Weekends at Bellevue: Nine Years on the Night Shift at the Psych ER

Weekends at Bellevue For nine eventful years, Dr. Holland was the weekend physician in charge of Bellevue Hospital's psychiatric emergency room. In an absorbing memoir, Holland recounts stories from her vast case files that are alternately terrifying, tragically comic, and profoundly moving. Full description

Chapter One
Mother Nature’s Son  

On a warm day in early spring, two New York City cops and two EMS workers roll a gurney down the hallway, escorting a man to the entrance of Bellevue’s psychiatric emergency room, where I work. Lying on the stretcher underneath a white sheet, with a head of dirty blond hair beaded and dreadlocked, he is naked, sunburned, and screaming. I walk out to greet my new patient as the drivers hand me his paperwork to sign.
 
“What’d you bring me?” I ask eagerly. I can see he’s a live one. I love the live ones.  
Over the shrieking, one of the EMS guys gives me “the bullet,” the few pieces of relevant information when introducing a patient to a doctor: age, chief complaint, pertinent history. “This is Joshua Silver. Twenty-three. No significant medical history, no allergies, no meds. Also, he denies a psych history,” he says archly, shooting me a look.  

“And how’d he get to you guys? Who called 911?”  

“NYPD called in an EDP.” This is cop-talk for a psychiatric patient: emotionally disturbed person. “He’d taken off his clothes in Times Square and was parading around, barking like a dog. And growling,” he adds.  

This gets the patient’s attention, and he interrupts the driver to clarify, “It was my way of showing them that I was not an animal. I am not a dog!”

  Barking and growling to prove he is not a dog? His logic is lost on me, but at least he’s stopped yelling and started communicating.

  “You can talk to me,” I say, turning my full attention toward him.  

“See, there were some guys from Nation of Islam preaching on the corner, and they told a woman who was arguing with them that she was just a dog—God spelled backwards—to which I took offense.” He then explains to me, as he did to them, that all people are art. “ ‘Thou art art,’ I told them. ‘Once you accept that all people, all objects, are art, you will live in heaven as I do.’ ”  

“You know what, Joshua?” I ask, having decided it is time to move out of the triage area and into the locked area. “I think you and I should go talk about this inside.” I want us to sit in an interview room so I can try to get some more history, and I don’t feel like standing over him while he lies on a stretcher. I can already tell he’s an admission and will need to be in the detainable area for patients awaiting beds upstairs.

I let EMS and NYPD know that they are free to leave, and I grab my new patient some hospital pajamas. I help him off the stretcher, wrapping his sheet around him, and walk him into the larger, locked part of the ER. As I escort him through the entrance, the door clicks definitively behind us, and I hope he doesn’t notice that he is now locked in. Because he is naked, we can dispense with the contraband search, which is good. The search is often the point where people become uncooperative and agitated, ending up restrained and medicated.  

Prior to entering the detainable area, a patient must remove his belt, shoelaces, rosary beads—anything that can be used to hang himself or choke a fellow patient. Inevitably, the patient will insist that he is not suicidal or dangerous, but it doesn’t matter; these items are not allowed in the detainable area. Neither are cell phones, crack pipes, backpacks, knives, pens, wallets, and the list goes on. The patient has to give up just about everything along with his freedom.  

Luckily, Joshua is oblivious. I show him to the bathroom where he puts on the pajamas quickly. I alternate between keeping an eye on him and setting up the interview room. There are several windowed rooms within the detainable area, each with a desk and two chairs. I put my chair closer to the door. As we settle into our talk, the first thing I notice is that although he is disheveled, he seems well-educated with an impressive vocabulary. He tells me he has written a twenty-eight-page manuscript, which he calls a prose-poem, based on his newly embraced credo that everything is art. He is hoping to reach millions of people by delivering his manifesto on the Howard Stern show on K-ROCK, a radio station in the city.  

“I am a holy man,” he tells me, explaining how his writing has elevated him to this level. “I feel like King Arthur in a tower of Babel.” He is hyper-verbal, spewing non sequiturs. I try to keep up with him, playing follow the leader, as if we are hopping from rock to rock in a rushing stream, but he is pulling far ahead of me. Eventually, I have to tell him he’s not making a lot of sense.  

