“Line 1, Jul.”
I had just stepped into the E.R. when the secretary diverted my attention to the phone. It showed a single column of three red dots, two blinking.
I stabbed at the bottom dot and heard the voice of Tina, a nurse from the ambulance and helicopter communications center. “Three-year-old girl, drowning victim,” she said with a hesitant, sucked-in breath. “CPR in progress.”
A shared nightmare was about to unfold. “Shit. OK. ETA?”
“Five.”
“OK.” I hung up.
Coming in five minutes was a torrent of pain and grief whose name, for this story, would be Rebecca Rose. The summertime heat, between noon and 9 p.m., routinely invites a horror to emerge from the blue. An unattended child will go into a pool and drown. Once the rescue starts, the hard part of my job is not a matter of knowing what to do. I know what to do. The hard part is knowing when to stop.
The events run together seamlessly. A sunny-faced, moppet-haired toddler slips silently under the water and the dreamy summer day mutates into tragedy with the first, slightly raised calling of the child’s name: Re-becca?? Re- BEC-CA?!! A scuffling scramble ensues. The missing child’s name is called louder and louder until, with a wail, the facedown body is discovered in the pool. And then screams, sirens, the grunts of medics.
The Emergency Medical Services rescuers arrived at Rebecca’s side in roughly five minutes, but they were helpless. Two or three attempts to place a breathing tube and IVs failed. They abandoned their efforts and rushed the skinny, blue, inert girl, in full arrest, to the doors of Trauma One, aggressively applying CPR for the three or four minutes it took to reach us.
About 8,000 drownings or near-drownings occur in the United States each year, mostly of kids and adolescents, half in private pools. Seven or eight out of 10 survive, but the rest die immediately or end up in a permanently vegetative state, almost better off dead. Nothing — not cars, not guns — kills more children under age 5. Most drownings take place between Memorial Day and Labor Day between late morning and dinnertime. During peak hours, a ghastly rate emerges of about 20 submersions every hour nationwide, and three or four deaths. Before you pack away the Weber grill or toss out the last empty tube of sunblock, you’ll hear of a case on the late local news or read it in the Metro section of your hometown paper. Most of these drownings happen in pools, not at ocean beaches, lakes or rivers, according to Dr. Linda Quan, a pediatric emergency physician at Harborview Medical Center in Seattle. Quan surmises that more children drown at pools than beaches because fewer adults are present at homes than at public beaches to watch wandering children.
Aside from variations in setting and players, once a child goes into the drink, the same drama begins. It plays out in only two ways. In one script, the missing child is found within four or five minutes and is revived by CPR — by the bystander or paramedic — in less than five to 10 minutes. A splutter of water and a frantic thrashing accompany the child’s revival, followed by a hasty trip into the E.R. for an X-ray or maybe no X-ray, a CAT scan or maybe no CAT scan. It doesn’t matter: No harm is done. The parents or caretaker are another matter. When the horrified sobbing and hyperventilating stop they’ll depart for home with their healthy, uninjured child. Tremblingly grateful and scared still half out of their wits, some are secretly wracked by self-recriminations.
Some of these drowning cases take place under the supervision of a drunk or intoxicated “care” giver. “I’ve not seen any hard data,” said Dr. Quan, “but it plays a role.”
For Rebecca and the Roses, the story unfolded differently. Once they were inside the trauma bay, events started to go ominously “right.” The interval from putting down the phone to taking up my position in the code room is a clouded gap. This was the time to rehearse my terrible job, to imagine the face, the body, the bright cheerful bathing suit that would materialize and later, the ashen, shattered parents. There was no chattering with the nurses or techs, just a few muttered preparatory questions and responses. Then, without warning, a phalanx of white-shirted paramedics snapped the door open, marched in with tiny Rebecca, one bulky torso of an EMT rising and falling in the rhythm of CPR.
I remember seeing a small, blue, sweetly oval face and dark, wet hair matted this way and that. I remember every other damn thing, too: Both the intravenous and endotracheal tubes, impossible to insert out by the pool, went in right away. The clear plastic barrel of the breathing tube slid carefully, effortlessly into her trachea. The nurse’s crisp bark: “Line in. MEDS?” The way was paved for big resuscitation guns: “epi” or epinephrine, atropine, lidocaine, bretylium, cardioversion. In a hushed voice, I called for epi. Rescue drug No. 1.
The first epinephrine dose is a “low” dose: Sometimes just a whiff is needed to kick-start the heart. The second dose, a high dose, is a rocket blast. If that doesn’t work, the rescue is all but over. There are a few other drugs and a few other maneuvers, but basically, after the one-two epi punch, the rest is a foregone conclusion. Rebecca Rose, her pretty features partly distorted now by tape and tubes, did not respond to the low dose. I called for hi-dose epi, and again Rebecca resisted.
I waited a minute, absorbing the full impact. A little girl picking out her favorite outfit for the day perhaps only 40 minutes earlier — a pink one-piece suit with bright yellow smiley faces — now awaited my call for rounds of epi to fight for her life. I calculated the impact of our next moves. Another epi, hi-dose. Lidocaine. Shocks.
Ten to 15 years ago, there was uncertainty as to whether drowning in salt water was any different from fresh water, or if “wet” drowning differed from “dry.” Dr. James Orlowski, a pediatric intensive care unit specialist, demonstrated that four out of five cases are “wet.” Salt water, fresh water or no water, he and others have shown, makes not an iota of difference. The damage is done to the brain and to the brain only. After four minutes of lack of oxygen, called anoxia, irreversible damage occurs. Only unpredictable and scattered functions may survive after that. If the primitive, sub-limbic controls to maintain breathing and circulatory functions are spared, the cruel fate that awaits can last for weeks, months, years.
The heart tolerates much longer deprivation. It’s made of muscle, not nerve, which is far more resilient. The heart of just about any baby or child can be resuscitated after even 20 minutes of anoxia, sometimes more. Into this deadly zone of mixed destiny, from five minutes to perhaps 30, when the heart can be revived but the brain cannot, the cruelest outcomes emerge. Rebecca Rose came to me at precisely this treacherous interval: at a down time long enough to kill her brain, but short enough to spare her heart.
