“F***!” I shouted to an empty apartment. The blanket of white through my frosted windows told me instantly that my red car was gone.
It was the second day of the blizzard. The roads became impassible during my nap between shifts. Public transit halted and parking restrictions tightened. The note I’d left on my windshield saying, “I’m an ER doctor. Worked all night, need sleep! Nowhere to park! Please don’t tow!!!” hadn’t helped. The traffic cop didn’t care. No one cared.
No shower. No last meal. My final hour of freedom before my 14-hour overnight shift would be spent walking to work in the blizzard. Getting towed would cost more than I’d earn that day, so, net-net, I’d be paying the city to spend my night treating whoever was sufficiently suicidal, homicidal, or psychotic to be out in this storm. My life sucked.
Susie, the resident working day shift texted, “Code blue ❄😕🔫.” That meant the police were rounding up anyone outside who refused a shelter to bring them to the psych ER so I could evaluate if there was a psychiatric explanation for why they were willing to risk freezing to death.
I cursed my fate, shouting into my empty apartment, this time much louder. The muffled chatter on the other side of the wall suddenly quieted. I couldn’t help but smile.
I should have been worried about my neighbors – big guys I assumed were drug dealers from their constant stream of visitors who never stayed more than five minutes, but they worried about me – coming and going at odd hours, always alone, looking haggard, often cursing. On the front stoop, they’d ask if I was “aight” saying I looked “shot” or “glad I don’t have your job.” Why did I choose this again?
I put ski gear over my paper-thin scrubs and trudged through the storm. Snow was coming down sideways and going up my nose and frosting my glasses but it didn’t faze me. Nothing mattered except the doom I was sure laid ahead.
I slipped and fell. I looked like a powdered donut by the time I passed the glass dome of the cancer research center and ultra-modern, heavily-advertised surgery center with soaring ceilings and art in its lobby. You can always see where the money is in medicine just by looking at hospital campuses. Spoiler alert: it’s never in psychiatry.
Finally, I reached my destination: a long maze of hallways leading to the windowless back basement of an ugly but innocuous 1970s medical building where the psych ER was housed, right next to janitorial services. There were no signs identifying it. Like going to a speakeasy, you had to know what door to knock on, what hallway to turn down, and what buzzer to ring to get in. The guards were following my progress by security camera, so the buzzer rang loudly 10 feet before I arrived at the 6-inch-thick metal door that looked like it was designed for a bomb shelter.
“What’s up, doc?” the security guards said as they scanned me through the metal detector. I never knew if staff was respecting or mocking me with “doc” since I was one of the endless stream of frightened, clueless rookie doctors who circled these halls fresh out of medical school. It was probably both, or maybe they just didn’t remember my name. I didn’t care. I was just happy to have security. That metal detector was a hard-won battle after a string of assaults and years of complaints. I wondered what it cost compared to the art in the cancer building.
My glasses were encased in ice and dripping when I passed through the steamy waiting room, so full that there were more people than chairs. I should have worn ski goggles, too.
“Better than a brothel?” I asked Susie as she apologetically signed over a list of 10 patients, with three still unseen. It was a joke we had as interns, choosing if we’d rather be prostituting ourselves literally than metaphorically as we had, taking jobs as resident doctors where we were also “pimped” (medical lingo for public humiliation) and robbed of our freedom and put at physical risk for about $9 an hour after taxes.
“A brothel would be better,” she whispered with a smirk. I laughed. At least my colleagues shared my darkness. None of this was funny, of course, but sometimes the only choice is to laugh or to cry in psychiatry. Laughter buoys our misery.
“Good luck,” she said sheepishly, sliding a granola bar across the desk after explaining that we were out of stale turkey sandwiches and only had saltines and tiny juices left for desperate patients and staff. Two more new patients popped onto the board as we talked. “I’m so sorry,” she said, as she scurried out in a hurry.
“Better get to it, doc,” the charge nurse told me as I stared blankly at the board of patients, feeling paralyzed with fear of what lay ahead. She was a tough woman in her 60s with a hacking smokers’ cough and an expression that said she’d been at this too long.
“What’s the bed situation?” I asked.
As a medical student, I was trained not to consider practicalities like bed availability or insurance when making medical decisions as it taints the purity of clinical judgment. That’s a great policy if you live in a fairytale. In the real world, psych beds are scarce and insurance companies fight tooth and nail before paying for potentially life-saving psychiatric treatments, even though they’re bafflingly happy to shell out 100 times as much for surgical procedures and experimental cancer drugs. My colleague once had a suicidal patient come to the ER with the gun he wanted to shoot himself with and the insurance company asked if he brought ammunition too before they agreed to pay.
