Author: Maria Yang, MD

Categories
Consult-Liaison Lessons Nonfiction

Approach, Don’t Avoid.

I don’t think the crisis center had been open for even one week. There were dozens of staff and fewer than five patients. Most of the staff were young, eager, and brand new to social services. Only the nurses and I had experience working in higher acuity settings.

One late afternoon, an elderly woman using a walker got a hold of a pair of scissors. One arthritic hand wielded the scissors while the other gripped the walker. Her feet were heavy; she plodded across the floor, chanting, “Kill, kill.” The walker swiveled because her torso wobbled with each step.

Our colleagues fled; doors to staff-only areas clattered shut. A nurse and I looked at each other when we realized we were the only people left in the room with this patient. We both sighed. I used my chin to signal that I would follow him.

Later, I asked to meet with all the staff working that shift. Why did you all leave the scene?

“Because she had scissors and was talking about killing people,” they said. “She had a weapon.” We were fearful that she was going to kill us, dummy!

Because this was my first job as a medical director, I thought I always had to “direct”. I didn’t realize that I could keep asking questions:

  • How do you know that she wanted to kill other people?
  • What else might have happened if everyone left her alone with a pair of scissors?
  • What realistic damage could she have done with the scissors?
  • What unspoken message did we send to each other when we all left?
  • What unspoken message did we send to her?
  • Are there things we could have said to get more information from her?
  • What steps could we have taken to separate her from the scissors?

You can’t always believe what you think.

(To be fair, people who don’t know what to do often run away. Avoidance is a common strategy to cope with fear and anxiety.)

The nurse approached the elderly woman from one side. He took three steps for every one step she took.

“Hi. Can you put the scissors into the basket of your walker, please?” he asked.

“Kill, kill,” she continued to chant, holding the scissors in the air. She continued to plod forward.

“Hi. Put the scissors here, please,” I echoed, pointing at the basket.

Her forward movement stopped. The scissors remained in her raised hand. We stood in stillness together.

Mumbling, she dropped the scissors into the basket. I plucked them out. After thanking her, we asked her to please sit down. “And please don’t do that again. It scares people.”

“Please don’t leave when things like that happen,” I said, directing the team. “When there’s a situation, approach. People might need you to do something. Your presence alone can help de-escalate situations. And someone will send you away if it gets too crowded. But don’t immediately leave.”

For the remainder of my time there, staff never disappeared again during a crisis.

(inspired by claims that RFK, Jr., left the scene of Oval Office medical emergency)

Categories
Homelessness Medicine Nonfiction Policy Public health psychiatry Seattle

Who Gets to Be Sad?

For those of you who don’t follow baseball, the Seattle Mariners were in the running to go to the finals in baseball, called the World Series. (So American, of course, to call the finals the “World Series” when it doesn’t involve the entire world!) The Mariners are the only team in all of Major League Baseball that has never been to the World Series.

As such, you can imagine how much of a frenzy the city was in. The Mariners flag was hoisted to the top of the Space Needle twice! The downtown skyscrapers coordinated their night lights to glow in Mariners colors. The mayor raised the Mariners’ flag at City Hall.

Game 7 in the semi-finals, which happened last week, was the “win and go to the World Series, or lose and go home” game. The Seattle Mariners lost.

Over the past week, since that loss, the city has been distraught.

Immediately following game 7, there were brutal postgame interviews. Sports journalists, for obtuse reasons, asked weeping baseball players how they felt.

Here’s Cal Raleigh, our inimitable catcher, showing what his face looked like when he was seven years old and heartbroken:

See how he ran his hand through his hair? That was a desperate act of self-soothing while multiple cameras gave him no place to hide his flushed face and wet eyes.

Meanwhile, here’s Bryan Woo, who turned out to be the team’s ace pitcher this year. He’s not crying, but he is also just trying to get through the interview. A wail of despair interrupts him:

The man whose heartache was heard, but not seen, was our cool center fielder, Julio Rodriguez.

So, are grown men allowed to cry or not? Here were professional athletes caught in the throes of disappointment and sadness. They were crying. Sports journalists pushed microphones into their faces and asked them how they were feeling.

On the one hand, I appreciate this exercise: It’s a chance for these robust young men to model (to other males) how to use words to describe internal experiences. They’re not smashing bats into the walls or punching the journalists. You can talk about unpleasant emotions without resorting to violence or destruction.