This is the conundrum peculiar to pediatric emergency medicine. At 20, 30, 40 minutes of resuscitation, I can call an end to it, heavy-hearted. But at the 10-minute mark I’m aware, emotionally, that all true hope is lost. Intellectually, I still owe the girl with a blue face and damp, tangled hair and the parents I haven’t yet met one last round, perhaps two of resuscitative countermeasures.
I may pray it won’t do the trick. I cannot justify putting everyone through this final, terrifying ordeal, because at that point the only possible outcome, with vanishingly rare exceptions, is of a terribly damaged baby returning. Regardless, I press on. The awareness that only the hollowest of victories may result is no deterrence to CPR heroics. How could I, how could any doctor, look the parents in the eye knowing I’d held something back? How do I decide if a mommy would rather mourn her lost child or cling to a diminished, damaged one? I don’t, so the child must decide. I keep the resuscitative efforts going for at least half an hour, until all hope is truly extinguished. The heart may be more tenacious than the brain, but I’ve got the opposite problem. My brain is the more stubborn organ. When we can, we offer life; there are no guidelines for when to abandon hope.
One question ought to help resolve this dilemma: Would you offer the same treatment to your own child? Would I rather face my own child’s sudden, unexpected death or a bleak future of biomedical equipment, nurses and mournful half-life? I don’t know, and I hope I never know. Would my wife make the same choice as me? She can’t know, just as I cannot know. If the mom and dad find themselves on opposite sides of this unforgiving divide, their relationship may be destroyed. And yet, no couple can ever know this about themselves until they are placed in this terrible situation.
Hanging malevolently at the end of any CPR effort lasting more than a minute or two is the near certainty of either a declaration of death or the dreaded “ROSC” — the return of spontaneous circulation. That is when I leave to report to the family of the grave circumstances of the extinction of their hopes and dreams. Judge and executioner, long-faced, I slam the gavel, no appeal. Dead or inhumanly damaged. Sentence already carried out.
After I ordered a second hi-dose epi at the 15-plus minute range, Rebecca did the unforgivable: She came back. Then she did the unbearable: She stayed back. A beat appeared on a monitor, then another. ROSC. I waved off the medic still pumping up and down on her chest and felt for pulses. Strong. Her color: pinker and pinker. My heart sank, I broke out in a cold sweat.
Her parents, who were in the waiting room, looked exactly as I had pictured them: disheveled with anguish, fearing my arrival beyond any imaginable terror.
“She’s alive,” I said, tongue dry, thick voiced. I did not spell out for them that her revival would sour into something worse than defeat; that would be the job of the intensive care doctors. “But her prognosis” — a carefully chosen, scary word — “isn’t clear.” The toxic effects of prolonged anoxia could cause the revived organs to deteriorate within a day or two. But absent a spontaneous, quick death, a rigorous brain-death protocol would be enacted. A brain wave study, an EEG, awaited. Upon demonstration that the cortex, the highest functioning brain center, had not survived, Rebecca would have been declared brain-dead. The ventilator and life-sustaining equipment would be withdrawn and death would ensue in minutes.
Tough little Rebecca Rose, strong enough to hold back death for 15 or 20 minutes, was also resilient enough to withstand the first days of complications. She eluded brain-death criteria and has languished long years since then, most in a pediatric nursing home. Her limbs have contracted, her eyes dance crazily around and she cries out when her feeding tube or tracheostomy tube tug in the wrong direction. She has become this person.
It was all too much for her mother. She spent the first few days by Rebecca’s side, but seemed to vanish after the EEG’s damning sentence: not gone enough. Within months, she vanished, in order, I imagine, to resume her own life. Dad stayed by Rebecca’s side. He still saw his precious daughter bloom inside the twisted, damaged, vegetative creature that remained. Each cough, each utterance that emerged was filtered through the prism of who she was and what he thought he heard her say.
I understand the mom. She made a reasonable choice. I might argue in favor of her case every time. But I feel the heavy beating of the dad’s heart. As I said, one question should clarify the choices: What would you want for your own child?
Drowning is a quiet research front. The brain suffocates; prevention is easy in principle: Pool owners should put up a four-sided fence and master CPR. Don’t drink if young children are around a pool. Watch your kid every goddamned second. Don’t put me, us, your Rebecca Rose, through this again.
Start with 5,000 bodies. Five thousand steaming bodies. Five thousand steaming, bouncing teenage bodies. Packed into a space where, ordinarily, there would be no more than 3,000. There’s an inordinate amount of surging and shoving, but no one minds because we’re all so happy to be here — it’s the concert in the time to be 20 and surging and shoving in the pit.
No one ever had fun like this before, and it’s not possible that more fun can ever be had again in the future because the music is the coolest ever and the scene is the coolest ever and therefore no place, no time, can exist that is better than right now. The band hasn’t taken the stage yet, and beach balls bearing dot-com logos and Nerf Frisbees bounce through the space overhead. Over the speakers come the Violent Femmes: Add it up. A 1980 fossil (20 years old already!), but inside it creates the stirrings of a rhythm. A scrawny boy, spiky blond hair and naked to the waist, all that skin a clean slate still awaiting its first piercing and tattoos, has climbed on top of his friend’s shoulders. He is facing a pixieish girl 6 or 7 feet away on her friend’s shoulders. He wears a scrappy grin and his hands are held in front of him chest high. Like pinball flippers, his fingers gesture at his nipples, back and forth, back and forth. The girl, clearly the message’s intended recipient, blushes and looks over at her girlfriend, also clambering aboard her boyfriend’s platform of deltoids.
Folks in the crowd nearest the two players pick up on the game vibe, and a couple of guys start to chant: Show your tits! Show your tits! The girl ducks her head again in the direction of her girlfriend, who pushes her back to face the grinning kid with fingers flipping again, a beat faster now. Even girls have picked up the chant: Show your tits! Show your tits! Show your tits! Again she feints toward her friend, ready to give in, with a “I can’t believe I’m gonna actually do this, Jenny!” look on her face, and reaches down to the bottom of her cropped plum-colored blouse. Jenny’s face registers shock: Chris-see! And then Chrissie chickens out.
The scrawny blond guy knows better than to give up. He mouths the words of the Violent Femmes song: “Why can’t I get just one fuck! Why can’t I get just one …” and the fingers begin flipping again. The crowd goes at the cheer again — Show your tits! — and Chrissie, the leap made, no turning back, ups the top and dazzles the blond kid. A giddy whoop of cheers rises up from the crowd, accompanied by a volley of raised arms. A flash from a disposable camera goes off. The shirt drops and Chrissie hides her face in Jenny’s neck for a moment as the two laugh at the crazy stunt.
