The following is excerpted from Weekends at Bellevue: Nine Years on the Nightshift of the Psych ER. (Bantam, 2009)
On a warm day in early spring, two New York City cops and two EMS workers roll a gurney down the hallway, escorting a man to the entrance of Bellevue's psychiatric emergency room, where I work. Lying on the stretcher underneath a white sheet, with a head of dirty blonde hair beaded and dreadlocked, he is naked, sunburned, and screaming. I walk out to greet my new patient as the drivers hand me his paperwork to sign.
"What'd you bring me?" I ask eagerly. I can see he's a live one. I love the live ones.
Over the shrieking, one of the EMS guys gives me "the bullet," the few pieces of relevant information when introducing a patient to a doctor: age, chief complaint, pertinent history. "This is Joshua Silver. Twenty-three. No significant medical history, no allergies, no meds. Also, he denies a psych history," he says archly, shooting me a look.
"And how'd he get to you guys? Who called 911?"
"NYPD called in an EDP." This is cop-talk for a psychiatric patient: emotionally disturbed person. "He'd taken off his clothes in Times Square and was parading around, barking like a dog. And growling," he adds.
This gets the patient's attention, and he interrupts the driver to clarify, "It was my way of showing them that I was not an animal. I am not a dog!"
Barking and growling to prove he is not a dog? His logic is lost on me, but at least he's stopped yelling and started communicating.
"You can talk to me," I say, turning my full attention toward him.
"See, there were some guys from Nation of Islam preaching on the corner, and they told a woman who was arguing with them that she was just a dog-God spelled backwards-to which I took offense." He then explains to me, as he did to them, that all people are art. "‘Thou art art,' I told them. ‘Once you accept that all people, all objects, are art, you will live in heaven as I do.'"
"You know what, Joshua? I ask, having decided it is time to move out of the triage area and into the locked area. "I think you and I should go talk about this inside." I want us to sit in an interview room so I can try to get some more history, and I don't feel like standing over him while he lies on a stretcher. I can already tell he's an admission and will need to be in the detainable area for patients awaiting beds upstairs.
I let EMS and NYPD know that they are free to leave, and I grab my new patient some hospital pajamas. I help him off the stretcher, wrapping his sheet around him, and walk him into the larger, locked part of the ER. As I escort him through the entrance, the door clicks definitively behind us, and I hope he doesn't notice that he is now locked in. Because he is naked, we can dispense with the contraband search, which is good. The search is often the point where people become uncooperative and agitated, ending up restrained and medicated.
Prior to entering the detainable area, a patient must remove his belt, shoelaces, rosary beads-anything that can be used to hang himself or choke a fellow patient. Inevitably, the patient will insist that he is not suicidal or dangerous, but it doesn't matter; these items are not allowed in the detainable area. Neither are cell phones, crack pipes, backpacks, knives, pens, wallets, and the list goes on. The patient has to give up just about everything along with his freedom.
Luckily, Joshua is oblivious. I show him to the bathroom where he puts on the pajamas quickly. I alternate between keeping an eye on him and setting up the interview room. There are several windowed rooms within the detainable area, each with a desk and two chairs. I put my chair closer to the door. As we settle into our talk, the first thing I notice is that although he is disheveled, he seems well-educated with an impressive vocabulary. He tells me he has written a twenty-eight-page manuscript, which he calls a prose-poem, based on his newly embraced credo that everything is art. He is hoping to reach millions of people by delivering his manifesto on the Howard Stern show on K-ROCK, a radio station in the city.
"I am a holy man," he tells me, explaining how his writing has elevated him to this level. "I feel like King Arthur in a tower of Babel." He is hyper-verbal, spewing non-sequiturs. I try to keep up with him, playing follow the leader, as if we are hopping from rock to rock in a rushing stream, but he is pulling far ahead of me. Eventually, I have to tell him he's not making a lot of sense.
"Joshua, you need to slow down. I want to understand what you're saying, but it's difficult for me. I'm focusing on the illogical connections that you're making…"
It sounds like "theological connections" to him, and his smile beams; he's pleased that I've grasped his religious message. I don't bother to correct him.
