Weekends at Bellevue: Monday Morning Signout Redux

It is the Summer of 2003. We've been pretty busy lately and it looks like I'm going to need to call EMS for diversion again. When there are too many patients on triage and we have no empty beds upstairs, or there are simply too many patients in the area, then I can call the diversion desk at EMS and ask them to take us out of the loop. It is a phone number I know by heart by now, and even though the call is supposed to be made by the CPEP director, I often make it myself.

As EMS is quick to remind me, diversion is a courtesy. The city will try to shield us from any new patients arriving by ambulance, but there is no guarantee. It works to some extent; maybe we get seventy-five percent fewer EMS cases, but inevitably they still arrive. Either the drivers will say it didn't come up on their screen, or they didn't hear the announcement, or the diversion call came in after they already had their patient in the bus and were en route to Bellevue. Then there's the driver's iron-clad no-fault excuse, which is that the patient wasn't called in as a psych case but as a medical case, so dispatch thought they would be brought to the medical ER. Either way, once they show up I can't turn them away. There's nothing I can do to stem the tide of EMS cases beyond calling in diversion, and the walk-ins are still going to come regardless of whom I call, so there's only so much I can do to relieve the pressure of the incoming patients on the area.

I start my sign out by announcing, "We're on diversion. Confirmed by EMS operator 8758. It's good 'til noon, for what it's worth."

"So, on the admissions team, we have a voluntary, Mr. L, thirty-six year old African-American male, walked in saying he needed to talk to someone. He states he feels depressed, and that two days ago he tried to jump in front of a bus. He gives a questionable history of saying he was in the military in Korea as counterintelligence, but he can't talk about it. We have no idea if this is true or not. He seems odd; he's a loner, he's gone through many jobs in the past few years. On exam, he is thought disordered, with circumstantial speech. He's also markedly hypervigilent, and he didn't sleep at all last night. We put him on Risperdal and Effexor, and prn's for agitation.

"Next up is Mr. B, a forty-one year old Hispanic man who was brought in by his family, who all asked for the infamous Bellevue baloney sandwiches, by the way. We started him off in the EOU, but he's not looking any better, so we switched him to a 9.39 last night. He's got a history of seven detoxes at Bellevue alone, and at least twenty stints at rehabs. He steals from everyone, including his family. He has a history of multiple suicide attempts, he's been pulled off more than one bridge. He looks internally stimulated and has persistently been voicing suicidal ideation with a plan. He's on a Librium taper, Depakote, Seroquel, and vitamins.

"Mr. L, a thirty-two year old Asian male with a history of schizophrenia, Cantonese speaking only. 18 South is full for the moment so we're holding him. He was brought in by his sister after he disappeared for six weeks and showed up in the Tufts ER in Boston. His sister says he has a Bellevue history, but he was registered with a new number so I have no idea if he has an old chart floating around but I'm hoping someone on18 South will recognize him. He's grossly psychotic, disorganized, disheveled. He looks like he's hearing voices and his sister interpreted for him that the voices tell him to go to Boston. He's on Zyprexa 10mg.

"Then we have Mr. D, a twenty-eight old white male transferred from the Tisch ER, where he walked in saying that government agents were following him and he felt unsafe. He has a prior history of bipolar disorder and he's off his meds. He's irritable, grandiose, referential, hyper-religious. Apparently at Tisch he made threatening statements about his brother. I have no idea if the brother has been warned or not. I doubt it because the patient isn't giving up any phone numbers. He had lots of weird things with him when he got to Tisch, kitchen implements, a certificate that says he's a minister which I'm assuming he got off the internet. Anyway, we put him on Depakote, Risperdal, Klonipin, the holy trinity of mania meds. He's a good teaching case if we have any med students today.

"Another 9.39, Mr. X, sent over to us from the Peds ER. He's 21. Peds goes up to 25, in case anyone doesn't know. But child psych stops at 18 so he's ours. Apparently his father dropped him off saying 'he's crazy.' Four months ago he had a car accident and he's been complaining of headaches ever since. Also for the past four months dad says he's increasingly bizarre, talking to himself, laughing maniacally for no reason. He smeared his own blood on his face and all over the wall. The patient says he's been using cannabis for the past four months to treat his headaches. We ordered a head CT, obviously, and he's on standing Risperdal. Also, prn thorazine works great for him.

"Also a 9.39 is Ms. T, eighteen year old Hispanic female, brought in by EMS after her boyfriend called 911 because she's been acting paranoid, responding to internal stimuli. On exam, she is absolutely paranoid, convinced the CPEP staff was planning to kill her. She's also voicing homicidal ideation toward her mother. Mom says she's been like this for about a year. So, she needs a first break workup. Oh, here's the most important thing, she had her thyroid removed or partially removed about eighteen months ago and for some reason she's not on any thyroid meds, so there's a chance this is all related to that. She's on Risperdal and half prn's. We're waiting for labs and thyroid numbers and I bet they'll be off the wall. See if she can go to the teaching floor, will ya?