The Femmes song is abruptly cut off and the DJ, the self-proclaimed afternoon demigod, gives a slackerly introduction to the band — Staind, Godsmack, Filter, who-the-fuck-ever — complete with majestically inarticulate pauses and a dropped mike. It’s the coolest damn thing, because he’s anti-polish and a million years from Casey Kasem or even the MTV veej’s and it’s broadcast on a screen so big it can probably be seen from Mars. And not a single person cares or is barely listening, not, at least, in the pit, because there’s no way to tell what he’s saying and all we know is that the group is coming on in two seconds and streams begin to mix the crowd.
One set of streams is exiting before it gets really hairy: skinny, younger guys clearing a path for their skinnier and younger girlfriends, chains of girls with arms locked, guys a-hunting brewski. The incoming stream is bigger, skankier: They want stage. Because the crowd’s so locked with bodies, neither stream moves swiftly, but the tug and pull make for some interesting forces. I’m tipping laterally, and so are Jenny and Chrissie, who have made it down from their boyfriends’ shoulders and are sticking around for the scene when the music starts. My own mass, all 180 pounds or so, is about to smother what must be a 14-year-old girl in a blue ribbed tank top emblazoned with the legend “I [heart] boys” across her smallish bosom. “Sorry,” I half-croak, and lean my shoulders back the way the force is coming from, and while this squeezes Chrissie and Jenny, it does give a couple of other guys just in front and around the chance to counterpush as well, and in a moment we’re all upright again and the band is onstage.
The music arrives like a detonating bomb. The opening blast of guitars, bass and drums is a thunderclap of bone-dissolving vibration. It’s a song we all know, and 90 percent of the mouths are singing along, a sort of paean to a hopeless future, late girlfriends and grown-ups who can’t seem to understand. And in that opening riff, there’s room again, at least enough to spread my legs into a stance I can balance on when the tides really start, as they will in a minute.
The space has expanded incrementally thanks to a dozen or so bodies that have gone aloft to surf. From my point 10 yards from the stage, I have to watch for bodies coming in from both front and rear. The pogo-ing crowd is all arms extended; I keep mine halfway up to my shoulders, my head scanning side to side, back to front. The closest airborne bod, 5 yards away, is a not-so-skinny blond girl in a white bikini top and blue shorts, who’s being passed stageward, a dozen hands suspending her legs and back, grabbing at her breasts, trying to free them from her bra.
She’s protecting them as best she can, a screamy laugh across her face. As I’m wondering if they’ll get it off, I’m kicked in the back of my head by a muddy sneaker belonging to an amused, tubby Asian kid who was hoisted up behind me as I watched the blond. In another moment his massive butt is directly in my hands. I am his center of gravity. His direction is mine to choose. I hurl him forward, into a patch of males who don’t want to be bothered. He lands feet first and immediately begins trying to climb up again.
I scan again for the blond; she’s being tipped to one side by a couple of head-shaved guys, one of whom sports a black tattoo over the ear and across the right temple. They’re tipping her so they can get at her boobs better, and when they finally land a feel, she’s laughing no less but manages to snake out of their hands. A sudden shift of direction and she’s launched away from them. All around her, now at the shoulder-riding level, girls are perched and bouncing to the song. Many are flashing boobs, the crowd no longer individually cheering them on but appreciative nonetheless. The display is, frankly, stunning. Opalescent gems, carved from shimmering droplets of spring water: breasts that calm the savage music. Guys who could be throwing punches and jabs are slack-mouthed at the scenery.
In rhythm now with the tidal surges and flesh sailing overhead, I grab and pass the incoming torsos, keeping my arms ready for any size and weight class. The falls are numerous. I’m close to the stage, where the crush is the tightest, but small gaps of a third to a quarter of a human width are still to be found. An orange-haired girl flips feet over head and is about to splatter, but a chivalrous pair of football-looking types catches her before she can hit. They exchange glances, her eyes indicate she wants back up again and they sweetly comply. No gratuitous manhandling of vulnerable breasts. Up in the air it’s a game; down here rules apply. Or maybe it’s just the luck of the draw.
I am impressed by the following sociological phenomenon: Guys are allowed to fall while girls are rescued. Civilization is hard to kill, even in the pit. They a woman was gang-raped in front of the stage at Woodstock ’99, but that was three days into it. Maybe it takes that kind of time to sever the ties. You just can’t get that primitive over the course of a single afternoon. Medieval, yes. Primitive? Nah.
A sudden gust of shoving backward, accompanied by a massive Doc Marten boot planted firmly across my sandaled feet, snaps my attention to another phenomenon immediately ahead. A clearing, an open ring, maybe 7 feet around, has suddenly materialized. Three guys with huge arms, shoulders and beer guts are violently charging and flailing at one another like rams or bulls. As they prepare for or emerge from one of these collisions, they whip around the circumference of the circle, careening off bodies lining the circumference. A bloodied, sandpaper-headed dude, goatlike patch of hair under his chin, has been going at it more viciously than the others, and the wild steam from his eyes suggests he’s about to get out-of-control ugly. His arms, a detailed masterwork of thorny branches and snaking vines, pump to an internal beat. As he swings past, a colossally detailed emblem taking up the northern half of his back, black and complex with a central red orb, flexes and pulses as if alive itself.
Oh, shit. His head whinnies and snorts in bursts, hunting for a new partner to charge, and slaps at his chest, menacingly. He repeats this, then, with a quizzical look, stares down at his chiseled pecs. His studded metal collar is missing. He throws his arms up to halt the proceedings, eyes scanning the ground. The other guys get the message and begin pawing the ground, too. It looks like they’re searching for a contact, until someone holds the necklace up. Distracted by a new song and a new pair of flashing orbs, they lose interest in body-butting one another and the hole closes.
