Twelve Patients: Life and Death at Bellevue Hospital (31 page)

“Well,” Mahendra concluded, “the smarter you are, the harder to accept treatment. I prefer the Bellevue patients to my Lexington Avenue patients in terms of drug adherence. They understand that mental illness is like diabetes. It is for life!” He knew as well as I did there was a relapse rate of better than 80 percent a year for patients who stopped their medications. They were now entering into the world of a chronic disease where accepting the illness and adhering to the drug regimens were the major challenges. As one of my psychiatrist colleagues at Fountain House on the west side of Manhattan said to me, “Eric, it is all about the medications.”

“Did he have any relationships?” Mahendra asked.

“No. A few guys he occasionally went out with. Pizzas and Chinese takeout most nights. Pretty normal for geeky mathematicians, physicists, computer scientists, and engineers. But by this time he had switched to studying religion with a mathematical twist. Ancient
languages and hidden messages in texts were his thing. He was studying Aramaic, deciphering Kabbalah and Midrash, when he came to New York City by bus to find Scarlett Johansson or the mother of Jesus. Meanings within meanings, hidden symbols in abstruse texts in dead languages completely absorbed him. Physics and religion were one and the same.”

I realized that I had seen Jeffrey over a long period of time now and watched his schizophrenia or what we call the natural history of an illness in real time, up close. After his initial psychotic “break” he had been treated with a combination of medications and psychotherapy, with excellent results. As one of his therapists told me, “You couldn’t tell he was schizophrenic—he had that good a response.” From his first psychiatric admission as a graduate student to the unkempt Prophet before me unfolded a tragic series of downhill steps.

French researchers developed the first anti-psychotic medication in the 1950s while looking for a way to assist anesthesiologists in preparing their patients for induction, to make them drowsy just before giving them a general anesthetic. The Thorazine class of medications was serendipitously noted to change the mood of patients and reduce psychotic delusions and hallucinations. Executives at the French pharmaceutical company Rhône-Poulenc recognized the possibilities and an entire class of medications was developed over the next ten years and licensed to Smith, Kline & French. The remarkable had happened. There was a pill for psychotic patients. The barbarities of a generation of frontal lobotomies and insulin-induced hypoglycemia were finished. Over half a million patients with serious and persistent mental illness were warehoused in state hospitals across the country in conditions that were more reminiscent of the Gulag archipelago in the old Soviet Union than asylums conceived by nineteenth-century sanitarians.

A nationwide movement followed to “deinstitutionalize” these patients and move them into community settings over a decade. The lack of adequate resources, and appropriate oversight, however, along with the exponential growth of a prison industry enabled by the war on drugs, shifted the newly deinstitutionalized patients onto the street, into the prisons, and into poorly regulated facilities in a booming new
“industry” of community therapeutic living. The comprehensive community mental health resources promised by President Kennedy never materialized as the Vietnam War spun out of control and siphoned off both the will and the dollars. While there were many success stories, and Bellevue worked closely with many of these community patient-based organizations, the full dark story has yet to be written aside from the occasional scandal of sexual abuse and another state politician being prosecuted for funneling funds to family members.

Mahendra and I went into the common room together. I went up to Jeffrey and said hello. “Do you remember me, Jeff? This is Dr. Mahendra, he’s the head psychiatrist on the emergency unit and will be in charge of your care here.” I spoke to him softly and slowly.

He looked at me and said, taking his time, “I know you.” His eyes skittered around the room, rimmed in red. With his tangled graying beard and pungent smell, it took imagination to make out the young man I had met twelve years ago behind the wizened weathered face that bore the marks of street-years like intergalactic light-years.

His urine tox screen was positive for cocaine, speed, alcohol, and benzos. This was the cocktail in different combinations that each time led to his “relapse” and progressive deterioration over the years. The CPEP team had put him on sedatives to mitigate drug withdrawal symptoms, along with a rapid-acting anti-psychotic medication that dissolved under his tongue to quickly bring the frenzy of psychotic thinking under some kind of control, along with its more general sedating effects.

