Author: Maria Yang, MD

Categories
Consult-Liaison Education NYC

D5 Hold.

I had arrived in New York City only six weeks prior. It was the fifth week of my fellowship. I still couldn’t find some of the units in Bellevue Hospital.

“There’s a new consult,” the attending told me. “The patient is on a D5 hold. It could be interesting.”

I learned many new acronyms during my first few weeks in New York:

A PES is a Psychiatric Emergency Service. It means that psychiatric services are available in an emergency department. This, however, does not guarantee that the PES has its own dedicated space.

“There’s a PES in the city that is literally an open hallway of the emergency room. They put pink gowns on all the psychiatric patients,” a resident told me. “Can you imagine? No one wants to wear a pink gown. Patient privacy is out the window, too!”

A CPEP is a Comprehensive Psychiatric Emergency Program, which is part of a hospital system. As its name suggests, it offers comprehensive services: a mobile crisis unit (think of something like a Batmobile, holding a combination of social workers, nurses, and psychiatrists, that responds to urgent mental health situations in the community); a dedicated physical space that provides emergency psychiatric services in a hospital; and EOB beds.

“What are EOB beds?”

“Emergency observation beds. It’s like a mini-psychiatric unit in the emergency room. If someone gets hospitalized involuntarily and there aren’t any inpatient beds available, he can stay in an EOB bed. Or if someone comes in drunk, he can stay in an EOB bed until he sobers up. He doesn’t need to take up a bed in the hospital. It’s quieter in the EOB. They don’t have to see and hear all the stuff that happens in emergency room, like when a lot of nine-three-nines come in.”

“And a 9.39 is when someone is involuntarily committed to the hospital for psychiatric reasons, right?”

“Yup.”

I didn’t know what a “D5 hold” was.

The attending said, “A D5 hold is when someone is held involuntarily in the hospital because they haven’t been able to finish a course of treatment for tuberculosis. There are different levels. D5 is the most restrictive. Patients on D5 holds couldn’t—or wouldn’t—take the tuberculosis medications as outpatients or even under ‘directly observed therapy’, which is when they have to show up at a clinic and a nurse watches them take the medication.”

“Oh.”

“These patients on D5 holds often have severe substance abuse problems and personality disorders. They can be here for a long time.”

“Like how long?”

The attending chuckled.

There was a security guard posted outside the door. He glanced up at me.

“Hi, my name is Dr. Yang”—I pointed to my ID badge—”and I’m here to see—”

As he started to look away, he mumbled, “Talk to the nurses inside.”

I shut my mouth and peered through the thick glass windows. I saw open doors, but no people. As I was turning around to point this out to the guard, a nurse passed by. I shook my hand at her. After looking at my ID, she unlocked the door and let me in.

“Hi, my name is Maria Yang, I’m one of the psychiatric consult fellows and—”

“Oh, you’re from psych!” she said, pulling her glasses down while peering up at me. “You’re here to see George?”

“Yes—”

“—in that room.”

“How long have you been here, George?”

“Too long.”

“How long is ‘too long’?”

“I was stupid when I first got here, I was dicking around, I don’t know, I just didn’t think it was a big a deal. I was okay, ya know? I’m better now. I think I got six months left.”

“Six months left, okay. But how long have you been here?”

George was reclining on his bed. He looked up at the images he had taped to the wall; they were glossy magazine photos of slender women in bikinis. He sighed.

“When I was outside, I talked to women who looked like that all the time. They liked me. They wouldn’t leave me alone.”

“When’s the last time you had a conversation like that?”

He pushed himself up into a sitting position.

“Almost two years.”

For the next two months, I saw George on a weekly basis for informal psychotherapy. Thankfully, he was housed in the unit that didn’t require respiratory precautions. We didn’t have much privacy. His roommate offered to leave each time we met.

George told me that the last time he had been physically outside was the day he was forced to enter the hospital.

“I coulda left over a year ago, Doc, but some guy brought in dope and planted it in my pillow and told everyone else that I was dealing. I coulda killed him, I really coulda. They drew my blood around that time, Doc, ‘cuz they thought I was using, too. My rifampin level was low, it was too low, so they made me stay longer. And then this other thing happened and I couldn’t get out.”