It’s hot, satanically hot, and each body’s odor rises up in distinctive wafts. The guys carry a rank, sweat-mixed-with-fart aroma; the girls smell not so bad. At 6-2, I’m considerably advantaged by the occasional breeze that circulates in. A half-foot below me, a purple-haired girl and a green-haired girl make nauseous faces at each other in a wave of warm air, fan at each other, then, as if simultaneously possessed of an unbearably urgent notion, lock faces in an extended, tongue-wrapping kiss. They continue as the first drops of rain drizzle down, then break to catch the raindrops as they bear down bigger and harder.
There was only one way to add another dimension to the revelry, to the animal contact high, and that way was rain. The thousands of bodies already electrically connected to one another at the hip, belly, leg, chi-chi now are slithery and slick, body oils and sunblock, sweat and spunk. Vibrating, blasting guitar chops hack away at any final remnants of intelligent thought, drums pulverize, bass chords grind. Nirvana, bodhisattva. Hello cowgirl in the sand.
A billowy cloud of steam rises off the sea of bodies, and even more suddenly ascend to shoulder-ride, to surf. The blistering aural assault from the stage continues without cease, the visual details blur and shift in the thick fog and in a moment there will be a total disconnect from the mothership. When that happens, all there will be is the music and the crowd, eternal and infinite, and no other reality except the humid, sultry now. Which is the avatar of cool.
What the fuck. A nod of my head to the dudes by my side, signal-response, and I’m up. The rain pounds me from above, hands and heads swipe and push at me from below. I attempt to spread my arms in the sheer joy — and am bonked hard onto the ground, first a shoulder, then the flat of my back. No worries, I’m headed up again and ready to sail, for real, once again.
But the set ends and with that the moment and people are turning away and heading out. The sudden cessation of concussive noise leaves a migrainous void, pulsing and aching. Each muscle in my body has been pulled and stretched; floral bruises are in bloom. Time for a beer. Definitely. Rage is gonna be on soon and I can’t wait to get back.
Rachel came to our E.R. one afternoon shortly before Christmas. She had been found by a friend who came to visit her — suspended by a rope around her neck.
The chart in my hand conjured up vivid images even before I entered her room. A portrait that pretty much matched her reality: not particularly pretty, her skin pallid, pasty; long, full, frizzled brown hair, indifferently gathered by a dark scrunchy. She wore dark grunge-style clothes: dark plaid shirt and jeans, a choker and metallic bangles. Couple of earrings, but not excessively pierced or tattooed. Uncommunicative. Vacant eyes. She told me too little for me to properly judge if she was inarticulate or merely silent.
It didn’t much matter, thanks to a single word on the chart: Kaiser.
Nowhere have the ravages of bottom-line scrutiny of modern medical practices so thoroughly gutted the ability to provide care for patients than psychiatry. It is akin to post-AIDS Africa: direly afflicted, worse with each acid day. And if a single story can portray a ruinous state of psychiatry today, perhaps it is the story of Rachel (not her real name) because she received routine-or-better care.
Not only did she have insurance, but hers was the only easy one to work. Kaiser provides (relatively) ample psych benefits and I wouldn’t have to grovel, beg or lie in order to get her a bed somewhere. The most time-consuming task an E.R. doctor performs, in proportion to tangible benefit to the patient, is arranging for a psychiatric admission with an insurer. There is no extreme to which these voices on the phone will not try to push us to deny an admission. A fellow E.R. doc recalls being asked if he — the E.R. doc — had gone to the house to determine if his patient actually owned the gun with which he was threatening to commit suicide.
The benefits provided by insurance companies for mental illness are starvation rations. Reimbursement to providers for face-to-face services have been cut in half over the past 10 years. Dr. John Iglehart in the New England Journal of Medicine described typical benefits as consisting of “a maximum of 20 outpatient visits and 30 hospital days each year.” They make Scrooge look like Raoul Wallenberg. With Kaiser Permanente, at least, getting through the door was far less of a Kafkaesque nightmare. They have beds and psychiatrists and are generally willing to marry them to the patient.
The E.R. is the current front line of psychiatric care. For the suicidal, the homicidal, the terrorized-by-voices, we have become the “de facto dumping ground,” says the chairman of psychiatry at Inova Fairfax Hospital, Dr. Thomas Wise. A poor choice. A physical ailment can be readily summarized and packaged, without fear of shame or indignity, in the space of a few short questions and answers. At least enough to move a patient through an immediate crisis and into decisions regarding treatment and hospitalization. This we do well. Psychiatric illness, a disorder of mind and emotion, is also a malady with varying rates of therapeutic success, just like heart or liver disease. And we train, minimally, for these emergencies, too.
But the true pathologies are buried and layered beneath deceptions, embarrassment, anger. It can take hours to establish the true degree and nature of illness. Scratching the surface of a problem, an E.R. doctor’s true specialty, in a psych patient only reveals another level of constructs to keep out strangers. When we’re the ones to whom these patients are sent, everyone suffers.
Rachel was alone when I met her. Her friend had been exiled to the waiting room, as no visitors were allowed to accompany the patient until a doctor examined her. The girl’s parents had not yet arrived and, since Rachel was 18, they were not automatically needed. The busy triage nurse and registrar would have ordinarily thought to call them but, this being the midst of a Christmas rush, other patients clamored for attention. So Rachel remained alone.
I spent a few perfunctory minutes with her; a half-hearted attempt to understand her misery, the ghoulish and lethal choice of a rope. Teenagers usually gobble down pills or slash wrists. A hanging attempt is rare. It speaks to a finality of purpose. If not for the friend, I could just as easily have been examining her in a body bag. It spooked me. Rachel’s were the deadest eyes I’d ever seen in a living person. They lacked self-reflection, doubt, any second guessing. I moved on to the other part of my job: assessing physical injury. Then I got the hell out.
I called the Kaiser line, got a psychiatrist, got assent for a hospital bed, and then I went back to Rachel to let her know she’d be admitted. A nod in acknowledgment. I never saw the friend, and Rachel never asked for her. In short, I did my job and I have nothing to be ashamed of. My other patients also had pressing needs: narcotics for broken bones, CAT scans to rule out appendicitis, an examination for a pregnant girl with vaginal bleeding. All had a legitimate claim to my time and attention. I went the extra step for Rachel and asked a social worker to step in and talk to her. Having been of little therapeutic assistance to a person facing the blackest of despairs, the least I could do was send her someone who might have time to listen to her or, at the very minimum, hold her hand and offer some company. The milk of human kindness.