Doctors are in a bind because holding someone when there is no treatment to offer anytime soon directly conflicts with our vow to “First, do no harm.” Hospitals are dangerous places and just being there increases patients’ risks of injury, infection, and trauma. Holding someone in the ER is doing harm.
“No beds,” she said. I hoped she was referring to our psych units and asked about other local hospitals.
“I said … NO … BEDS,” she shouted about six inches from my face, like my hearing was the problem. “No psych beds, no detox beds, no rehab beds, not here, not anywhere. Got it, doc?”
“Loud and clear. Who can I discharge?” I asked, with the sinking feeling that there wouldn’t be much else I could do to help anyone tonight.
She pointed me to a 23-year-old man who wanted “detox” from PCP. There is no detox for PCP use and no one’s getting detox tonight, I told him. Discharged.
Next was an 80-year-old woman with dementia who thought she was back in communist Russia and was hoarding food and supplies, burying them in the snow for future use. Can’t initiate an involuntary petition for dementia, I told her son. Discharged.
Then there was a lonely middle-aged woman having panic attacks after spending 48 hours confined to her tiny studio apartment. Being here won’t help you, I explained. Discharged.
“Three down,” I told the charge nurse.
“Great,” she replied. “Because there are four new.”
I felt desperate as I looked at the security camera and saw police bringing in three more people from the street. They pushed past a tall man in a suit who was loitering by the security station, having an animated conversation with the guards and not emptying his pockets as instructed.
James chose the wrong night to come to the ER. The minute he saw a waiting room full of patients, mostly homeless, he balked. He demanded to leave before going through security, but it was too late. Now that he was behind locked doors, he couldn’t get discharged until he was evaluated.
When the charge nurse heard from security that a man in a suit was politely asking to leave to care for his son, she asked me to see him before he was triaged, since I was the only one with the authority to discharge him. We were getting close to maximum capacity and already had patients from the previous shift who were agitated, pacing, screaming, psychotic, and restrained, so I agreed, for the safety of the ER.
James was an earnest looking middle-aged politician I recognized from the local news, where he talked about cracking down on crime. I told him to follow me to the examination room. He didn’t budge. In a deep, commanding voice, he said, “I need to speak to the doctor in charge.”
“You’re in luck,” I said. “That’s me.”
He looked suspicious, eyeing my sneakers, and asked me how old I was. I ignored the question and told him again to come with me. This time, he followed.
James looked like a politician. He towered more than a foot over me and had a chin like a cartoon superhero and a deep, booming voice. I couldn’t figure out why he was wearing a suit in the middle of a blizzard. He probably wore a suit his whole life.
The first words out of his mouth behind closed doors were, “I want to go home. I didn’t realize what this place was.” His disgust was palpable.
“What brought you in tonight?” I asked.
“A misunderstanding,” he said. “My son is intellectually disabled and home alone. I need to look after him. It’s not safe.”
“That’s quite the tremor,” I said. He was shaking like a leaf, hands dancing in rapid motion on his lap. Sweat was beading on his brow but he didn’t seem nervous.
“My son is 27 with the mind of a 7 year old, and he probably has a hamster up his a** or is f***ing our dog right now. I need to stop him,” he said. He paused for dramatic effect, probably thinking I didn’t believe him or was too shocked to respond. I wasn’t. Nothing shocked me anymore. He continued to make his case saying, “I swear, he did those things. I found him. It started with the goat at our lake house. I got rid of the goat and got rid of the hamsters, but that dog was my wife’s. She died last year. It’s just us now. I have to protect him.”
My bullsh** detector was going off. It sounded like a sad story, so why didn’t I feel sad? He was being evasive and trying to run the show. I was annoyed. Psychiatrists are trained to evaluate our own emotions to clue us into our patients’ emotional states. Depressed patients should make you feel sad, anxious patients should make you nervous, and psychotic patients should leave you confused.
The sex with animals might be true, but it was a red herring, I was sure of it. Something else was going on. Something important enough to bring him out into the blizzard. What could have given him shakes and sweats? Alcohol withdrawal was at the top of the list. I thought of calling James out, saying his story made no sense –why had he left his son alone in the first place if it was so dangerous? Why was he here tonight if no “misunderstanding” ever led him to a psychiatrist before? He was clearly upset and I imagined scared and we were all in a rush, so I cut to the chase.
“When was your last drink?” I asked.