He told me about the special Friday night meals: They had Chinese take-out last week. It was probably going to be tacos this week. He liked fried chicken the best.

“They give you these tokens if you do stuff. You make your bed, you clean up, you get tokens. Tokens get you chips and candy. They get you magazines sometimes, too.” He pointed at his paper harem.

He told me about all the different doctors involved in his care.

“I’ve trained a lot of the docs here, I met them when they were interns and now they’re big residents! They’re only here for a lil’ bit, though.”

Soon, my time came to rotate off service.

“Okay, see you, Doc. I only got four months left. Maybe you’ll see me outside, that’d be nice, right? You can meet all of my girls.” He winked at me.

Our paths never crossed again during my time in New York. And, thereafter, I never took for granted the daily opportunity to breathe fresh air.

References:

Categories
Lessons

Our Best Teachers.

Inside the church bookstore were rows of religious icons. Some were the size of newspapers; others were smaller than a deck of cards. Saints, the mother of God, and the Son of Man himself gazed serenely back at me.

The icons made me think of Kelly.[1. Kelly is based on an actual person, but all the details are fiction.] She was the patient of another psychiatrist at the agency. Kelly came to the office every morning and greeted me with the enthusiasm of a puppy chasing a frisbee.

“HELLOOOOOOOO, DR. YANG! How are you? You look wonderful today! The angels above are shining a special light upon you! Have a blessed day!”

How could I not smile with a greeting like that?

One day, Kelly came in wearing a purple backpack. After saying hello, she asked, “Would you like the see my icon?”

Pushing aside the thought of a small pictogram on a computer screen, I nodded. She pulled the backpack off and carefully unzipped the bag. Using her left hand she pulled out a panel of wood about the size of a standard sheet of paper. The lacquered surface reflected the fluorescent lights overhead. A man with a beard and a halo around his head looked back at me.

“Who is that?” I asked.

“That’s St. Christopher,” Kelly said, tilting the icon so she could look at it. “I got it at church last week.”

“Tell me about St. Christopher.”

“St. Christopher is the patron saint of travellers. We ask St. Christopher to watch over us and keep us safe. That’s why I always carry him around in my backpack.”

I hadn’t thought about Kelly in months. Upon stepping inside the church bookstore, though, I heard her melodic voice and saw her broad smile with clarity.

I don’t know how many patients I have met. Probably over a thousand. Have I seen two thousand patients yet?

All of those people have helped me become the doctor I am today. They all taught me something about health, illness, diagnosis, treatment, and coping. Some of them wanted nothing to do with me; others wanted me to do something that I could not or would not do. Some of them highlighted my weaknesses; others trusted my strengths.

Practically all of them demonstrated extraordinary patience with me, especially during their times of suffering.

I don’t think I ever thanked Kelly for sharing herself with me. She reinforced the rewards of taking an interest in patients as people. I hope that she continues to find comfort in St. Christopher.

Steve Jobs made a remark during the commencement speech that he made at Stanford:

Again, you can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust that the dots will somehow connect in your future.

I often don’t realize what lessons patients have taught me until months to years have passed. What I learned from one patient may not become apparent until another patient points it out. Sometimes a number of patients are trying to teach me the same lesson and I still don’t get it.

Patients aren’t dots. For doctors, they are some of our best teachers. Let’s not forget that.

Categories
Education Fiction

Timing.

It was 4:38pm and the consult pager beeped. The attending psychiatrist sighed with displeasure. That pager always seemed to go off during those last few minutes at work.

The resident returned from the phone call and reported, “It sounds like there’s a young woman who just got through surgery. She’s in the PACU (post anesthesia care unit) and won’t stop crying, no matter how much pain medication she gets. Surgery is asking for help.”

The attending looked at his watch and grunted. “We don’t have to do a full consult now. We can patch things over for the night and finish up tomorrow.”

His legs were long and the tassels on his loafers swished with each step he took. To keep up with him, the resident was almost running.

When they arrived in the PACU, the nurses looked up. As they put their heads back down, they wordlessly pointed to the other side of the room.