There is, frankly, a dirty lie in that last paragraph. I didn’t do my job, I did the psychiatrist’s job. Sorry, another lie: I pretended to do the shrink’s job. Because pretending is all I’m really qualified to do. Insurance companies would no more pay for an anesthesiologist to perform cardiac surgery than they would if a cardiac surgeon performed anesthesia, yet an E.R. doc is deemed appropriate to perform a detailed psychiatric assessment.
As psychiatrist Dr. Karen Pratt points out, as a psychiatric patient “you want someone to listen long enough to diagnose you, to elicit specific signs and symptoms and decide on the right course of treatment. This can mean hearing almost your whole life story.”
But that scenario — a mentally ill patient in crisis meeting with a psychiatrist who has the time to listen — is woefully rare. Patients in need of immediate psychiatric assistance who are lucky enough to have insurance first call the toll-free number on their card, where they will almost universally be instructed to go to the nearest E.R.
When confronted by these poor souls stumbling into my hospital, I have phoned these toll-free numbers again trying to track down the source of this advice. This has yielded a general response that the plan cannot possibly know all the resources available in every city they cover; therefore, they cannot direct a patient to any one specific emergency psychiatric facility. Contractually, however, knowing the resources offered by their own plan is exactly their responsibility. This is met by more vague huffing and waffling including, “I don’t make the rules,” “You’d have to speak to someone higher than me” and “It’s simply a recommendation.”
Thus psych scares me more than any other field of medicine. No one cares. Period. State and county mental hospitals have shut their doors, and the beds have disappeared. In 1984, there were about 130,000 psychiatric beds in state and county hospitals in the United States; that dropped to fewer than 80,000 10 years later. Private psych hospitals have picked up some of the slack. These increased from 20,000 beds to 40,000 over the same time period. They are businesses first and foremost, however, and have profiteered on the misery of their patients. The country’s biggest network of private, for-profit psychiatric hospitals, Charter Behavioral Health Systems, declared bankruptcy this year amid the glare of an ugly “60 Minutes II” piece and allegations of neglect and fraudulent practices. Some help.
According to the National Center for Health Statistics, outpatient visits have risen steadily during the 1980s, both in absolute numbers and as a proportion of the whole population. So does this mean that hospital beds have been disappearing because we no longer need them? That’s dubious. When other diseases experience a rise in cases, hospitalizations rise as well. Something funny is going on if more psychiatric ill-health occurs in the face of fewer hospitalizations. Fifteen years ago, it was not uncommon to have patients hospitalized for months as a time as the worst of the storm burned through their psyches.
“But no one gets away with that anymore,” says Pratt, who practices in South Carolina. Nowadays a patient needs to be demonstrably dangerous — homicidal or suicidal — to gain access to precious inpatient services.
So E.R. doctors like me end up taking care of the Rachels of the world. But the E.R. is not the only place where mental illness is treated by non-psychiatrists. Dr. Ronald Manderscheid, a senior analyst at the Substance Abuse and Mental Health Services Administration (SAMHSA, part of the Department of Health), has spent much of his career tracking how mental health services are provided.
“It’s happening,” he said of this tilt toward primary-care physicians providing psychiatric care, “but I don’t have the numbers.” Why this lack of hard information? Because clinical practice guidelines, report cards or even outcome measures cannot mutually be agreed upon between practitioners and payers. “Hence,” says Manderscheid, “the field cannot dialogue or negotiate effectively with payers, for whom price is a primary, if not the only, consideration.” In other words, no one knows just how badly the state of psychiatric care has deteriorated in the name of cost-effectiveness.
With the state of psychiatric care in such disarray, is it any wonder that fewer young doctors are entering the field? There are roughly 1,000 positions open each year for residency training in psychiatry, compared to eight times that number each year for internists, and three times that number each for surgeons and pediatricians. Fewer than 500 medical students applied for these slots.
Why? Well, why would someone want to be a psychiatrist? The salary is the lowest in all of medicine after hovering around second or third lowest –after pediatrics and family practice — for years. In 1996 psychiatrists captured rock bottom. The handcuffs on clinical practice are tightest. A psychologist or psychiatric social worker has as much freedom to make clinical decisions and probably fewer work hours, not to mention the years shorter training to become a practitioner. Any takers?
The disappearance of dollars from the mental health care picture is as central as, say, severed heads are in Picasso’s “Guernica.” Insurance companies have usually allocated 3 to 5 percent of their gross expenditures on mental health services, despite the fact that nationally such services account for closer to 10 percent of all health care costs.
How do insurance companies get away with it? Maybe it’s because unlike so many other expensive, long-lasting diseases — breast cancer, Parkinson’s, heart disease — the mentally ill have no one with power to lobby for them. Sure, depression and manic depression have had their contingent of middle-class poster children, but often those who suffer from serious mental illness fall into a downward spiral in which they lose contact with those who might help them.
Schizophrenics descend toward the bottom of the socio-economic heap, no matter how high up they started. The symptoms of illness prohibit economic stability: A seriously depressed or agitated person who disrupts meetings, yells at colleagues or fears or stalks customers is not tolerated. A person suffering a heart condition, by contrast, is quietly, gently supported back into her full-time commitments. Nor would an insurance payer cut such a person loose after a single month of illness. But those with mental and emotional disorders quickly lose their financial foothold in society and never fully regain it.
For most doctors and patients, the one bright spot in psychiatric care is the brave new world of psycho-pharmacology. Dr. Rex Cowdry, medical director at the National Association for Mental Illness, describes the new-generation medications like Zoloft and Resperidol as remarkably easy for a primary-care practitioner to use. Safer and more effective, they generally lack the horrific side effects of some of the older drugs such as Navane, Thorazine or Elavil. Antidepressants, in particular, in overdoses could produce seizures or fatal arrhythmias. In other words, you could easily kill yourself with the medication the doctor had just prescribed to rid you of your suicidal tendencies.
With the new drugs, the ethical and therapeutic dilemmas are greatly reduced. The popularity of drugs like Prozac has destigmatized mental illness and allowed patients to more freely confess symptoms to their primary doctor. This saves the referral to a psychiatrist for those times when conditions deteriorate. According to Pratt, the dollars spent on Zoloft may obviate the need for hundreds or thousands of dollars spent on inpatient care: “Studies have shown this,” says Pratt. “Patients on the newer meds need fewer hospital days.”