Flashes of anger and shame crossed his face, then he softened. He told me that since his wife died of breast cancer, he coped with whiskey. When his son started acting out, he drank more whiskey. He ignored the masturbation, but when he found videos of humans penetrating horses and horses penetrating humans along with a file he deleted without opening, afraid it was child pornography on his son’s tablet, he “lost it.” He threw a plate at the wall enraged that his son was going to get them both arrested and ruin his career. He disconnected the WiFi and took away his son’s phone and tablet. Now, they had no way to communicate, but it didn’t really matter because they weren’t speaking, anyway. The internet was his son’s only hobby, and he hated James for shutting it down.
“I come home to an empty bed and a son who can’t stand me,” he said. “I know he didn’t mean anything bad. He acts like a kid and thinks he’s a kid, but that’s not going to hold up in court. I’m living a nightmare. I worry about my son all day at work and about losing my job all night. So, I drink. I’ve been checked out. I think all this sex is a ‘f*** you’ to me and I probably deserve it. I was never the world’s best dad.”
“That sounds tough,” I interjected, quickly following with, “So what are we going to do?”
It was rude, but I had no choice. If I didn’t interrupt patients, I would be neglecting the zoo of other potentially violent or physically ill patients waiting as I spent the whole night having a heart-to-heart with James. Practicing good medicine felt challenging in school and impossible in the real world.
James droned on. His son needed intensive supervision he couldn’t provide. They were stuck on an indefinite wait list for long-term residential treatment. He called in every favor he had, but it hadn’t helped. He was grieving, despondent, and in over his head.
“When was your last drink, James?” I asked again. Other patients needed my medical attention. It wasn’t the time for supportive therapy.
James continued, as if he hadn’t heard me. He was so worried about his son. He was a life-long drinker, but it was worse since his wife had passed. They were high school sweethearts, married for 35 years. She was a kindergarten teacher with “the patience of a saint” who cared for their son lovingly, basically without James’ help, until she died.
“Could you help get him into residential treatment?” he asked.
I almost laughed because it was so absurd, but decided to ignore the question. His son had Medicaid after aging out of James’ insurance. Doctors lobby politicians to try to get patients into state hospitals, not the other way around.
“When was your last drink, James?” I asked for a third time, because this was one of the most critical factors to evaluating how serious his alcohol withdrawal might be. Now, we were both annoyed.
Finally, he explained he ran out of booze the day before the blizzard. He was fighting with his son and distracted. He was sure he had a bottle at home, but it was in his desk drawer at work. He did okay for about 24 hours before things went downhill. He didn’t know what was happening. He’d never heard of alcohol withdrawal. He felt sick, sweaty, and jumpy. He wandered the streets, shaking, looking futilely for an open liquor store and finally offering a crisp $100 bill to a man on the street for his flask. He was incredulous when the man refused to sell it but pointed him towards the ER, noting his shakes. Out of options, he came to check it out.
“I didn’t know it’d be a damn zoo,” he said. “I shouldn’t have come. I thought this was a hospital, not a homeless shelter. I’m ready to go now.”
James demanded I discharge him. He was stern and commanding. He probably felt humiliated. These were his constituents.
Against my better judgment, I almost agreed. James was accustomed to giving orders and I was accustomed to taking them. There is no involuntary alcohol or drug treatment, anyway, for good reason – it would never work. I sighed and took a deep breath, preparing to lecture him on the dangers of withdrawal, what to look for, and when to seek help before I let him go.
“Listen,” he said. “It’s been a good talk. You’re a nice kid. I wish you luck and all those sad souls out there luck, too. But this place is chaos and the chipmunks aren’t helping. I have to leave now.”
“Chipmunks?” I asked, confused. Was that some kind of zoo metaphor?
“I know the psych system is strapped for cash, and honestly, they’re sort of cute,” he chuckled, eyes cast down at the floor, “but if you want to make this place into a respectable emergency room, you need pest control. It’s just not hygienic.”
“Are the chipmunks here now, James?” I asked.
James looked confused and a bit disgusted saying, “They’ve been circling your feet for 20 minutes. You haven’t noticed?”
It took me until then to realize James was in a potentially life-or-death situation.
“Stay,” I said, “Do not move.” I was so commanding, he listened.
I ran down the hall and grabbed the nursing equipment to take his vitals myself. I fumbled. I hadn’t taken a blood pressure since medical school, and we weren’t trained to use automated electronic machines.
All of my worst fears came true – his heart was racing, his blood pressure was high and he had spiked a fever. I didn’t want to believe the numbers, so I repeated them all manually twice. It took forever. James was getting more and more annoyed that I was “practicing doctoring” on him.
My mind was racing. I got the same numbers again and again, and they were terrible. Now, I was sweating.
