Brooklyn Zoo Page 24

  We left his bedside, and Dr. Jonas told the doctor that she was sorry but that her patient did seem to understand the consequences of signing out AMA—against medical advice.

  “Well, I guess we’re doing the right thing ethically,” his doctor said, trying to soothe herself. She walked away defeated, and we went to look for the chart.

  “What if he had consented to the procedure, would she have called us to evaluate his capacity if she’d thought he was making a good decision?” I asked Amari, thinking of her comment earlier, that doctors called CL only when they disagreed with patients.

  Dr. Jonas took it upon herself to answer. “No, but the nurses would have. If they see doctors shoving consent forms at patients who can’t understand them, they tell the doctors to call psych.”

  I headed back to the G Building at lunchtime reflecting on my morning. I found it all interesting and was having a good time, but it was hard to say what relevance any of it had to me, to what I knew or could offer or learn. Still, I’d been wanting a break from complication. If I was to be irrelevant somewhere, CL seemed as good a place as any.

  Dr. Kapoor gave all his trainees a lot of room to maneuver, and soon he had me going around alone with the medical students. They were young and had memorized so much. I really couldn’t figure how they’d done it. They did not know a thing about graduate school in clinical psychology, though, and because I was called an intern, just like the first-year residents, they figured I was above them, instead of just outside their hierarchy altogether. Newly released from classrooms and not comfortable being in charge, they decided to rely on me. This was a nice change of pace, and so I nodded as if I understood when they spoke about patients with words like “hemiparesis” and “sepsis.” I went with the students Camille and Raymond to do a follow-up. All CL cases got follow-ups. The woman had a urinary tract infection and had become delirious as a result. Delirium was unfamiliar to me. It was a condition they saw a lot at CL, Dr. Kapoor explained, because it often appeared postoperatively and along with infections, especially in the elderly. “It’s characterized by severe, rapid, and fluctuating changes in brain function. Attention waxes and wanes along with confusion. Delirious people sometimes have psychiatric symptoms like paranoia and hallucinations—usually visual, not auditory. We treat it with a short course of antipsychotic medication, and it usually resolves within a few days.”

  When we got to the woman’s room, a sign outside her door warned us to protect ourselves against the germs inside because apparently she had more than just a urinary tract infection, and there was a cart holding paper hospital gowns. Camille handed me one. “People don’t always wear these, but I’m a little paranoid,” she said. Sign me up. I asked what we were at risk for catching.

  “Nothing if you’re healthy,” Raymond said. “The danger is that you get spores on your clothes and pass them along to other patients you see who may be immune compromised.”

  Inside, our consult’s roommate had a hacking cough, and I thought that we might get TB. One thing I’d taken for granted working in the G Building was that nobody was contagious. Our follow-up was surrounded by men in long white coats, attending physicians, and they paid us no mind. We would have to come back later to assess the state of this consult’s cognition. We left the room and stripped off the green paper garb. As we did, Camille got a call from Amari, who instructed us to meet her on pediatrics. Pediatric ward: the very juxtaposition of the words made me want to avoid it. My friends sometimes asked how I could take hearing about people’s problems all the time, but the kinds of problems I specialized in were largely self-generated and malleable. The rabbi marrying George and me was a chaplain on the pediatric oncology unit of another hospital. Those were problems I had less aptitude to bear. Upstairs on pediatrics, miniature people wandered around in colorful hospital gowns, and my heart ached predictably. Camille and I met Amari (whom she and Raymond called Dr. Malou) in the small office behind the nursing station.

  Amari explained that the four of us would see an eighteen-year-old with “end-stage renal failure.” I knew “renal” meant kidneys, guessed “end stage” meant grim. He’d had two unsuccessful transplants in the last five years, Amari told us, and was in the hospital being treated for an infection.

  “What’s the prognosis for end-stage renal failure?” I asked.

  “People live an average of three to five years on dialysis,” said Camille, “but that’s just an average. It depends on how his health is otherwise.”