"Next up, Ms. W is a thirty-three year old white female, also a 9.39. She was brought in as an EDP, smelling like booze. She was trespassing at an apartment building where she hangs out a lot. She's been having sex in the basement, probably smoking crack, I'm waiting on a urine drug screen. The landlord called 911 because he was sick of her hanging around there, I guess, and she wasn't being quiet about it. She came in on Saturday, really loud, agitated, incoherent, talking about aliens. She was definitely drunk and probably high on cocaine, but on Sunday, she was still really manicky, grandiose, paranoid. She threw all the food off her tray all over the place and got five of Haldol, two of Ativan, and fifty of Benadryl IM as a prn. The big problem with her is she's hypersexual. She's been propositioning everyone, staff and patients alike, and she touched the penis of one of the guys in the EOU. She's got a history of being on lithium, but we started her on Depakote, Risperdal, and Klonipin, amen. She's going to need sexual acting out precautions when she goes upstairs, whoever updates her chart.

"We got another hypersexual patient who needs acting out precautions for upstairs too. Ms. W, twenty-six year old African American woman brought in by EMS naked, grossly psychotic, screaming about how the cops raped her. She denies a psych history but keeps saying 'I relapsed' and 'I'm crazy.' She's been masturbating and flashing since she got here. Urine tox is pending. She's on Depakote and Risperdal as well as prn Librium and vitamins.

"Ooh, actually, we have one more hypersexual patient. I might as well clump 'em. Ms. K, a late thirties, early forties German woman. By the way, she has insurance, GHI, so we gotta transfer her out of here. God forbid Bellevue should make a deal with some of these carriers. You can probably ship her back to Cornell; she just got out of a one month stay there a week ago. I already called billing to let them know we need a transfer. Anyway, she lives here and her mom came to visit from Germany and I guess she didn't like what she saw. Cornell discharged her on four different meds but she's taking none of them. She seems to prefer Vivarin and Benadryl. So she's totally agitated from the caffeine, but she's confused from the anticholinergic effects of the Benadryl. She's also been drinking. She's been bumping into people on the street, getting violent with strangers, very labile and irritable with mom. Mom called 911 and then our gal ran away from the cops. When she got here, she started to do a little strip tease for the triage nurse. She's going to need sexual acting out precautions too. I restarted her meds, more or less. I simplified the Cornell regimen a little bit, not that it matters because she's not going to stay here anyway.

"You know what? There's still one more hypersexual patient. Something in the water, I guess. Mr. F is a twenty-eight year old man from Africa with a history of psychosis. He was sent over here from the shelter after he assaulted a worker there, unprovoked. Well, maybe he felt provoked. He was dancing and she asked him to stop. Anyway, he's very odd, sexually preoccupied. He's got a history of delusions but currently he's calm here and his only complaint is that people don't want him to be happy. He says he used to have a chemical imbalance but he's fine now. Also, he keeps trying to touch the other patients because he believes he can heal them. He's been taking Zyprexa at the shelter up until about five months ago, then he stopped it on his own. He's willing to restart the Zyprexa and he's been compliant with it all weekend. He's also been propositioning the doctors, nurses, psych techs, and disrobing every chance he gets. He'd be good for the teaching ward if any beds ever open up upstairs.

"The EOU is full. No surprise there. We have a couple of peds cases, and one of the patients is probably an admission but we put him in EOU cause the hallway is completely full of stretchers with patients waiting to go upstairs. So, first peds case is Ms. M, a seventeen year old Hispanic female who was visiting New York City from Georgia with her mom and ran away. She was found two weeks later at grandma's house in the Bronx. She is very thin, dressed in men's clothing. She's got a history of truancy, assaultive behavior with questionable criminal charges, cannabis abuse, lying to mom. It sounds like oppositional defiant disorder versus conduct disorder. Her urine was positive for cocaine and she's got track marks on her arm, which is new behavior for her per mother. Mom is understandably freaked out, asking to maybe file a petition to let the state try to handle her for a while. Does anyone here know what a PINS petition is?"

"It stands for Person in Need of Service," one of the psychiatric residents answers. "The parent asks the state to supervise the child. Sometimes they go to a foster family, sometimes they get court ordered to a locked unit."

"Right. The mom met with one of the social workers over the weekend. I think it was Julia, who explained all her options to her. Someone from child psych will follow up with the mom and the patient today."

"Next kid is Mr. B, seventeen year old Hispanic male who ran away from the foster home where he's been staying for nine months due to an abusive father there. He got lost, got upset, ended up calling 911. He seems very simple when you speak with him, and he may be mentally retarded. He's got a history of conduct disorder, marijuana and alcohol abuse, and mood swings. He was in a state hospital for two years, ages fourteen to sixteen, and he has a day program, so we should be in touch with them today. Also, he needs some face time with social work, or a psychology intern maybe. He just found out his biological father was killed in the Dominican Republic recently. Peds knows to come see him today.