James was in trouble. He was in delirium tremens or “DTs,” the most dreaded and fatal form of alcohol withdrawal. Visual hallucinations of small animals is classic. I didn’t have the staff, equipment, or consent to treat him and there was a decent chance he’d die if I didn’t.
“It’s amazing you made it here without having a seizure,” I told James. “We need to get you to the medical hospital right away. You could die tonight.”
He looked grim and pale. I explained medical treatment would decrease his risk of death by 80%. He nodded, silently consenting. He was staggering like a drunk man as I led him back to the waiting room. I went to the back office and was logging onto a computer to order medications as the charge nurse stood over me.
“If you’re going to take 45 minutes on a discharge, it’s going to be a long night,” she said, annoyed. “We have two you need to see right now. One is shadow-boxing and the other is pacing, they’re about to lose it.”
“Look at these vitals,” I said circling my chicken scratch, confirmed three times, on my clipboard. “DTs.”
“Sh**,” she said. She gasped audibly. “This guy needs to be on an IV drip in the ICU.”
She told me to order a shot of Ativan since we don’t have IVs in the psych ER for safety (since the plastic tubing can become a noose) and then to hustle to the next patient before the waiting room “blew up.” She ordered the tech to dial 911 for an ambulance to the medical ER.
I called my supervising doctor who said to be “generous” with Ativan, the medication we would use to treat his withdrawal, because this guy was going to need it. I called the admitting doctor in the medical ER to alert them he was on his way. I was instantly annoyed by how quiet the other side of the line sounded.
We had a plan and I thought things were in order. I was halfway through evaluating a “suicidal and homicidal” homeless man whose biggest concern was the turkey sandwich shortage when I heard shouting in the hallway.
“I’m going to sue every one of you!” James was shouting. He had just been told that the ambulance wait time was 6 hours due to the road conditions and he wasn’t taking it well.
He kept trying to stand, swaying on his feet, and the nurse kept telling him to sit back down so he wouldn’t fall. He went from standing to sitting four times in two minutes before I told him to come with me. I gave some saltines and juice to the homeless patient who said, “You can’t treat me this way.”
I apologized for interrupting the interview and explained that I had to take care of something urgent and I’d return soon.
He said, “I meant the saltines. I want a damn turkey sandwich. This is bullsh**.”
I pulled James into a side room intended to be a closet and pulled one chair in with us, which was all that would fit.
“I am not sleeping in this zoo tonight,” he said. “I’m a lawyer. I’ll sue you and win if you don’t sign my discharge paperwork now.”
He was wagging his finger at me and flicking spit. His breath stank. I didn’t know what to do. He was being a jerk, but he was right. Legally, I couldn’t hold him against his will. I also couldn’t let him walk to the medical ER even though it was only a few minutes away because I’d probably lose my job for going against hospital policy and safety standards – he could slip and fall or even die en route. Morally, I couldn’t live with myself if he died from something treatable. That left only one option: I had to convince him to stay to save his life.
“Sit down now!” I shouted. He was swaying on his feet. I never had a dog, but being in the psych ER I got very good at commands to sit. James and I were in a power struggle, standing on either side of the chair with him towering over me.
“Sue me! Have a field day! I have nothing but debt. But if you want anything from me, you better sit down right now!” I said, now almost shouting.
“What about your license?” he asked. James was a smart guy. Every doctor’s biggest fear is losing their medical license, especially during training, since earning a full doctor’s salary seems the only chance at ever paying off the debt it takes to get there.
“No doctor ever lost a license for saving a life,” I said. I wasn’t sure if that was true, but I was mad as hell that he was trying to intimidate me into doing a bad job. “And I don’t care. Not tonight. Do I look like I care? You want me to sign your discharge paperwork, you better sit down right now.”
Finally, he sat. I stopped “playing nice” and pushed him, saying, “I’ll let you go, but I want to know the plan for your son if you die tonight. Which relative will take him?”
I went on, “Can he manage money? Drive? Take care of his needs?”
“No,” James said, his eyes cast down, ashamed. “But I’m sure he’ll get in soon.”
“How many psychiatric beds do you think there are today compared with the ‘50s, when you were born?” I asked.
“Half?” he guessed. “A quarter?”
“I wish,” I grunted. “Try 5%. If you die tonight, your son dies too, probably in jail as a sex offender. Did you know pedophiles are incarcerated separately because the other prisoners try to kill them? If you leave now, it’s his life on the line as much as yours. Is this what your wife would have wanted?”
It was a sucker punch and we both knew it. It’s not often I try to make a patient cry, but I’ll do it to try to save a life.