  “His doctors are worried he’s depressed,” said Amari.

  We went to his room, but he was not there. “Dialysis,” the nurse told us. She said we could come back in two hours or that we could go see him in the dialysis room. I didn’t know what dialysis looked like, did not want to, but Amari was her usual exasperated self and said that she had no time to return in two hours. The four of us marched in a column to the appropriate room at the end of the hallway. Inside were two padded reclining chairs, each occupied. In the first was a girl covered completely by an afghan except for her pretty long hair. In the other was a boy, face exposed, plastic tubes thick with blood poking out from under his blanket. I tried to keep my eyes away from those tubes. He looked twelve and could not be our consult. I hoped that we would make a quick exit. Amari asked the boy his name, and it matched the one on her papers. Trying to hide her surprise—he really looked so young—she introduced us all and asked if we could talk to him for a few minutes.

  “About what?” he wanted to know. Speech seemed effortful. He looked as if he was in some agony and that he knew it well.

  “Your doctors are worried that you’re depressed,” Amari said.

  “I’m not depressed,” he said. He shifted in his chair, and his tubes moved along with him and he winced.

  “It doesn’t look like now is a good time. Can we come back later to talk?” she asked. She looked uncomfortable but in a different way from the patient.

  “Not if it’s about depression,” he said.

  We left in a flash, as if the room were underwater and we required air. I wasn’t sure if Amari was supposed to try harder to establish some connection or get more information from this poor kid, or to what purpose any of it was. I asked her.

  “His mother says he hasn’t been taking his medication. Is he passively suicidal or just hopeless?” she proposed. I reflected on the meager difference between the two.

  Camille went off to call the boy’s mother for more information. Raymond and Amari and I found one of the boy’s doctors and asked him for his impressions. “He’s really dependent on his mom,” the doctor said with some disdain, though it only made sense. While other kids were out navigating psychological separation, this one had been on an operating table getting a kidney transplant, or in a hospital room having his blood cleaned by machine. I felt angry toward the doctor then. If we were all angry and critical enough, maybe none of us would have to think about this boy and his horribly raw deal.

  Back at the nursing station, Raymond and I sat down. Amari turned to me: “Present the case.”

  I had spent the last five months learning this model, but applying it to psychiatric patients exclusively. Of what relevance was it to this kid, and what was I even supposed to know based on our very brief interaction? “Uh, he’s oriented in all spheres?” Was he? He knew his name, certainly, but Amari had not asked him the date or where we were. These questions would only have irked him more. I’m not crazy.

  “Start with appearance,” she said.

  “He’s adequately groomed?”

  She shrugged. “Looks much younger than stated age,” she said.

  “Right,” I agreed. “Speech: low volume, normal rate. Mood: depressed.”

  Raymond interrupted. “No. Mood is subjective. He said he’s not depressed.”

  One-upped by the med student and his meticulous memorizations.

  “Affect is appropriate to content,” I continued. “Speech is goal directed, indicating an organized thought process.
”

  Camille came back and interrupted our exercise. “His mother says he’s been sad for two weeks,” she said triumphantly.

  Camille, too, was a conscientious learner. When one is differentiating among the depressive diagnoses—our immediate goal here after all—duration of illness was defining. A diagnosis of “major depressive disorder, single episode” (DSM code 296.2) required two weeks of sadness. Dr. Malou weighed in. “We can’t rule out mood disorder due to a general medical condition,” she said sagely. (DSM code 293.83.) “We can’t really know.”

  But even if we could, what then? Amari spoke as if these distinctions were meaningful here, rather than just bureaucratic, and I began to feel the familiar agitation that psychiatrists engendered in me, with their unspoken insistence on the primacy of their truths. Who was this kid, and why did we all need to flee him so quickly? If that was happening with everyone in his life, his isolation must have been unbearable. We could conclude that this boy had an adjustment disorder with depressed mood (309.0) or dysthymic disorder (300.4) or depressive disorder not otherwise specified (311), and maybe based on the symptom checklists of the DSM-IV-TR, one or the other of these would be more technically correct. This was medical psychiatry at its worst, treating people like math problems, adding up symptoms and their duration and pretending it meant much.