But progress will be slow. Getting a new drug through the marathon of R&D, clinical trials and FDA review can take as much as a decade. While new drugs do help and have offset some of the damage done by dismantling the infrastructure, they cannot work miracles: They don’t take the place of a structured, inpatient bed for a suicidal teen or a violent old man.
For at least a century, we have maintained scrupulous records of infant mortality rates. A down tick in the infant death rate is — rightly –heralded as a grand achievement of any number of public health measures. A society that can protect its most defenseless creatures is a strong, prospering society.
Has the death rate among psychiatric patients gone the way of infant deaths? Are patients in the grip of acute psychoses (or depression, agitation or mania) being cared for less and less by psychiatrists and more by non-specialists? Once again, no one knows. Why? There is no mortality rate for psychiatric illness.
The National Center for Health Statistics charts health in the United States in so many ways the mind reels. It can tell you that the percentage of impoverished Mexican children with untreated cavities has doubled in the past 20 years. But it can’t tell you if those with mental health disorders are receiving better or worse care, dying more or less than 10 years ago when the safety net became unhooked.
“This is an Achilles’ heel in the health statistics system,” says Ed Hunter, an associate director at NCHS. “We don’t cross over well from general to mental health.” Teenage suicides are up, way up. But other than that, we won’t really ever know how this vulnerable segment of society is really doing. The information about the cracks in the system, the degree to which acute mental health care has shifted from psychiatrists to internists, family-care physicians, E.R. docs, just is not there. The true rate of suffering and human cost can only be guessed at. But a sense of it comes through upon hearing the rest of Rachel’s tale.
Remember, Rachel was one of the lucky ones. Because she had Kaiser, she was admitted to the hospital. After talking to a shrink for an hour or so, she was given an antidepressant. A day and a half after I saw her, she went home. Then she hanged herself again and died.
Would anything or anyone have been able to save her? Maybe not. Even for doctors who want to help, psychiatric patients are scary, unattractive and forbidding. No one cares about them and it shows. They have no home in the health care system. A call to a health plan directs patients to the nearest E.R., where often not a single person is available who is truly qualified to assess their problem. Our inability to care for them can do more damage than good. We have other patients to tend to, the ones we can (and have been far better trained to) help.
When assailed by the voices on the phone, with their ludicrous and irrational demands for deeply personal information about the patient, I start to feel agitated and violent myself. And when mistakes are made, let them be tormented by Rachel’s ghost, not me.
When I introduce myself to people and reveal that I’m an E.R. doc, they get this excited little gleam in their eyes and ask one of two questions: “Is it tough?” or “How do you deal with the stress?”
I hate to disappoint the voyeuristically inclined, but the truth is, the tough, stressful part of the job has very little to do with plunging tubes down throats of unconscious people or yelling “Clear” and slamming defibrillator paddles. The hardest thing is to uncover the spiraling cascade of events, each one worse than the last, that sends a person to the E.R.
And that’s why the healthiest-seeming patients are the ones I fear the most. For so often, they have the problems I’m simply not trained to fix.
Last month a colleague of mine working at an E.R. across town sent me a 15-year-old girl with a request to do an ultrasound to determine whether she was pregnant. I looked at her chart. Gulp. She had already been given a pregnancy test and the results were positive.
So why had my colleague deemed it necessary to order a wholly unnecessary test?
This was a board-certified E.R. doctor, an otherwise perfectly competent practitioner whom I had worked with for several years. While many doctors do have substance dependency problems, this guy was not on drugs. I called the doctor and he confessed: He was scared of facing the girl’s mother.
The mom had made clear to him, in no uncertain terms, that her daughter was a good girl; her daughter didn’t do that. We E.R. doctors like to think we’re tough, that we can handle just about any hostile or obnoxious personality type. But he had caved.
He acknowledged that, yes, there were certain conditions that might result in a virgin’s having a positive pregnancy test, but these were uniformly nasty: ovarian, pituitary or some other kind of hormonally active tumors. Rather than rule any of these out, he sent her over to the mother ship — to me — for an ultrasound.
Upon cross-examination as to the girl’s presenting symptoms, he confessed that the mom had brought her to the urgent care center because she was vomiting and tired all the time. In other words, she was acting pregnant.
Just to be perfectly clear about it, this was the stupidest referral for a medical test in the annals of medicine. If she had been bleeding or complaining of crampy abdominal pain, and was in danger of miscarrying, she would, indeed, have needed an ultrasound. The procedure could have also found out if the girl was in any danger of having a tubal, or ectopic, pregnancy. But to do it to make sure that a pregnant girl is pregnant — well, that’s lunacy.
Once they arrived, I understood. This shameless act of cowardice by a doctor who knew better was fully excused by the fact that the mother was as big as a mastodon and wore the demeanor of an irritable boar. She bullied her way past the triage nurse and planted herself in the middle of the E.R., loudly demanding the whereabouts of Dr. Orenstein. Her daughters (a younger sibling was also in tow) cowered in terror behind her.
My initial plan — to extricate myself by telling her that her daughter was with child and to check in with the OB-GYN clinic — was not going to do. So, in what was arguably one of the most wasteful moves in my career, I sent the daughter for the ultrasound. I figured it would give me time to formulate a Plan B, not to mention devise retribution against my colleague for sending me this mess.
By the time she arrived at our hospital, the girl was thoroughly distraught. At least the sonogram would give her time away from her mother. With her I sent our social worker, a wonderfully sensitive, empathetic human being who could cajole a confession out of John Gotti. But she was powerless to get the girl to own up.
My shift is only 12 hours long. I checked my watch. If I could somehow stall the girl in the ultrasound room for another, oh, nine hours, then I could palm her off onto someone else. As I deliberated how I would actually go about doing this, the girl was wheeled back with her sister, accompanied by the only report possible from the sonographer: normal, intrauterine pregnancy.
Plus, three words from the girl: Don’t tell Mom.
Now it was my turn to do something eminently dumb. The only problem was, I didn’t know which dumb option to pick: Respect the girl’s wishes and leave her to figure out how to deal with her pregnancy, or sweet-talk her into letting me tell Mom and thereby preclude any chance of her ever getting an abortion — which, according to the social worker, was what the girl wanted and what the mother would never approve.