This was an all-too-common scenario for so many of the mentally ill patients in the large room. Unable to get a handle on their meds, they became recidivists, frequent fliers, high utilizers of health care dollars, cycling in and out of the medical system. The staff knew them well, down to a fine-grained level of detail about their lives—the lost families, careers, wives, and children, and their delusional systems. Their medical histories were filled with the most common diagnoses of hypertension, diabetes, obesity, high cholesterol, and, for three-quarters, heavy tobacco use. The statistics were revealing. Average age at death was twenty-plus years younger than among patients without
serious mental illness. These common undiagnosed and untreated medical conditions were the bread and butter of an internist’s practice. All were treatable with access to quality medical care, and the consequences were all preventable. I decided to see Jeffrey on the inpatient unit when a bed was available.

Our visit was abruptly interrupted by Isabel Humala, the middle-aged veteran head nurse who poked her head in from the nursing station door: “Captain Stanley needs to talk to you guys right away. Mr. Snickers is on his way. And to make your lives sweeter, he has finished his sentence and needs to be placed on a civilian unit! I knew you guys were blessed.
Suerte, amigos míos
.” She let the door shut behind her with a heavy bang and was gone before we could say anything.

Mr. Snickers. I was not thrilled to have this patient transferred to Bellevue at any point, regardless of our expertise and position in the public health system of New York City.

My first inkling of his existence was a phone call from my counterpart at another city hospital over a year ago. One of the psych nurses had nearly been killed by a prisoner who refused his anti-psychotic medication. He used her head as a battering ram on the floor until six health tech aides could grapple and manipulate him off her limp body. It took a prolonged hospital course and a long period of rehab for her to recover physically. The emotional toll would last a lifetime, and the contagion effect through the system was profound and instantaneous. The newspapers picked up on the story briefly and then let it drop. It was much more salient and clearly financially more rewarding to report on our imperfections and mistakes than when one of our own was caught in the line of fire doing her daily job.

At the time of the assault, Mr. Snickers was in prison for a parole violation and possession of marijuana. The additional assault charge was made a misdemeanor. The result was that he finished his year at Rikers Island with some intermittent hospitalizations for psychotic symptoms when he stopped taking his medication. His delusions were a mix of Old Testament imagery, garden-variety paranoia, and his response to watching Hassids annexing large swaths of his Crown Heights Brooklyn neighborhood.

And now he was back, unmedicated no doubt. Six foot four and weighing three hundred pounds. Maybe the Prophet could talk him out of thrashing living beings. The legal rules of engagement allowed prisoners to take their medications or not, even if they were severely psychotic. Their legal right of refusal was sacrosanct in the system of public health law that used the “least restrictive” test to decide whether they should have the medication or not. For many prisoner-patients at Rikers Island, it was rational to refuse medications—counterintuitive as that sounds. The medications are sedating, and the challenge of survival meant you needed your wits about you at all times. Better to have racing thoughts and command delusions (“that guard is teleprompting messages to my temporal lobe”) than a jailhouse rape or loss of your hard-earned cigarettes.

Mr. Snickers had been at Bellevue a couple of times in the last year, both on the prison forensic unit, where we were used to violence-prone patients in the throes of a hallucinatory storm. Despite having Department of Corrections officers present and a staff trained for this type of work, the triggers for violence were often subtle, and our people were not immune to attack, beatings, attempted rapes, inappropriate touching, and every type of verbal harassment. An amicus brief, the Reynolds Agreement, brought by local and national patient rights groups supporting prisoners’ rights, had “pulled” the Corrections Department from its traditional role of first responder. We were in a sea change of managing undertreated and undermedicated patients with a cornucopia of mental illnesses and drug addictions, criminal records from insignificant parole violations to homicide, and a textbook of medical issues. All of the patients had histories filled with shame and humiliation, the substrate for a volcanic rage that seeped to the surface with seismic results.