On the other hand, asking people about their feelings on camera when they are obviously distressed seems unkind. Sure, baseball players, as public figures, have training about and responsibilities to the media. But such pointed questions do nothing to soothe or support the person. Reporters can also learn the exact same information — how do you feel about losing the biggest game of your professional career to date? — an hour later, when people have had the chance to cry and wail in private. Show some respect, give people some dignity!

But we apparently want to see our heroes cry. We want to know that they feel just as sad as we do.

There are many other people throughout the nation who are crying. They are not professional baseball players; they are not famous. Many of us will never know any of their names.

Some of them were looking forward to leaving the street and moving into an apartment! With winter right around the corner, the anticipation of living somewhere dry and warm was thrilling. Because of the government shutdown, though, the mainstream vouchers that would have paid for those apartments are invalid. So they will have to wait for the government to open before they can move inside.

Many of these same people have Medicaid for health insurance. There are also millions of other people with Medicaid who do know where they will sleep tonight.

The federal government has somehow concluded that it’s not worth it to spend money on health insurance for poor people. But, it is somehow cool to take that money to give tax cuts to people who are wealthy. Yes, it is true that, one day, we will all die. Taking health insurance away from poor people, though, is spiteful. It only makes it more likely that they will needlessly suffer while they are alive.

You know what makes suffering worse? Hunger.

The government shutdown, if not resolved by November 1st, will also shut down the Supplemental Nutrition Assistance Program (SNAP). This program, also called “food stamps”, gives financial aid to poor people to help them buy nutritious food. Food banks are already struggling to provide enough food to visitors. Furthermore, here in Washington State, many grocery stores have closed.

Some people are already hungry. More people will join them.

Yes, you’re reading this right: Soon, the same group of people will have increasing struggles to access food, health care, AND housing. What they all have in common is poverty. Literally no one ever says, “When I grow up, I want to be poor and rely on welfare!” Being poor is not a moral failing. No one, regardless of how much money they have, deserves to have the foundations of wellbeing — food, shelter, and health — taken from them.

But we apparently don’t want to see poor people cry. We don’t want to know their sadness. Some people think poor people deserve to be sad. Others think that poor people are not people.

What would we have to admit to ourselves if we felt their sadness? What would we have to change if we acknowledged that their sadness is real?

Categories
Homelessness Nonfiction

Neither Sex Nor Drugs.

While it was happening I recognized that it didn’t look great.

My outreach colleague was driving and slowed down. After rolling down my passenger side window, she leaned over and shouted a name.

The Woman she was shouting at was walking on the sidewalk towards us. Her stiletto knee-high boots were the same color as her miniskirt. The bustier did not fully cover her waist. Bright eyeliner and false eyelashes made her eyes pop. The purse slung over her shoulder swung with each confident step she took.

The Woman didn’t hear my colleague, so I shouted the same name out the window. She turned and took a few steps towards the car. I pointed at the driver. The Woman smiled in recognition, revealing many missing teeth, and came to talk with us through the window.

It could have looked like we were negotiating money for sex.

“I’ve been looking for you,” my colleague said, turning on the emergency lights. “I have a lot of mail for you.”

The Woman and my colleague discussed meeting at the office so she could get her letters. A toothless smile again bloomed on The Woman’s face as she blurted out, “Oh! I haven’t used fentanyl in 14 days!”

Dear reader, I had no idea who this person was; I just met her. That didn’t stop me from bursting into applause. I was the only one clapping. It was a reason to celebrate! She beamed.

“Where are you staying now?” my colleague asked after congratulating her.

“I live in That Neighborhood now,” The Woman said. “Near That Street and That Avenue. There’s a hole in the fence near that intersection. Go through that hole and a little further back through the trees, and you’ll find me there.”

Through a fence and then on a dirt path in stiletto heels!

Don’t judge a book by its cover.

Categories
Homelessness Nonfiction Policy

The Man in the Tiny Village.

Almost 30 minutes had passed, but The Man was still standing outside in the grey morning chill. His soiled tee shirt and loose pants hung from his tall frame. Over the next few minutes, he rarely shifted his feet while staring at a distant point on the ground.

“Hi,” I greeted again. He did not move.

“I’m worried about you,” I offered, hoping for any sign of acknowledgment. None came.