Fortunately, the social worker provided me with a third way out. I would call in the authorities on the case. The girl had the right, as an emancipated minor, to make her own reproductive decisions. If, however, the boyfriend turned out to be older than 18, she was also a rape victim and we had the onus to report it. If not, we might not have to call in the child welfare workers.
I played bad cop, the social worker played good cop, but we were both cops: Tell us the truth and we won’t say a word to your mother. Coercion. The social worker had her pegged better than I did. She bet the girl would sooner face her mother’s wrath than give up the boyfriend. I bet she would jump at the chance to get an abortion by giving up the father and eluding her mother.
She clammed up about the baby’s father and broke the truth to her mother. Mom exploded into torrents of maternal despair. She wailed, shrieked, sobbed, threatened, beat at her mammoth breast and finally swore on her grandmother’s grave that her daughter would never leave her sight again. She would personally raise her grandchild until her own daughter became a fit mother.
When the social worker and I explained that she didn’t have the right to make that decision for her daughter, she dared us to do anything about it. Talk about scary. Here was a 275-pound hailstorm of fury daring us to interfere in her family dynamics, and all we had for protection was a scrawny security guard 50 yards away.
The social worker held her ground, firmly repeating that if the girl’s boyfriend was older than 18, she was legally in the purview of child protective authorities. Barely audible, the girl miserably admitted to a 15-year-old boyfriend who had returned to their country in Central America. The sister nodded briskly at the revelation, as if unburdening herself of a long-held secret. The social worker and I still gamely played out our hand, but it was over. The girl had the right to choose what she would do with her womb, but she was no match for her betrayed, towering mom.
The social worker went to the authorities anyway — to nominally check on the girl’s story but also to give her a fighting chance. The girl wanted an abortion, and at eight weeks pregnant, she had only four weeks left before she would be too far along.
The investigators very quickly found out what, I believe, the social worker had already guessed: The “boyfriend” was no pimple-bound adolescent but her own father. We were not, it turned out, the first ones to coerce her to give up some hidden part of herself.
It explained a lot: not only why she couldn’t reveal the true father, even at the risk of incurring her mother’s wrath, but also why her mother had so ferociously denied her pregnancy. On some level, she must have known.
With that information, the case was brought before a local magistrate. The child protection workers recognized the girl’s desire for an abortion but also listened to the mother’s case. She obviously cared for her daughter a great deal, was adamantly opposed to an abortion on religious and personal grounds and would be a willing and loving godmother for the baby. The judge, in full possession of the facts, and presumably in full possession of his faculties, ruled that a mother knows what’s best for her daughter. (Or maybe he, too, was afraid of the mother.)
The girl was now at 10 or 11 weeks and within a week would be beyond hope of an abortion. Her appointed attorney filed an appeal and the social worker testified on the girl’s behalf.
In a rare act of courage, I offered to appear in court as well. E.R. doctors spend an average of eight to 12 minutes with a patient and then move on to the next case. We jump in and out of people’s lives; we don’t jump back in. The demands of negotiating an acute injury or sudden illness create a thick, tough skin, but come at us the wrong way and we’re only as tough as eggshell. The same eight to 12 minutes spent consoling a family or sharing in their mourning is beyond the ability of most of us. It takes a certain cowardice to intervene in someone’s life — offering lifelong consequences good or ill — and then not face the family.
I never needed to appear. A few days after the filing, the deed was done. The court of appeals judge expedited a review and quickly sided with the girl. I imagined her being whisked away, alone, to a secret clinic for an intimate procedure, and then it was over.
Dad vanished; the girl disappeared into the custody of a foster family. Reduced to a husk by losses she’d never comprehend, the imposing mother went home to raise her remaining daughter.
So sometimes it’s the patients who have nothing wrong with them who are the worst off of all. Given the terrible pathology lurking behind it, the girl needed her pregnancy terminated, and the family that allowed the sin needed help. But there were far better places to go to have the situation treated. The E.R. has no cure for a broken family, but in this case, as in so many others, it was where the family ended up. Our door was open and in they came.
Television has the Emmys, film has the Academy Awards. If emergency medicine had an award, it would be for Stupid Patient of the Year. Why SPY? You can blame it on the Emergency Medical Treatment and Active Labor Act (EMTALA), which guarantees that anyone who comes to an emergency department of a hospital, for whatever reason, is entitled to see a doctor — whether or not the person is actually sick.
The top award, for best picture, goes to the patient who expended the greatest effort to get to the E.R. in the face of the least degree of illness or injury. People certainly deserve some recognition for their inspiring creativity and determination to attain emergency care when they have no discernible pathology. As in any good awards show, I’m saving the big prizewinner for last.
Yet the subcategories are spicy and bountiful: most horrifying self-inflicted injury, nonlethal; most horrifying self-inflicted injury, lethal (oops, stepping on the Darwin award turf — apologies); most disproportionate fear of poisoning; most overblown symptom; most worried by a worrisome health report; and most creative excuse to cadge a prescription for antibiotics.
The aggravatingly common, loathsome practice of scamming for narcotics is not without its own distinct pathology and might also qualify as a category (the Jim Carrey: These patients come in all the time with nothing wrong — other than their craving — and leave empty-handed).
It must be stipulated that psychotic patients are not eligible. We’re only interested in those who, seemingly, understand and abide by the boundaries of normal behavior.
The floodgates are jammed open. The EMTALA requires emergency room doctors to provide a “medical screening exam” and to stabilize all patients, but does not specify who should do the examination or how extensive that exam must be. Mercifully, litigation has given substance to these wispy vagaries. A doctor must treat every person who opens our doors. This has been a boon to worried patients everywhere, an invitation to healthy people to clog up an already overburdened system.
Want a doctor to see your child? Come on in — and immediately become eligible for a SPY! Don’t worry, we recognize the sacrifices made by parents: A humble bow to those mommies and daddies to whom no sacrifice is too great for their children. Current nominees are those who recorded the following chief complaints for their completely healthy babies:
Baby is breathing like a pig. (There was no respiratory distress.)
Lumpnoids (never found out what these were).
Problem with tentacle (testicle).
Can’t move her bible (bowels).
His breath smells like pussy (pus).
My baby farts like a man (gassy newborn).