Physicians could (and did) get a judge to sign a court order mandating that a patient take medication despite “refusal” when harm to self or others was imminent. The court at Bellevue met every Tuesday. Our lawyers helped with the Treatment Over Objection paperwork, and the prisoners were assigned lawyers provided by the Department of Health of New York. We invariably received the okay to treat the
patients, usually after a ten-day delay to get to court while the patient’s brain was in a psychotic short circuit, burning through neurons. Being psychotic was not a free lunch for the hippocampus and the billions of neurons and their packets of neurotransmitters. Untreated or partially treated psychosis led to profound and permanent cognitive decline and a loss of intellect.

Captain Stanley, a compact and meticulous officer of corrections, found Mahendra and me in the warren of small glassed-in offices off CPEP proper. He was impeccable in his deeply creased trousers, polished black shoes, and custom-tailored white shirt.

“Gentlemen, Prisoner Duprey will be here in an hour and I understand you have chosen 18 North for him. Excellent choice since the team there is first-rate.” The captain had a Jamaican accent that softened his stern exterior.

I let Mahendra break the bad news: “Captain Stanley, we are packed, in fact we are over census. The only place we can provide adequate space and supervision for Snickers is 18 South.”

Before Mahendra could explain further and justify the choice, Stanley was off and running. “That is not a good decision and I cannot support this decision. We planned for 18 North and worked with the staff to ensure everyone’s safety.”

“Captain,” I said softly, learning over some years that when things heated up we needed to lower the temperature, “I have worked closely with the South team and they are completely prepared to provide excellent psychiatric care and a safe environment for Duprey. Besides, they have had a lot of experience with violent patients. I know it is an Asian unit, but at any one time a third of the patients don’t speak a word of Mandarin, Cantonese, or Fukienese, so this is not an exceptional circumstance.” I then said the one thing that he couldn’t and wouldn’t argue with given his paramilitary training, even though my pants never saw a crease. After all, I was the “captain” on this ship. “I accept full responsibility for this decision, Captain Stanley. It is a done deal.” After a few minor pleasantries—he was a gentleman after all—he turned and left us alone in a crowd of thirty-five patients both voluntary and involuntary, ten staff members, five police officers, a
hospital security guard, and a Mexican guy with a wispy beard and mustache who just showed up with four pizzas in a red insulated bag, with white stuffing showing at the corners.

I put off going to see Jeffrey for a few days. The brief visit to CPEP had been unsettling. He was admitted to the eighteenth floor two days later. Mr. Snickers was there as well, so far without incident. The chief of the unit called and invited me to their community meeting. An email followed with a full-page color invitation for Chinese New Year with food and karaoke. What made me cancel some meetings to spend some time on the unit was a call to the trauma slot. Another Chinese woman had jumped in front of the Q train.

Dr. Rosalinda Estrada, a Filipina psychiatrist with mainland Chinese ancestry, greeted me at the door to the unit. A number of years ago, a bad incident at a state psychiatric hospital involving a monolingual Chinese-speaking patient had forced some facilities to reserve a small number of beds for chronically ill patients with staff that could speak Mandarin. Bellevue had responded by creating an “Asian” unit on 18 South with a polyglot staff fluent in many of the dialects that echoed the waves of immigration. The last twenty years saw a movement of Tibetan patients from political persecution and poor rural Fukienese-speaking immigrants who were not participating in the Chinese capitalist “miracle.” Many borrowed the eighty-five thousand dollars from extended family and Snakeheads—as the human traffickers are called—to make the long and hazardous journey.

Rosalinda smiled broadly, put on her white coat, took me by the arm, and opened the door to the day room just as the meeting was getting under way.

Patients trickled in over ten minutes and sat in the semicircle of hard-backed chairs. Half were in pajamas with bathrobes and slippers, half in street clothes. The day room was a functional recreation room for movies, television, group therapy sessions, parties, and celebrations. There were signs in Mandarin and English reminding patients about the Chinese New Year celebration with red cutouts hanging from the ceiling and “Year of the Ox” spelled out for English speakers like myself. The room had been impeccably cleaned, and rectangular
tables were being readied with paper tablecloths for the take-out Chinese food feast in the afternoon.