"Also in the EOU is Mr. J, a thirty-seven year old Hispanic man brought in by EMS after he scratched his wrists in front of Saint Luke's Roosevelt hospital. SLR asked EMS to send him down here. I guess they know him already. He's a heroin addict, alcoholic with a history of violence. He stabbed someone about six years ago and was in prison for awhile. He seems pretty impoverished when you talk to him, probably borderline IQ. The weird thing with him is he has nystagmus and we have no idea why. Anyone know which drugs cause nystagmus?"

"Dilantin?" asks one of the visiting psychiatrists from North Shore Hospital.

"Right, that's one. You can see the eyes wiggle horizontally on extreme lateral gaze. Tegretol does that too. What about drugs of abuse?"

"PCP," mentions a psychiatry resident.

"Good. That's an important one. The other time you can see abnormal eye movements is with MDMA, or Ecstasy. Anyway, he denies ingesting any drugs beyond his usual heroin, so we're not too sure what to make of it here. He needs a neuro consult."

"Next up is Ms. W. She's a thirty-seven year old white female with a long history of alcohol abuse and a recent Beth Israel detox three days ago. She relapsed immediately. She walked in, tearful, saying she can't take it anymore and she's suicidal. She seems pretty depressed and hopeless, so we put her in the EOU and started her on a Librium taper. She got put on Effexor at BI so we continued it. Also, she's on synthroid so we're waiting on thyroid bloodwork. She's divorced and she's been sleeping at shelters. She's in pretty bad shape. She feels like she has no one who will take care of her. But now, at least, she has us. Right?"

Silence.

"Okay, so, onward. EOU bed five is Mr. P, a thirty year old white male who walked in asking for help, stating he tried to overdose on heroin, alcohol, and Xanax. He came in pretty high, and his story is inconsistent. He's changed the amount of heroin he shot; he says he shoots a bundle a day, which is ten bags for those of you who don't' know. He usually shoots five at a time, twice a day, but his overdose was only six bags. Then he changed it later to say he shot all ten at once. Also, he initially denied hearing voices, then later reported them. He's using a lot of psych lingo like he's been through this all before. 'I'm unsafe. I'm a danger to myself.''I'm severely depressed and need to be hospitalized.' Anyway, he is still endorsing suicidality the last time we interviewed him, but there aren't any beds anywhere, so I'm not too sure how long we can sit on him. He needed twenty of methadone on Sunday. If he'd contract for safety, there's one bed left on the detox ward. See if you guys can explain that to him, okay? As long as he's reporting hearing voices to kill himself, we can't admit him to an unlocked ward, but that's the only place that has a bed open, so he's gotta recant if he wants to be off the street.

"Last up in the EOU is Ms. T, a twenty-five year old white female who was brought in by her boyfriend of two years. She's Catholic, and currently suicidal. She got pregnant unexpectedly, lost her job due to morning sickness, and then had an abortion last week. She's feeling terribly anxious and guilty. She scratched her face up pretty bad. She's got a history of being raped about six years ago, and also made a suicidal gesture by overdose not long after that. I think this AB is bringing up a lot of old memories for her. She needs some time here to get it together, and a good outpatient therapy referral after that. Maybe crisis clinic can follow her during the transition? I think she can probably go in a day or two.

"On Hold we have a thirty-eight year old woman, Ms. F, who was brought in by EMS with ESU escorts in a body bag. When we unpeeled the bag, she was swathed in bright orange clothing. She was spitting, cursing, and threatening staff so she got 5,2, and 50. I don't have much of a story on her. She was found on Fourth Avenue and Third Street drunk and agitated, and she hit a cop, so I guess they called ESU for back up. Do people know what ESU is?

Silence.

"It stands for Emergency Services Unit. They're basically 911 for the cops. When the police need help, especially with psych cases, they call ESU. ESU helps to sedate the patient, or just wrap them up in a body bag to get them here. If a patient comes in wrapped in those blue canvas bags with the handles, you know ESU was involved in transport.

"Anyway, she's on hold. She's pretty drunk, and now she's sedated so I just have her on prns' and Librium prn.

"Also, we're expecting a transfer from Lincoln Hospital. A guy who's arrested for assault. He punched a wall at the precinct, so they brought him to Lincoln Hospital for X rays but there's no fracture. He was too agitated for Lincoln to send back with the cops, so they shlogged him and sent him here. Also, Lincoln said he's very irritable, making both homicidal and suicidal threats, and he's drunk. Last time I looked, he was still sleeping.

"Enjoy!"

I gather my folder, my water bottle, and my sweater and head for the door. EMS is bringing in another case as I walk out.

"We're on diversion," I say as I head for the door.

"Oh, really? No one told us that," answers the driver.