Penis swollen and skin tight around his vagina (uncircumcised boy).I must admit, the intentions for the EMTALA were good. Hospitals were turning patients away because they had no money — which isn’t ethical — and the EMTALA was supposed to change that. So the federal government, in effect, legislated a right to health care — but not the correspondent legislation that would require insurance companies to pay for it. Both houses of Congress adopted “prudent layperson” language last year stating that when people go to the E.R., they know they’re sick enough to need emergency care, so their health insurance should cover it. But the language was ultimately killed.
So the government can define what constitutes a medical emergency in order to require me to see a patient but not when it comes to making the insurance companies cough up for my enforced service.
Although I’m confused by all this, at least prudent laypersons throughout the land are not. They know that enjoying completely good health is no obstacle to being checked by a doctor. That can be the only explanation for the episode of the Farouk family (whose names have been changed), a nominee for the group achievement award.
The Farouks were at some sort of ethnic carnival, delightedly partaking of native costume displays, exotic dance, music and magic. When it came time for lunch, the entire clan — five or six children, a couple of uncles and aunts, and grandparents — drank juice from boxes. Within an hour or so, six of them started hurling, and hurling repeatedly. So they did what comes naturally in this rich country: They called 911.
The ambulance folks quickly made an important discovery. The juice boxes had expired, by about five months or so. No need to worry, much less go to the hospital, they said, prior to departing. By then, many of the Farouks had stopped vomiting, but this reassurance did not deter them. All feared poisoning from the sour juice, despite the fact that they felt better after disgorging themselves. All were, at the point I saw them, fine.
In truth, I don’t expect patients to know when something is wrong. That’s my job. But I’d like to care for just the ones who are pretty sure something is wrong, as opposed to those who feel OK but just want my confirmation. I’m pretty sure the Farouks would never have come in for that final degree of reassurance if they had thought they’d have to pay up.
This is our dirty little secret, the biggest gripe of emergency doctors and nurses everywhere: The only patients we truly despise are the ones who would never come in if they had to exchange money for their peace of mind.
Here’s how this ludicrous, egregiously excessive episode looks from inside the pit: We had to evaluate six patients who had already recovered from a minor gastric irritant, tying up the ambulance people, triage and treating nurses and keeping the doc (me, goddamn it!) from taking care of someone else who might actually have been sick or injured.
Candidates for the SPY, like contenders for the Museum of Bad Art, are not as plentiful as it might seem at first glance. The shortlist is colorful and instructive all at once.
To wit: In the midst of an ice storm, I once treated a store clerk who had sprained his ankle four or five days earlier; it looked mildly swollen but otherwise unharmed, and signs of resolution were clearly evident. And while I had not actually watched the guy walk in on his own two feet, he crossed a sheet of ice to get to me, which indicated he could get from place to place.
Hemming us in on all sides were literally dozens of other people with freshly fractured bones. I put on my “honest guy” face and told the clerk squarely that he was clinically clear, that I was relying on my judgment, and my judgment alone, to penetrate through the layers of skin to see that his ankle bones were intact. He looked right back at me, in his “honest guy” face, and told me that he would feel much better if the final say came from an X-ray.
I traded my “honest guy” face for my “customer is always right” face, but just for a second. Then I tried to be a hero. “Honest guy” face came back and said that the backup in X-ray was hours, and that it would take even more time to look at his film and then have the radiologist confirm my reading. I really wanted to save him the wait.
But he put on his “what do you take me for, some kind of a chump?” face and told me he wanted the X-ray. So I put back on my “customer is always right” face and promised I’d be back in a jiffy. And sure enough, hours later, he found out that nothing was wrong.
Now while you may find his story intriguing, just wait until you hear about the progenitor — and the inspiration for the SPY award. Her story comes from the category with a fathomless pool of aspirants: stupid genital tricks.
The amateurs vying for this award have run through a numbingly familiar ensemble of tricks: the lock around the testicle, the exotic-lotion burns on moist mucous membranes, the items inserted into various openings. Yadda yadda. But the most sublimely ridiculous encounter of my entire medical career, one that has nestled itself quite fondly in my heart, occurred when I was a resident. Janey (not her real name) showed up one day in the pelvic room after her boyfriend found something in her vagina that, try as they might, they couldn’t get out.
“Did you put anything in there?” I asked.
“Not really,” she said. She knew I was going to ask this; she had already been asked by the triage nurse. The registration clerk had duly noted her chief complaint as “FB vag,” or foreign body in the vagina.
“What do you mean, ‘Not really’?”
She and her boyfriend had been playing “rough” a week earlier, and he may have put something up there in order to just take it out again — like a game. “I don’t remember leaving anything in there, but, you know, something might have gotten lost. You know?”
No, I don’t know about these things, but I do know fishing, and this was a fishing expedition. A female (nurse or tech) always escorts male physicians who perform pelvic exams, and the nurse helping me that day relayed (out of earshot) the string of things that had at one time or another been recovered from vaginas in the E.R.: a condom, a dildo, a french fry, an egg (in the shell), a marble, a Tylenol bottle, a light bulb (small, dicor-style), a roll of film, a set of keys, one of those poofy-hair voodoo dolls.
After several attempts outside the door to quell our hysterics, we returned to the room to position Janey in the stirrups and trawl for treasure. I opened the speculum and looked.
Nothing. Empty.
“Ummm … ” I started. (How does one go on in such a situation? What would Miss Manners do?) “There’s nothing in here. Are you sure it didn’t come out?”
“No, I felt it in there just before we got here.”
Alrighty, then. I looked at the nurse and she shrugged, biting her cheeks. “You look,” I told her. She didn’t see anything, either.
I stood up to do a manual exam. Maybe it was really small and somehow hidden behind a fold or recess. I pushed on Janey’s cervix to see if there was any tenderness.
“That’s it. You got it.”
“This?” I said, wiggling it.
“That’s it. It feels round.”
“What did you find?” the nurse asked.
“When did you lose this in there?”
“I don’t remember. Maybe a couple of months ago.”
Months? I thought. “This is your cervix, it belongs there. You’re supposed to have one of these.” I jiggled it again. The nurse lost it, bending over in a fit of choking laughter.
“That’s what my boyfriend was grabbing on to.”
I hope he didn’t try too hard to get it out.
When, as sometimes happens, I burst into spontaneous laughter, it’s because I find myself thinking of Janey’s acceptance speech for her lifetime achievement award.