  We finished writing a chart note and tromped down the stairs to report to Dr. Kapoor. He said that maybe this was my first CL therapy case. He must’ve thought there was something I could offer this boy. I wondered what that was. The next day I returned to pediatrics alone to find that he had already been discharged.

  The psychiatrists knew scintillating facts. Like: IQ predicts the idiosyncratic success of antipsychotic medication (the lower, the better Depakote and Haldol; the higher, the better Seroquel and Clozaril). Or: cocaine can cause a psychotic depression up to two years after the drug’s last use. And: people in the midst of delirium tremens are at risk for stabbing themselves. (“Bipolars stab themselves in the stomach, schizophrenics in the genitals!” declared Dr. Cherkesov.) I was so impressed with what the doctors had learned that the things they did not think about tended to befuddle me. The very fact of my befuddlement, time and time again, stood out in my head. These people were authority figures, and yet I seemed to have picked up some things that they had not. Here it was again, this ridiculous fact. If it did not bolster my self-denigrating tendencies, at least it supported a multidisciplinary approach.

  Two mornings a week Dr. Kapoor worked in Downstate’s outpatient HIV clinic, seeing patients whose doctors thought they might have psych issues. His job was of course to diagnose them and then to prescribe medication based on the diagnosis or to refer them out for therapy. The HIV clinic had different policies from the rest of the hospital. Whereas the medical students and I generally traipsed around seeing inpatient consults as casually as if they were traveling museum exhibits, the clinic patients had to consent to our presence before we were allowed into the room. Most often, quite reasonably, they said no, and so I had already spent more than one morning just sitting in the clinic’s comfortable waiting room with my laptop and my dissertation data while Dr. Kapoor worked alone.

  That morning, though, Dr. Kapoor called me into his clinic office when I arrived. He was seated with a bulky white man in his early thirties with close-cropped brown hair. The man introduced himself as John. John was dressed in black jeans and a black T-shirt, with two prominent tattoos keeping company on his bicep, a colorful crucifix and a black-as-night shotgun. John had just arrived and didn’t mind if I listened in. I took a seat in the small consulting room. John explained that his doctor had referred him to Dr. Kapoor because he’d been experiencing panic attacks. He’d been having them for about a year actually, ever since he’d gotten clean after fifteen years of heroin use. He’d tolerated the attacks for many months, but the more comfortable he got with his sobriety, the less willing he was to put up with whatever his body doled out, and so he’d finally mentioned them to his primary care physician. Could Dr. Kapoor prescribe him something to stop the attacks?

  Panic attacks, by definition, have no discernible precursor. They come on suddenly and apparently apropos of nothing, and so it’s easy for people who suffer panic to feel as if it’s simply a random physiological event. I wasn’t certain that psychiatry disagreed with this, though I knew that psychology did. The psychoanalytic take on “apropos of nothing” is that it is not “nothing” at all but rather some unacknowledged meaningful stressor that triggers rage. Intense anger is not something that many people, and panic sufferers in particular, are comfortable feeling, and the overwhelming need to keep it out of consciousness necessitates a physiological response: the shortness of breath, the sweaty palms, and the fear of death itself are potent distractions. Panic symptoms are a compromise, as unsatisfying as any. Their occurrence suggests specific unconscious conflicts that serve an important psychological purpose, and bringing these conflicts to awareness is the specific goal of psychological treatment. The panic attacks go away, and the patient has access to a necessary depth of human experience as well.

