Twelve Patients: Life and Death at Bellevue Hospital (6 page)

The child psychiatric emergency room had bright colors, flat-screen television sets, and a glass-enclosed nursing station. A nurse and health tech escorted Tanisha into a private exam room. They asked her to undress and gave her some hospital-issue pajamas to wear on the unit. They told her she could have her own clothes back later. The aide searched her carefully and discreetly as she handed her the tops and bottoms and a bathrobe. This wasn’t a new routine for Tanisha; she had been through it half a dozen times before. In her own mind she had run out of options and had to find the safest place possible.

I was having lunch with Francesca Durat, the on-call child psychiatrist, when she was beeped urgently to the emergency room to see the new admission. We had been deep in a discussion of her experiences with childhood trauma. She was French Algerian, and we had been talking about her years working in the
banlieues
, or immigrant ghettos ringing Paris. The populist anger, economic deprivation, racism, and religious intolerance that had led to riots in the suburbs of Paris resonated loudly in post-9/11 New York City. The overhang from a decade of foreign wars, failure to resolve immigration issues, globalization’s domestic effects, and the growing unemployment and inequality was creating combustible domestic politics here, too.

We walked back to the child unit together, and I asked if I could sit in on the intake interview. Tanisha showed no emotion when I shook her hand and asked if she minded if I sat in with Francesca. She nodded okay, looking me directly in the eyes. It made me feel vulnerable. This sixteen-year-old, five-foot-one Dominican Haitian teenager with a thick Bellevue chart from multiple hospitalizations, evaluations, emergency room visits, and psychological testing was rapidly sizing up the two adults in the room who would be evaluating her and making some determination about her future. I switched roles with Tanisha and felt the weight of her “chart” on all of us, the caretakers over her lifetime. What secrets, tragedies, and small mercies were buried in its pages?

I had canceled my afternoon and asked Patty not to put through any calls unless they were true emergencies—and even then to come down and get me, since I turned off my phone and beeper. The consultation room was a corporate back office, a cell with a windowed door leading to an outer vestibule. We sat there for nearly three hours while the psychiatrist tiptoed into Tanisha’s life.

She was very smart with a sharp wit and gradually became more spontaneous and talkative. Monosyllabic answers gave way to short responses.

“Why did you run away from the foster home in Bushwick?”

“I did not run away. I left of my own free will at a time of my choosing. I never ran.”

“Sorry, I didn’t mean run away in that way. Why did you leave?” Francesca practically whispered this time. She was getting quieter and softer as Tanisha was getting more assertive. It was as if there were a scale in the room for affect or emotion. As Tanisha heated up, Francesca turned down her emotional volume.

Carefully calibrated, Tanisha responded, “ACS has sent me to so many shitholes, with so many assholes that want to fuck with me or fuck me. Just who should you be interviewing?”

Tanisha did not blink for a long time. She held us in her gaze and kept us there. This was not a usual kid in crisis who was melting down in a rage-fueled episode of “acting out,” cutting herself, homicidal, or suicidal. You could feel her intelligence in the small room. She had a special-education plan or IEP that had put her in small classes with other “disturbed” adolescents. Most of the kids in these special programs had low to normal intelligence; many were severely retarded from drugs or alcohol in utero, and many from sheer intellectual deprivation. Socially isolated, the parents of many of these children were themselves marginally literate. The level of stimulation in a home was limited to shouts, obscenities, and a 24/7 blasting television.

“I do have a plan to kill myself,” she answered in response to another question from Francesca.

“What is your plan, Tanisha? Have you had these thoughts recently?”

“Doctor, I have had a plan for a long time if things don’t work out. If I cannot get out a back door. I won’t tell you my plan, then it wouldn’t be a plan, would it? I mean it wouldn’t be my plan, it would be our plan. I don’t have hardly anything at all in my life. Every time I get moved in foster care I lose half of my stuff and the other half gets ripped off. Like I have nothing except what I have in my head. If that motherfucker had made it into the room again I would have killed him or myself or both of us. That is for fucking sure.”