It no longer feels uncomfortable to talk to someone who doesn’t respond. Remember the people in the ICU, their bodies puffy from inflammation and fluid, their respiratory tubes hissing with each mechanical breath? Or the young men tucked into the corners of their jail cells, their heads cradled in their slender arms? Or the people so preoccupied with voices only they heard, their unblinking eyes quivering?

“I’m going to prescribe medicine for you. The goal is to help you think better. I’ll ask the staff to remind you about it. I hope you’ll try it, but if you don’t want to take it, that’s fine. I’ll see you again soon.”

His gaze remain fixed on the ground.

“It’s cold outside. Go back in,” I said. He stirred and mumbled something.

“Go back inside,” I repeated, pointing and taking a step towards his Tiny House. After a beat, he lifted a leg and meandered back to his unit.

Tiny Villages are clusters of small wooden structures, called Tiny Houses. A Tiny House is less than 100 square feet, so most people have only a bed and a storage rack inside. Each unit has heat and electricity, along with at least one window. The door locks. Outside of the two dozen or so Tiny Houses are shared bathrooms, an enclosed kitchen and dining area, plus covered laundry facilities. The houses are usually painted in bright colors. Residents often add personal touches to the small area in front of their house: Wild flowers in small pots; stickers and signs; sometimes inflatable yard decorations. Surrounding the entire Tiny Village is a wood or chain-link fence. Visitors must check in before they enter the front gate.

Village staff had introduced me to The Man about an hour earlier. When The Man opened the door to his Tiny House, the stench of body odor rushed out. For nearly five minutes he stood in the doorway and looked around at the ground. His face was scrunched up in confusion while he mumbled under his breath.

With repeated coaxing we got him out of the morning chill and into a Tiny Office. He didn’t talk to me; he instead talked with someone that only he could see. While seated in the folding chair he laughed, made animated gestures, and muttered about truth and lies. I ended our time together. We all exited the office.

Village staff pulled me aside to tell me more about The Man: Just a few months ago he was able to have a coherent conversation. Before moving into the Tiny House, he lived in a trailer. Before that, he worked in warehouses and lived in an apartment. Alcohol overuse led to problems at work and dismissals. Now he smoked methamphetamine once in a while. Other people in the Tiny Village were worried about his wellbeing, too.

It was when I was leaving the Tiny Village that I saw that The Man was still standing outside. Had he been there, motionless, for almost 30 minutes?

The medications came in a bubble pack, each row marked with the date. One pill for each day, at any time of day, for one week.

On day one, The Man popped a tablet out of its bubble, then swallowed it. Nothing changed.

The e-mail I received a week later contained exclamation points: The Man took the medicine most days that week! He was making more sense! He wanted to take more medication!

Of course I obliged.

The next time I saw him, his unit still didn’t smell fresh. However, he immediately came out and walked with us to the office.

“I’m sorry for having an attitude when we last talked,” he offered. I shook my head; he didn’t need to apologize. What he thought was an “attitude” was actually symptoms of psychosis.

When I asked him what was happening when we last spoke, he replied, “I was annoyed. People kept talking to me.”

“Who?”

He shifted uncomfortably in his chair. “I don’t want to snitch on them…”

I waited. He looked up, took a breath, and continued.

“… but I hear them all the time, 24/7, on and off, it doesn’t matter.” He shared that he had been hearing those voices since he was a kid. “Sometimes I want to tear them apart, I get so annoyed.”

What did he think of the medication? “It helps me ignore them better. When I get annoyed I take it, so I’ll take two a day.”

I nodded serenely. Thank The Universe that nothing harmful happened with his doubling of the dose!

As our time together came to a close, I asked, “Is there anything else I can help you with today?”

A moment passed. He scratched his head. He then quietly asked, “Is there anything that can help me stop using meth?”

When we bring services to where people are, they can make great gains in building the lives they want to lead.

I was worried that, because of The Man’s symptoms, we would have to tread down the road of involuntary treatment. But, the interventions and support of the team prevented this. We avoided the circus of the police and medics coercing him into an ambulance. He escaped the chaos of waiting in an emergency department while restrained to a gurney. Residing in a Tiny Home is not an ideal living situation, but at least he was able to keep the freedoms there that are absent in a psychiatric hospital.

In addition to preserving his dignity, these interventions saved costs throughout the system. First responders were freed up to attend to other emergencies. Because The Man never went to the emergency department, he never received an ambulance or hospital bill. All together that would have summed in the thousands of dollars.