James cried and cried and cried, but he stayed. He sat on a plastic chair in a waiting room with a bunch of homeless people all night. He never tried to leave again.
I returned to the man who was outraged about the saltines and said, “Do you want to sleep in the waiting room tonight? I might not have anything else to offer you, but at least it’s safe.”
He looked like he’d won the lottery and said this beat any turkey sandwich he’d ever gotten here. I offered every homeless patient there the same deal. I didn’t have any more fight left in me, and with so little to offer, I wasn’t going to withhold saltines and heat.
James needed ten more rounds of medications to get him through. I was afraid I was going to kill him with the Ativan I was slamming him with – it was enough to tranquilize a horse – but he never even got sleepy.
My supervising doctor reassured me that he was definitely minimizing how much he drank based on his vital signs and response to the meds, and that I was doing a great job with a fraction of the staff, space, and equipment needed, but it didn’t feel good. I was scared I was going to kill him whether he stayed or left. I felt like I was practicing wilderness medicine.
I got really good at taking blood pressure that night, because the nurses just couldn’t do it frequently enough. They were busy and overwhelmed and thought James was an a**hole.
They said, “The ER acuity is too high,” and, “He only wants to speak to the doctor,” which translated to, “You convinced him to stay, he’s your problem now.”
I didn’t sleep a wink that night. Every time I thought he’d stabilized, his heart rate and blood pressure skyrocketed again. But he took all the medications I prescribed and boarded an ambulance late that night, just around the time it stopped snowing and the sky brightened.
“I’m sorry for being such a pain,” he said when the paramedics came to get him. “I’m glad you were a pain, too. I’m going to work on this psych situation for you. I had no idea what’s going on. I don’t think anyone does.”
I wanted to scream. Was I a pain for trying to save his life? For assuming legal risk and getting yelled at for trying to help? He was going to work on the psych situation “for me” and not his son?
I gritted my teeth, said nothing, and waved goodbye. What an a**hole, I thought. What a thankless job.
Maybe I helped James, but I felt terrible. I became a doctor to help people and to be of use to society. I didn’t realize getting yelled at constantly was part of the job description. I never anticipated having to kick sick people to the curb because there were no resources available for them or interrupting as they shared their deepest secrets because my time and attention were spread so dangerously thin. The worst part was, it didn’t bother me a fraction as much as it used to, or as much as I thought it should. I felt dead inside.
One reason I cited for becoming a doctor after getting an MBA was that I never wanted to sell anything. But here I was selling expensive, insufficient, inefficient treatments to customers who didn’t want them. People appreciated my advice as a bartender. As a psychiatrist, they resented it.
As I suited back into ski gear and signed the patients back over to the daytime resident, I wondered: What am I doing with my life?
I walked past plows clearing the streets and stores opening for the first time in days. When I got home around 9AM, my neighbors were out shoveling. They looked at me and said, “Damn, girl, you look like you went to hell and back.”
“I did,” I said, hurrying to push past them as tears welled in my eyes.
I’d been dreaming of my bed all night but I didn’t make it that far. I collapsed on the living room floor and sobbed. What was the point of a bed in a world without comfort?
I was in a really dark place. I mourned what I’d lost professionally, the idea of what it meant to be a doctor, and what I’d lost personally, which felt like everything. I’d missed weddings and funerals. It didn’t really matter, I told myself, since I only wanted to binge on Netflix and junk food, anyway. Sometimes, even that was too much, and I just stared at the wall and basked in the silence.
As my friends married and bought homes, I gave myself over completely to a job that asked everything of me and gave nothing in return as my debt climbed towards half a million dollars. I had two graduate degrees and could barely pay my bills working 80 hours a week.
Getting my car took most of the rest of the day and the money in my checking account. I ate a pint of ice cream, slept for an hour or two, and went back to the ER to do it all again.
I was depressed again. It feels like drowning, the desperation of realizing you’re sinking no matter how hard you thrash. I thought I’d recognize it faster as a psychiatrist, but I didn’t. I told myself I was having ordinary reactions to extraordinary stressors just like I had before. What resident isn’t tired, distracted, glum, and guilt-ridden? Humans weren’t built to work like this.
A week later, Susie signed out to me and asked with a smirk, “Do you ever wish on your way to work that you’ll get hit by a bus?”
It took that for me to realize that the universality bit doesn’t matter if things are bad enough to make young doctors want to die. It wasn’t funny like the brothel joke. It was scary. It hit too close to home.
I restarted therapy and medications and told no one, worried I wasn’t fit to be a psychiatrist.