of residency at Mount Sinai. Rounding on our patients in the ward, we asked a man with schizophrenia if anything was hurting him.

“Yes,” he replied. “My family doesn’t come to see me.”

Not all countries treat their disabled in this way. Jeremy and I took our first trip together to Vietnam in 1996. I could see how differently the Asian people dealt with the mentally ill. The “patients” were kept with their families, absorbed within the community, their impact diluted among its healthier members. I would discover them in the villages, where they were assigned menial jobs and managed and attended to by their peers. It is a better system than ours, which lumps all the mentally ill together and concentrates them in state hospitals, nursing homes, and adult homes, where they feed off the insanity of their neighbors.

Instead of integrating them among us, we shutter our psychiatric patients away so that we will not have to be reminded of all that can go wrong with our own minds and brains. It is unfair, not just to those who are in some way mentally “defective,” but to us all. I have learned a tremendous amount about myself and the world, about what is important in life and in love, by spending time talking to people with broader worldviews than my own, and that certainly includes the patients I have met at Bellevue. Too quickly, we take away the civil liberties of others due to our collective phobia about insanity, and about altered states in general. This is the basic fear that also fuels our war on drugs, and it is shortsighted and impractical.

We are shortchanging ourselves as a culture by not taking better care of our own psyches, and of the psychiatrically wounded among us. But it’s not an easy job, obviously, to fix their wounds. Nearly every shift, I’m asking myself, What do I do with this patient now that he has shown up here in my ER? What does he need from us right now? Unfortunately, the most common answer is: He needs a childhood transplant, he needs to start over—with loving parents this time, in a caring, nurturing environment.

Most psychiatric patients, especially addicts, alcoholics, and criminals, have horrendous histories of neglect and physical and sexual abuse.

Since there’s no way to fix that after the fact, it’s a lot harder to fix them. Many of the addicts and alcoholics that I triage don’t seem all that interested in getting into treatment, or sticking with a program long enough to make real changes in their lives. Letting them sleep in the ER for a night or two rarely works miracles, and one thing I got used to early in the game at Bellevue was seeing some patients over and over: the drunks who’d show up regularly, the crack addicts who’d come in like clockwork when their checks ran out. I learned to regard the revolving door of my workplace with equanimity. I was not going to be able to change a damn thing, more often than not.

“I’m a cog in the machine; I am a spoke in the wheel.” I chant my mantra in front of the nurses as I twirl in a circle, waving my arms like Shiva. Between the bureaucracy of working in a huge city hospital and the recidivism of the patients, I develop my own version of the serenity prayer:
Help me learn to accept that I cannot alter the machine, and I will try my hardest to make sure that the machine does not alter me
.

I
t is June 27, 2005, my last Monday morning sign-out. July first is next week, but just as I planned last winter, I have not re-upped for another year in Bedlam. I am O.T.D.

I often joked that I’d be working at Bellevue until I was a stooped-over, osteoporotic old woman, and when I said it, I usually believed it, but I’ve finally worked my last weekend. I’ve decided to trade in the psychotics for neurotics: I’m going to do full-time private practice. I always assumed I’d stay hospital-based, mired in academia, teaching and performing clinical research, but my path is pulling me in a different direction. I feel as though I’m heading out to pasture, and I’m not even forty.

I tell people that the reason I am leaving is because of Molly; I need to alter my schedule to accommodate hers. She’ll be starting kindergarten in the fall, and we have decided that we’d prefer her to go to school in New York City, which means reversing our schedule and spending our weekdays in the city and our weekends upstate. That in turn means I can’t keep working my weekend shifts at Bellevue, but working weekdays at Bellevue doesn’t make any sense financially. I can work in my private practice three days a week and still spend plenty of time with my family. And I’m starting to feel that I can be a better doctor in my office than I can in the ER, with a chance of effecting real and lasting change in people’s lives.