This man, like the women described here, was homeless. Like them, he did not contribute to crime and disorder on America’s streets. He was not a safety threat.

Who was truly unsafe: Us, or him?

Categories
Nonfiction Reflection Seattle

How About Those Mariners?

In January of 2024, I made a deliberate choice to be a Baseball Fan. There were two reasons behind this:

  • My spouse is a lifelong baseball fan and I wanted to be a better spouse. We had gone to a few games when his team was in town to play the Seattle Mariners, but my appreciation was limited to “vibes” only.
  • Someone I loved very much was disintegrating. Cheering a baseball team was a socially acceptable way to shout and channel my heartache in public.

I had choices to make, though: Do I invest my enthusiasm in my spouse’s team? In their pinstripes they have won the most number of World Series (and reminds everyone of it). Or do I dedicate my ardor to the team that has never been to the World Series, the Seattle Mariners?

Dear reader, you already know who got my vote. The West Coast is the Best Coast.

A sponge for learning, I asked many questions during my 2024 baseball education. Once I understood what “starting rotation” meant, what made the Mariner pitchers so effective? Why does “Wins Above Replacement” matter? What does “On-base Plus Slugging” represent? Why did Ty France get hit by pitch so much? Teams can designate players for assignment just like that???

My spouse’s eyes never rolled out of his head, though that would have been a reasonable response to some of my questions. Every morning I read the SB Nation site for the Mariners, Lookout Landing. I announced my burgeoning interest in baseball to other Mariners fans. They all looked at me with some amount of pity.

In our 2024 Christmas card I commented that my choice to become a fan of the Seattle Mariners was a mistake. I now understood the shirt I had seen around town: A trident, to represent the Mariners, and the text, “Maybe next year!“

Before the baseball season started in 2025, the person I loved very much died. As the year unfolded, wars continued, injustice ascended, ethics eroded. Cheering a baseball team is a socially acceptable way to redirect the energies of grief and anger in public.

My investment in the Seattle Mariners grew. This culminated in the sheer amount of kilojoules I spent this week on this team, which is now the American League West champion! This hasn’t happened in 24 years.

Furthermore, our humble catcher, Cal Raleigh, made home run history, both as a catcher and as a switch hitter. (His nickname is “The Big Dumper”. Have you seen the size of his butt?)

This has prompted questions about identity:

  • I didn’t grow up in a baseball household. (Basketball came first, then football.)
  • I historically have found baseball boring.
  • Could fans of America’s pastime look like me?
  • Am I now one of those people who can spout random facts about baseball?

Dear reader, the answer to all those questions is yes. That’s super weird.

As the Seattle Mariners crested towards the end of the season, baseball became a laboratory of communication.

I previously envied the way men who did not know each other could immediately engage in energetic conversations about sports. Sometimes it seemed like they had known each other for years.

What I noticed now, though, was the increasing amount of communication — particularly in the form of text messages — solely about baseball. Practically all these people are good friends I have known for years. There are real tragedies happening in their lives: parents who are deteriorating; pets dying; friends with conditions that elude treatment; people losing their jobs.

Meanwhile, they send messages acknowledging Cal Raleigh’s 60th home run.

How are they themselves doing? No comment.

I don’t know if it’s true that, because of my professional training, it is easier for me to have in-depth conversations with people. Do I have skills to create conditions so people will be more likely to share sensitive personal information with me? I hope so, but I don’t actually know.

It’s true: Talking about baseball is easier than talking about hopes, fears, dreams, and loss. It’s natural to avoid delving into more meaningful topics. We fear how others will react to our vulnerabilities, to the soft spots we keep covered to prevent bruises from the outside world.

The thing is, we’re often our own harshest critics. Our good friends aren’t umpires. They’re not calling balls and strikes on us. They are instead in the dugout or on deck, admiring our approaches to the plate.

But let me be honest: Have I already forgotten the reasons why I chose to become a Baseball Fan? Weren’t there thoughts and emotions I sought to shun? I couldn’t escape anticipatory grief. The crying was exhausting. Wasn’t I looking for a healthy yet avoidant way to cope?

So, here’s to the 2025 Seattle Mariners. May their success continue. May they go to (and win!) the World Series. May they continue to be a bright spot amid the challenges we all have in our small lives and big communities.