After a few hours of conversation with Tanisha, I felt spiritually dehydrated. Like everything had been sucked out of me. It was like watching an accident over and over again in slow motion. Kids like Tanisha are trapped. They will die, and there is nothing you can do to save them. You cannot keep playing that script over in your head without hurting yourself. I had gone through her chart before going in the room and had a sense that a form of soul death was foretold for this young girl. What were her chances of making it out the other side of childhood emotionally intact, considering what she had been given?

Tanisha’s diagnosis at admission was provisionally depression with suicidal thinking secondary to PTSD or post-traumatic stress syndrome. There were a million social risk factors listed in the diagnostic categorization. Every box was checked off. She had not been given her medication by her “family.” She made it clear she wouldn’t have taken it under any circumstances, since the medications made her feel worse and gain weight. She had been on an anti-depressant and an anti-psychotic medication used to “augment” or improve the effectiveness of the anti-depressant. I had seen the drug advertised on television, in popular magazines, and on the subway.

PTSD is a diagnostic category that emerged from the Vietnam War. In the 1970s when the war was grinding its way to a close, the range of symptoms seen among returning vets did not fit other categories of mental illness. The cluster of symptoms was not just depression, not simple anxiety, not only related to the use of drugs or alcohol. The PTSD complex included flashbacks of the traumatic events, extreme vulnerability, irrational fears, nightmares, depression mixed with anxiety and rage. Vets were placed on cocktails of prescription
medications—with mixed results—as the diagnosis became widely accepted and many millions of dollars were invested by the federal government to understand the syndrome or “disease” better. PTSD was made an “official” disease in 1980. This is twenty-seven hundred years after Homer described the effects of war on warriors in his majestic
Iliad
.

Recently the category was being refined to fit kids who had been subjected to violent and abusive events. Some kids who witnessed parental abuse and violence or had been physically or emotionally abused became emotionally unhinged. Tanisha lost control of her emotional regulators. She couldn’t think her way out of a flash emotional discharge. Her emotional centers were “hijacked.” Ordinarily children learn how to control their emotional states. This is one of the major tasks of childhood. When kids are subjected to trauma during vulnerable developmental periods that make them children and not mini-adults, they miss the development of emotional control. This emotional dysregulation flows through many childhood disorders. It is almost a universal symptom.

Tanisha described a fleeting anxiety—what she called her “third eye”—continuously scanning the environment for dangerous people. They could be anywhere, her experience had taught her. “They look just like you, Doc. How do I know you are not one of them? You can’t tell by just looking at someone. The worst shit has happened to me from the most smiling, most friendly, let-me-help-you-out-young-lady bullshit ones. In fact, they are the ones I worry about the most. They want you. They want you to like them and they disarm you. Man, I been there and done that and never again doing that. I have an alarm detector, a regular LoJack for that shit.” Then, when it got activated, she said, “I don’t even remember what happens, it is so fast. I am being pulled off someone or in the hospital injected with one of your latest and greatest medications and then I just go to sleep for a whole day. I have no idea what goes on when it hits me.”

I left to go back to my office. The back stairs to my office are down the hall from the emergency room. Yolanda from the Organ Donor
Network spotted me before I saw her. “
Qué tal
, Dr. Eric, how are you?” she boomed, carrying a cardboard tray of coffees and croissants.

“What’s up, Yolanda?” I asked. “You are not here for good news?”

“You heard about the kid, Ignacio?”

“I haven’t heard anything, Yolanda. I’ve been locked up for hours with a patient and had my cell phone off.” I remembered and reached down to fiddle with the buttons.

“Kid wearing iPod earbuds leaned too far into the path of an oncoming Q train.”

I knew the story from a middle-of-the-night phone call from Jamila, the night administrator, whose calm and sonorous Middle Eastern accent took the edge off even the worst events. I realized what all the activity was in front of the family waiting room down the hall and now could make out sobbing more distinctly. The young man had never felt anything, and his heart was strong and beating when the ambulance picked him up. They had controlled the bleeding with pressure, then radioed ahead and brought him to the trauma slot.