Laying in the gurney was a young woman who was sobbing. Her breaths were irregular, choked. Tears flooded her flushed cheeks and plastered locks of hair to her face. The hospital gown was too big for her and she was somehow slumped in a reclining position.

The attending approached and wrapped his hands around the railing of the patient’s gurney.

“My name is Dr. Tom.”

A new wave of tears washed over the patient. Shoulders quivering, she put her hands over her face and nodded at him.

“We’re from the psychiatry service.” He tilted his head to gesture at the resident standing behind him, who nodded and offered a meek smile. His speech was cool, clipped. “The surgeons say that you’ve been upset since the surgery. What happened?”

“I… don’t… know,” she sobbed through her fingers, her voice thin and strained.

“Are you feeling sad?”

Uncovering her face, she nodded. She raised a limp hand and wiped her eyes.

“Are you feeling scared?”

“I’m… so alone,” she blurted between gasps. “No one is here. No one is taking care of me.”

“Uh huh.”

The resident glanced at them. The patient looked distressed and the attending looked bored. The resident shifted uncomfortably.

“Miss, can I ask you a question?” Dr. Tom turned and cast a knowing glance at the resident: Pay attention. Here comes a clinical pearl.

The patient nodded, her red eyes still welling with tears.

“Were you sexually abused when you were a kid?”

The resident felt her breath catch in her throat.

The patient’s chin began to quiver. She tore her eyes away from the attending and buried her face in her hands. After choking on a few gasps, she mumbled, “Yeah.”

“Okay,” Dr. Tom said, leaning back and releasing the gurney rails. “Some people feel alone and scared after surgery. We’ll ask the nurses to give you more pain medication, that’ll help you feel more comfortable. We can talk more tomorrow morning, maybe about ways you can feel less lonely while you’re here.”

The patient nodded, sniffing.

“So we’ll see you tomorrow. Good-bye!” He flashed a toothy smile, waved, and walked away.

The patient looked at the resident, who waved weakly before turning to catch up with the attending.

Once out of PACU, the resident blurted, “Why did you ask her about sexual abuse?”

“Borderline personality disorder. They often have a history of sexual abuse. Her presentation was consistent with that diagnosis.”

She opened her mouth to say, No, I meant why did you ask her about it at that moment? Couldn’t it wait?

Instead, she heard herself say, “Oh. Thanks.”

“No problem,” he said, flashing that toothy smile at her. “Now you know what to ask when you see a similar patient in the future. Have a good evening!”

She watched him walk away and wondered if she had done the right thing.

Categories
Homelessness Seattle

Three Years.

My stomach lurched when I saw him.

He was leaning against a brick building, his fingertips gripping the walls as if they alone were holding him upright. His head swiveled back and forth in animated conversation.

He was standing alone.

He looked exactly the same as he did before I left Seattle for New York: Matted hair, unwashed skin, lopsided smile.

During my last year of residency, I spent one day a week working at a shelter. He unexpectedly appeared there one afternoon. Staff told me that he was an occasional visitor for the past fifteen years. When winter descended upon the city, they saw him more often. He disappeared during the dryer months.

Wary of psychiatrists—he had spoken to several in his lifetime—he kept our first meeting short.

“Would you be willing to come back next week so we can talk again?”

He shrugged.

To my surprise, he appeared the next week. And the week after. And the week after that.

He told me about his immigrant parents. He told me that he was an avid reader. He often had a copy of the local paper or a library book tucked under his arm when he came to the shelter. His vision was poor, so I’d often see his face inches from the pages. He squinted. He told me about the wooded grove he slept in, though would never tell me its exact location. He showed me the toiletries he kept in his duffel bag, including the razors he used to shave his face without any water or cream.

He never told me what happened that made him homeless. He never told me who he spoke to when he was alone.

Several months before my departure, I told him that I was moving to New York City. The lopsided smile blossomed on his face.

“I used to live there,” he said. The smile withered and his expression darkened. “Be careful. There are a lot of people there. It’s not a safe place. Especially the subway platforms. Make sure you always hold onto the columns in the subway stations.”