  I wasn’t sure what Dr. Kapoor’s personal take on panic attacks was—if he thought they were meaningful beyond the physiological symptoms. Dr. Kapoor was obviously smart and also thoughtful and had tried to get me going on a “therapy case,” but I had seen too many competent minds dismiss psychological underpinnings to maintain any faith that such an approach was always beneath him. While I began to think about John’s problem in the context of what little information I had about him—his history of heroin addiction, the dueling symbols on his arm—Dr. Kapoor’s questions for John did not imply that his symptoms warranted any further exploration. They were simply to be counted. Did he meet the criteria for panic disorder (300.21) or generalized anxiety disorder (300.2) or panic disorder with agoraphobia (300.22)? Whatever else Dr. Kapoor might have been thinking was not communicated to John, which would only reinforce the patient’s sense that such a problem could only be treated with pills. The attacks themselves would likely become less incapacitating as long as he stayed on the meds, but the medication would do nothing else to help him live a fuller life. For the momentary comfort the pills offered, their limitations precluded so much that was worthwhile and less ephemeral. Dr. Kapoor would see John to follow up on the meds but at least for the time being did not recommend psychotherapy. I sat there on my hands.

  I’d come to CL hoping for a certain effortlessness, a temporary engagement followed by a complete and permanent lack of involvement. I could already tell that there would be times when this would be enough, when all there was to say was “Patient did not have a panic attack” or “Despite tears, patient is not depressed.” But I also already felt that familiar resentment, the insult to my self-esteem as I watched people who had more experience than I—whose very job I’d presumed it was to know more than a mere trainee—address something psychologically treatable as if it were not so. In this way, CL offered me anything but ease, at least for as long as I chose to maintain my lesser-than position. Student. The moniker had worn so thin, my last and sorriest excuse.

  That afternoon I went to Scott to ask whether he might dig up a psychologist to provide some extra supervision during my time on CL. I craved my own discipline’s perspective, which was the implicit promise of this internship and one that had been only minimally fulfilled. He acknowledged the soundness of the idea halfheartedly, and we both knew we’d never speak of it again. Later in the week I asked him for a letter of recommendation. It was March and time to think about what would come next, and there was a job I was applying for. Scott hedged in a similar way, and I knew it was one more thing he wouldn’t give me. I left his office unsettled.

  Dr. Winslow was the youngest CL attending, and the best looking. He might have been a catalog model for J.Crew or the Gap, and he was yet another CL brainiac besides. He’d been on CL at Bellevue before coming to Downstate, and he sang the praises of the interdisciplinar
y team there, but he never sent me alone on calls like Dr. Kapoor did, and Tamar said he never would. One morning I walked into the consult office toward the end of a conversation he was having with a resident. They were discussing a patient in obstetrics we’d be following up with that morning. “She has an outpatient therapist who she’s been with for a while, but she’s no good. She’s a social worker,” he said to the resident. His last sentence dripped contempt. He looked at me and smiled handsomely. He was really very handsome. “I don’t know about you, but I don’t think much of social workers as clinicians,” he said with a conspiratorial glinting smile.

  Well, the damnable truth be told, I didn’t either. We all needed somebody to buttress our professional worth. Physicians had psychiatrists, who I’d come to learn were the scourge of the medical profession. Psychiatrists had psychologists. Whom did we have but social workers? One of my professors told this old joke, and George liked to repeat it: social workers want to be psychologists, and psychologists want to be psychiatrists, and psychiatrists want to be psychoanalysts, and psychoanalysts want to be tall. I suspected Dr. Winslow had no more regard for psychologists than he did for social workers.

  “When you see the patient, tell her she should really be in therapy with a resident,” Dr. Winslow continued, addressing the underling doctor again. Dr. Winslow was my own age and easier to challenge than the others, and I was starting to feel I’d earned the right to speak up, or that maybe I’d had it all along.

  “If she has a good relationship with her social worker, maybe it’s best if we don’t interfere,” I said. I wasn’t sure he heard me.

  The resident’s name was Dr. Long. She and I left to see the patient we’d been discussing, a woman who had earlier that week given birth to a baby with Down syndrome. Dr. Long was gentle and sweet and completely unwilling to hear about the patient’s feelings.

  “My husband wasn’t there when I delivered, and I felt so alone,” the woman told us.