My meetings with city leaders the next morning had been scrubbed—they headed to Albany in a shiny black SUV to lobby against the looming cuts to the public health system—so I walked down to the child psych emergency room. Tanisha was sitting having breakfast dressed in street clothes: skintight blue jeans, a long-sleeved tan T-shirt, and black Converse sneakers with fire-engine-red socks. She was talking to another girl, a late-evening admission, who was showing her a grade school black speckled notebook. She looked up and saw me through the glass in the nursing station. I nodded a hello, which she ignored and went back to eating and listening to the girl.

Coming into the emergency area, I had passed through the cramped waiting area past a fashionably dressed middle-aged couple. While waiting to get into the nursing area, I had said good morning, introduced myself, and asked if I could get them anything. The wife was attractive, with sharp-cut stylish dyed-blond hair and wearing a dark gray business suit. She gave me a weak, tense smile but said nothing. Her husband stood up and shook my hand. His tailored Italian suit
fit his trim body like a glove. They were clearly exhausted. In a deep voice, he looked me directly in the eyes and began thanking me for the excellent care his daughter, Emily, had received overnight. I gave them my card if they needed anything during the hospital stay and showed them where they could get a cup of coffee two hallways down to the left.

Ingrid Thomason, the social worker, was in the nursing station writing up her report from the night before on the new admission, Emily Abeloff. I pulled up a chair on wheels next to her. Ingrid was a polyglot thirty-five-year-old who had spent several years in Rwanda and other centers of genocide in Francophone West Africa before decamping at Bellevue. She had just returned from her honeymoon in Mali with her Senegalese psychologist husband, and I congratulated her. We shared an interest in the music mix from the griots of Mali infused with Cuban Son and traded favorite CDs. The concerts were fantastic affairs that continued into the wee morning hours and sold out the first day tickets went on sale.

“Your patient Tanisha has taken up with Emily. They were up most of the night talking and writing. The nurses suspended the bedtime rules since the other kids were watching a movie together and it was more like camp here than a psychiatric emergency room for once.”

“What’s up with Emily?” I asked.

“Sixteen years old, same age as Tanisha, transferred from Methodist Hospital in Park Slope last evening at the family’s request. Her parents called 911 when she told them she was filled with suicidal thoughts and they couldn’t leave her or talk her down. The nearest hospital from their brownstone is Methodist, which has only a small emergency room and a tiny pediatric inpatient unit. The parents called around and the private uptown units were full. Their neighbor is an NYU professor who knows you and he told them to transfer her here. Said their daughter would get the best psychiatric care in the city!” I made the connection. I could smell the barbecue and look into their backyard from my friend’s house.

I nodded and started to ask her for more information when she went on. “She has a long psychiatric history with multiple
hospitalizations and twice as many diagnoses. Evidently, she started to fall apart or decompensate when she was six years old. She was up all night, had tantrums, head banging, withdrawal into her room, and extreme irritability from minor provocations of everyday life. There were some family deaths, grandparents were killed in a freak car accident, that may have been triggers but nothing obvious. From what I can piece together, her first hospitalization was for depression and suicidality with a good response to SSRIs or anti-depressants. She had intermittent therapy for a few years and ended up in a pattern of a new therapist, a new diagnosis, and a new medication almost as an annual rite of spring. I am cataloging at least ten different switches over that many years.” She handed me a piece of graph paper. The time line had columns and lists in her precise handwriting with arrows to medications and assorted treatment regimens. After looking at it, I asked Ingrid for her interpretation.

“Eric, kids in this developmental period have pretty non-specific symptoms. Their brains are growing and maturing like crazy. They don’t have symptoms like adults. Depression in kids does not look like it does in adults, with depressed mood, sleepiness, a lack of enjoyment in life, decreased libido. Irritability is the hallmark symptom in kids. The kids’ psychiatric illnesses are pretty undifferentiated, and sometimes hard to tease out. One kid will turn out to have major depression, another schizophrenia, still another a personality disorder, and the last will outgrow everything. The worst mistake is to assume these little humans are little adults. They’re not. Adult rules do not apply here.”