To demonstrate, he stood up and dug his fingertips into the walls of the office as if they alone were holding him upright.

Three years have passed and I have returned to Seattle. Three years have passed and he remains homeless with limited to no options for supportive housing. Three years have passed and the only things he can hold onto are the walls along the city streets.

Categories
Education Homelessness NYC

How Long Do People Stay Here?

Let’s visit a homeless shelter in New York City.

There’s no sign on the building. On the sidewalk outside of the unmarked entrance are several men. Three of them are chatting with each other. Two others are leaning against the wall, taking drags from their cigarettes. After you pass, one of them coughs up a wad of phlegm and spits it out. A man sitting on the sidewalk asks, “Spare some change?” He shakes a tattered coffee cup at you. The few coins inside jangle.

You try to pull the door open. It’s locked. Through the glass you see a few people looking out at you. They’re not smiling. Finding the doorbell, you press the white button. A few seconds pass. A harsh, steady buzz suddenly fills the air, informing you that you may now enter.

“Sign in!” a man barks at you. Behind the splintered desk is a man in a security uniform. He’s pointing at a log book, the page nearly filled with names in blue ink.

As you write in your information, he asks, “Who are you? Where you from?”

“Empty your pockets.”

“Open your bag.”

Satisfied with your answers and confident that you don’t have weapons, drugs, or alcohol, he steps out from behind the desk with a metal detector wand. After he waves it over your body, he says, “Go. You’re fine.”

Before you see the thick, plastic chairs in the main room, you smell the odor of fetid sweat. Seated in the chairs are men wearing unwashed jeans, oversized shirts, baggy jackets, and generic baseball caps. Some of them are reading newspapers and books. A few older women are sleeping upright, their chins nearly resting on their chests. One of them is wearing sandals; her toenails are discolored and misshapen from fungus. Her ankles look like eggplants. A young man seated in a wheelchair tries to drink his coffee, but his tremulous hand cannot keep the cup steady. Next to him is a man wearing a porkpie hat, red lipstick, two winter coats, board shorts over torn tuxedo pants, and yellow sandals. Three women are shouting at each other; one of them reaches for the neck of another and screams, “I’M GONNA KILL YOU, YOU—”

“How long do people stay here?” you ask, realizing that the room is filled with people. You can’t imagine living like this; you’d get out of here as soon as you could.

They feel the exact same way.

But you ask an excellent question. What is the average length of stay in a homeless shelter?

Some caveats: Data on homelessness is almost always incomplete and inaccurate:

  1. Researchers can only collect data that is available. People who stay in homeless shelters are available. People who live in cars, abandoned lots, and in transit stations—away from researchers—are generally unavailable.
  2. Researchers often must rely on the information homeless individuals share (“self report”). For a variety of reasons, people who are homeless may not share much about themselves… if they consent to interviews at all.

That being said, available evidence suggests that people stay in homeless shelters anywhere from two [1. “The average length of stay in emergency shelter was 69 days for single men, 51 days for single women, and 70 days for families.”] to seven months. [2. “In a survey of 24 cities, people remain homeless an average of seven months…”] (I read a paper within the last year that I now cannot find—of course—that demonstrated that the majority of people who experience homelessness are homeless for less than six months. Furthermore, of those people, most of them are homeless for only one day!)

This suggests that the majority of people in shelters do not experience chronic homelessness. Emergency shelters, then, are arguably used just for that: emergencies. Those who enter shelters obtain the help and resources (either within or outside of the shelter) to get them back on their feet. They exit the shelter system in less than a year—sometimes within a few months—and never use the system again.

However, there are individuals in shelters who meet the definition of “chronically homeless”. Some researchers have “identified that approximately 10 percent of users account[ed] for 50 percent of the annual nights of shelter provided”. [3. See page 1-10 of this document for the statistic that 10% of shelter users account for 50% of annual nights of shelter provided.] These numbers should sound familiar to those of you who follow health care policy discussions, where “5% of patients use 50% of all health care spending dollars”. [4. More about “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending” here.]

So what’s going on with these individuals who experience chronic homelessness? Are there risk factors for chronic homelessness? If so, what do you think they are?