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Diary of A Mad Doctor:
The State Hospital Psychiatric Admissions

Chronicle #1

By Fiameta R. Vargas, MD

January 2, 2008

They all come here. Emergency rooms and the police and mental health clinics and doctor's offices out there send them here. Private psychiatric hospitals who had exhausted managed care's authorized hospital days send their patients here. Jails and homeless shelters and families themselves, they all send them here. Children and adolescents come here. The mentally retarded come here. The addicts, alcoholics, the homicidal and suicidal come here. Mentally ill individuals of all persuasions come here. Gay, heterosexual, the elderly, men, women, the medically ill, black, white, Asian, Hispanic, those who speak different languages, their own autistic language or tongues of nations far and away, the few rich, and many in poverty, they all come here. They represent the multitude. They all come here, we cannot turn them away, we are the last resort, the end of the line.

This past weekend the hospital was 35 over census. The nursing administrator can't find enough nurses and nurses aides to man the units. Sleeping cots had to be brought in. Social workers and doctors had to scramble and force discharges of still very sick patients but stable enough not to be an immediate danger to themselves or others. Many of them had no place to go but to shelters, and the mental health centers more than likely will not be able to provide intensive outpatient support services to maintain their improvement. There are no resources for supportive living for the chronically mentally ill. Soon the 5-day medication supply that the hospital provided would run out and they are back again in admissions, transported by the sheriff or police, decompensated, and we're back to square one.

Admissions Unit is the gate to the hospital. Everyone passes through here. I'm the gatekeeper. The workload can be intimidating at times, like when the Sheriff, who is mandated by law to transport legally committed patients to emergency receiving facilities, brings in a dozen patients all at once in varying degrees of agitation or dyscontrol, even violence. But there are times when meeting some of the patients bring awe and wonder, or insight, or humor, or inspiration, or disbelief and outrage, or an awakening to the realization that human beings everywhere are indeed made in god's image. These are gems of experience that are priceless and I bet you won't have the opportunity unless you are working in this setting.

The other day a young man was brought by the police. He hasn't slept or eaten for days. He was wandering the streets, mumbling, preoccupied, earnest, but disturbing the neighbors. He had bruises, someone assaulted him. He said he was looking for himself, he wasn't sure of his name. He looked puzzled when I called his name and hesitated to respond. He was very polite but very tense, he couldn't sit still. He was clearly accelerated, dehydrated, and exhausted but he couldn't rest. He said we are on the edge of a revolution. So I said, "Tell me more." And he went on to describe how he is the center of a music revolution that the world hasn't seen the likes of yet, not even the Beatles, or Elvis can come close. He believed this with all his heart and had been telling everyone and had been announcing the revolution with religious zeal, at the same time feeling lost in his identity. He was anguished. He was not mean or violent. He was quite sincere. His beliefs decided his actions.

He was committed and dedicated and single-minded in his purpose, just like any high-achieving scholar, researcher, politician, inspired leader of a cause, or multi-national business executive. I admitted him. In the Treatment Unit he'll be prescribed medications and in a week or two he'll be aware of the world as you and I see it and he'll be no longer doubting his identity. He will leave the hospital somewhat depressed and clearly lost in his spirits because he no longer has a mission.

I didn't have any patients waiting so I chatted up a man who was dropped off by the police after being arrested because he posed a danger to himself and others wandering the Interstate highway. He had been traveling from FL, hitch-hiked to GA, and he was tired. He was looking for a place to rest until he can be on the road again. He spent the night under the I-20 exit ramp. He was not on drugs or alcohol. He used to hear disturbing voices but now these voices are just a faint background in his consciousness, nothing malignant as before when they scared him or made him do bad things or spoke all at once which made him scream and lose control. To stop these deafening voices, he used to hit himself or hurl himself into walls or destroy objects or even hit other people. Now the voices just comment on what he's doing, they keep him company. He used to be in and out of hospitals, and he hasn't taken his medication for years. He had been all over the continent, left FL because he was ready for a change. His face was lobster-red, badly sunburned, his hair, shoulder length and frizzy and matted, his beard likewise, down to his chest.

He didn't want to come into the hospital, he felt fine, he didn't need any medication. He liked being homeless he said. He is free. To eat, he panhandles or if he can find odd jobs he works, and he knew where the shelters and soup kitchens were. He is free. The hospital can offer nothing that will change the outcome for him. He is in the residual stages of chronic mental illness. What will impact his situation is obtaining disability benefits, supportive group living, psycho-social programming, a sheltered work environment, case management and psychiatric medication monitoring. All these will be cheaper compared to the cost of several days of acute hospitalization multiplied many times over the years, but despite the much-heralded political de-institutionalization of the mentally ill, the community support services have not materialized. It reduced the numbers of hospitalized patients and closed down many State hospitals and reduced State budgets for mental health, but we also saw a dramatic rise in the numbers for the homeless. So I let my man go, advised him to stay away from freeways, and wished him the best.

Homelessness does not discriminate. Next I had a woman who had been without any address for a year. She lived in abandoned cars, in buildings under construction, occasionally in shelters, or in "cat-houses", the latter abandoned houses often occupied also by drug addicts and dealers. She was an addict. She was sober for 7 months until she slipped again a year ago and she had not emerged from that yet. She keeps herself clean. You wouldn't know just by looking at her that she's homeless. She knows where to get donated clothes from charity organizations, and where to get food when she can't find odd jobs. She was adamant that she does not steal, to eat or to support her addiction. If she can't find work, she sells sex. For her that is a commodity she possesses and can barter by choice and she thought that out very clearly. Her value system about such things were unambiguous and her actions were consistent.

Unfortunately she did not practice safe sex. I admitted her. Her drug screen was positive for cocaine and she was crashing. She was trying to kill herself by walking in front of traffic. The police picked her up. She also said she'll shoot her brains out. She used to be a member of a gang and she knew how to get her hands on a gun. During her periods of sobriety, she was competent in the regular life skills. She had an education, she was a computer network technician, she had an apartment, nice clothes, a car, friends, and she saw her family. When she's using she lives in her homeless world, she didn't want to upset her friends, and family. Medical science has cracked the genetic code and can mix and match gene characteristics in a dish, but hasn't found a way to treat addiction effectively yet.

Well, tomorrow will be another day.