“Joshua, you need to slow down. I want to understand what you’re saying, but it’s difficult for me. I’m focusing on the illogical connections that you’re making...”  

It sounds like “theological connections” to him, and his smile beams; he’s pleased that I’ve grasped his religious message. I don’t bother to correct him.  

Being preoccupied with religion is a classic manic symptom, and mania is the better-known half of manic depression, now called bipolar disorder. In a manic state, people have less desire for sleep; they will talk more, create more, do more. Commonly, bipolar patients get hyper-religious in their newfound frenzy and sometimes end up on a street corner and then a psych ER explaining that they are Jesus or the Messiah, or that they’ve discovered a new religion. They’ve been touched by the Lord who spoke to them. They’ve had a vision, an epiphany, and they want to share it with the world. Their grandiosity can be charismatic and alluring. Religions and cults are formed around this kind of energy, and I’m happy to warm myself by Joshua’s fire during the interview.  

In March and April, our ER becomes crowded with manic patients. For many bipolars, there is a seasonality to their symptoms. Just as more people get depressed in the winter months, increased exposure to bright sunlight can elevate moods. Also, the air is heady with religious themes during spring, when Easter and Passover coincide. The resurrection is reenacted in the budding trees and sprouting flowers, miraculously coming to life where once lay a blanket of snow. We get multiple Jesuses in the ER this time of year.  

Joshua’s pressured speech is another sign of his mania. It rambles hither and yon, like a butterfly dancing merrily among the flowers, setting down briefly on the themes of religion and art as if they were particularly colorful blossoms. I try to join him in his wordplay, to engage him gently in the hopes of learning more about him: where he’s from, where his parents are, and whether he’s stopped his medication, which is a good bet. Most of the manic patients who come through our doors have gone off their meds. The mood stabilizers have significant side effects, and people are often resentful about having to use them. Also, mania usually feels better than being medicated, at least for a while. It’s a bit like surfing, knowing it has to end with the inevitable wipeout, but loving the balancing act required to keep it going.

  Most of our patients battle with their need for medications. When they start to feel better, they abandon their treatment plan, thinking they’re cured. Even if they know they’ll get sick again, they hate taking the pills so much that they stop anyway. Coming through our doors is a painful and humbling lesson in how to manage their illness.  

“Joshua,” I begin yet again.  

“I fought the battle of Jericho.”  

“I’ve heard that about you, yes.” I smile. “Are you from Jericho?” I ask earnestly.

  “No, I don’t think so.”  

“Or maybe a town near there? You took a bus to New York City from where?” I ask. “Can you tell me where your parents live? Is there anyone who might be worried about you, who doesn’t know where you are?”  

A town near Jericho? What the hell am I thinking? I’ll tell you: I am trying to meet him where he is, to work within his delusions and focus on what’s important to him, and then gently lead him out to where I am, in reality. This is one definition of psychotic—broken with reality. He lives in a dream, but his hallucinations and delusions are as real to him as the movies we star in while we sleep.  

Despite my coaxing, I can’t get anything useful out of him. I want to find his parents because I need to talk to someone who knows him to learn whether he’s been sick like this before. And I want to let them know that he’s been found. I’ve made dozens of phone calls to parents of the bipolar kids who end up on our doorstep. We get plenty of “first breaks” at Bellevue, the first episodes of psychosis that often herald the arrival of bipolar disorder or schizophrenia. They tend to occur in the late teens or early twenties. This is when the brain is pruning back and reorganizing connections made throughout adolescence, and also when everything is getting more challenging: starting college, joining the army, traveling. Sometimes, during these phone calls, I hear about how bright and promising their children were before they got sick. Other times, when it’s not the first break, but the latest in a long series of them, the parent on the phone is terse and angry, burned-out, tired of being woken up in the middle of the night to answer the same questions from yet another psychiatrist. In many ways, that’s easier for me to deal with than the heartbreak of talking to the “new” parents, givi...