Being preoccupied with religion is a classic manic symptom, and mania is the better-known half of manic-depression, now called bipolar disorder. In a manic state, people have less desire for sleep; they will talk more, create more, do more. Commonly, bipolar patients get hyper-religious in their newfound frenzy and sometimes end up on a street corner and then a psych ER explaining that they are Jesus or the Messiah, or that they've discovered a new religion. They've been touched by the Lord who spoke to them. They've had a vision, an epiphany, and they want to share it with the world. Their grandiosity can be charismatic and alluring. Religions and cults are formed around this kind of energy, and I'm happy to warm myself by Joshua's fire during the interview.
In March and April, our ER becomes crowded with manic patients. For many bipolars, there is a seasonality to their symptoms. Just as more people get depressed in the winter months, increased exposure to bright sunlight can elevate moods. Also, the air is heady with religious themes during spring, when Easter and Passover coincide. The resurrection is re-enacted in the budding trees and sprouting flowers, miraculously coming to life where once lay a blanket of snow. We get multiple Jesuses in the ER this time of year.
Joshua's pressured speech is another sign of his mania. It rambles hither and yon, like a butterfly dancing merrily among the flowers, setting down briefly on the themes of religion and art as if they were particularly colorful blossoms. I try to join him in his word-play, to engage him gently in the hopes of learning more about him: where he's from, where his parents are, and whether he's stopped his medication, which is a good bet. Most of the manic patients who come through our doors have gone off their meds. The mood stabilizers have significant side effects, and people are often resentful about having to use them. Also, mania usually feels better than being medicated, at least for a while. It's a bit like surfing, knowing it has to end with the inevitable wipe-out, but loving the balancing act required to keep it going.
Most of our patients battle with their need for medications. When they start to feel better, they abandon their treatment plan, thinking they're cured. Even if they know they'll get sick again, they hate taking the pills so much that they stop anyway. Coming through our doors is a painful and humbling lesson in how to manage their illness.
"Joshua," I begin yet again.
"I fought the battle of Jericho."
"I've heard that about you, yes." I smile. "Are you from Jericho?" I ask earnestly.
"No, I don't think so."
"Or maybe a town near there? You took a bus to New York City from where?" I ask[ES1] . "Can you tell me where your parents live? Is there anyone who might be worried about you, who doesn't know where you are?"
He won't answer any of my questions directly. A town near Jericho? What the hell am I thinking? I'll tell you: I am trying to meet him where he is, to work within his delusions and focus on what's important to him, and then gently lead him out to where I am, in reality. This is one definition of psychotic-broken with reality. He lives in a dream, but his hallucinations and delusions are as real to him as the movies we star in while we sleep.
Despite my coaxing, I can't get anything useful out of him. I want to find his parents because I need to talk to someone who knows him to learn whether he's been sick like this before. And I want to let them know that he's been found. I've made dozens of phone calls to parents of the bipolar kids[ES2] who end up on our doorstep. We get plenty of "first breaks" at Bellevue, the first episodes of psychosis which often herald the arrival of bipolar disorder or schizophrenia. They tend to occur in the late teens or early twenties. This is when the brain is pruning back and reorganizing connections made throughout adolescence, and also when everything is getting more challenging: starting college, joining the army, traveling. Sometimes, during these phone calls, I hear about how bright and promising their children were before they got sick. Other times, when it's not the first break, but the latest in a long series of them, the parent on the phone is terse and angry, burned-out, tired of being woken up in the middle of the night to answer the same questions from yet another psychiatrist. In many ways, that's easier for me to deal with than the heartbreak of talking to the "new" parents, giving the first diagnosis, gingerly explaining the illness and its treatment, knowing as I do that they may be in for decades of calls from ER docs.
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, were 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 questions as far as I'm concerned-he's a definite admission[ES3] . 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 criteria 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 neuro-chemical 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 in 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 in order 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.
Julie Holland, M.D., is a psychiatrist specializing in psychopharmacology. An assistant professor of psychiatry at NYU School of Medicine, she spent her weekends running the psychiatric emergency room at Bellevue Hospital for nine years. She is the editor of Ecstasy: The Complete Guide–A Comprehensive Look at the Risks and Benefits of MDMA.
Image by ricoeurian, courtesy of Creative Commons license.