A Nightmarish Job for CMH Psychiatrist : County Needs to Devote More Resources to Care of Mentally Ill

It is Friday, 4 p.m., and I’m going on duty as staff psychiatrist at Hillcrest hospital, a 60-bed facility for the care of acute adult psychiatric patients who are unable to receive such care elsewhere. For the past year I’ve been the supervising psychiatrist of the Emergency and Screening Unit (ESU), and these eight-hour shifts twice a week are in addition to my regular 40-hour duties at the hospital, which is also commonly known as CMH.

All the staff psychiatrists are under pressure these days, putting in extra time so we can keep the unit operating 24 hours a day, every day. I’m thankful for those who have been willing to make the extra effort. Just a few weeks ago, a full-time psychiatrist left his position here for a similar job and a 50% pay increase in another county. Recruiting has been quite a problem, and applicants regularly say the salary is too low for such a high-pressure job--with no extra pay for working overtime, nights or on weekends. Who can blame them?

It is an average Friday evening. Two police officers have just arrived with a young man named Richard who was picked up at Horton Plaza, where he was waving his fist and menacing shoppers. He is barefoot, with long, unkept hair and a beard. Several of his teeth are missing, and he is wearing his torn and dirty pants inside out. It is obvious that Richard has not had a bath in several weeks.

The clerks quickly retrieve old records from the files indicating that Richard has been to the hospital several times since he arrived in San Diego. His family lives somewhere in the Northeast and has long been unable to tolerate his illness. Richard has no home and sleeps in Balboa Park. He is now 29 years old and carries the diagnosis of chronic undifferentiated schizophrenia.

He has done fairly well in the past, when he was taking medication--meaning he was able to live in a board and care home and stay out of trouble. However, episodically he will stop the medication and return to the streets, seeking more freedom; fortunately he has good survival skills. Today Richard is unfriendly and does not want to be in the hospital, but tomorrow he will appreciate a shower and a decent meal “in exchange” for restarting his medication. I hope that a bed will be available by then.

At the same time another psychiatrist is trying to interview Sally. Though this man has had many years of experience in emergency psychiatry and his style is gentle, right now Sally is unapproachable. She has been suffering from a mental illness called bipolar manic disorder for several years. She is in her 40s, and once or twice a year she will experience uncontrollable amounts of energy and self-esteem, subsequently becoming unbearable to those around her. This usually occurs when she stops taking her medication; it is difficult to take pills or capsules every day, when one is feeling well.

Four police officers were required to bring Sally to the ESU, and now she is restrained to a stretcher by her wrists, ankles and waist, yelling and singing, using four-letter words, talking about being God, controlling the universe and the people in the room, and wanting to show the doctor that she is stronger than he. It will take several hours until the proper treatment will be able to help Sally become calm enough to safely remove the physical means of control.

A second stretcher is occupied by a young man of about 20, who, amazingly, is sleeping through all the commotion. He was sent earlier today from another emergency room whose doctor thought he was “paranoid schizophrenic.” But as it turns out, he had been taking crystalline methamphetamine for several days and has become convinced a drug ring is going to kill him. His girlfriend took him to the emergency room after finding him sitting on the roof of his house, scared to death, with a gun in his hand. He is sleeping now with the help of some medication and because he had been up for three consecutive days. Most likely, his symptoms will be gone when he wakes up, but in some cases the damage done by the drug can last, requiring hospitalization.

Finally there is Harry, lying on the couch. He has just thrown up, barely missing a nurse who was trying to take his blood pressure. This same nurse had been less lucky a few days before when another patient successfully threw a full meal tray at her. Harry is 52 and was well into one of his many drinking binges when the police arrested him for being intoxicated in public. He had been trying to pick a fight in a downtown bar and was probably lucky the three Marines he challenged chose to call the police rather than take him up on it.

However, when the officers took Harry to the jail, he started talking about not wanting to live anymore, asking one of them to shoot him. Thus he was brought to the hospital. As in the past, Harry will be fine in the morning, when he is sober, and he will remember little of today’s events, including his suicidal statements. As I watch the custodian quietly cleaning the floor, I hope Harry will not develop any serious withdrawal problems.

Yes, it is an average Friday evening at CMH, and I know business will pick up later on--it always does. The ESU is already expecting two more patients to arrive any moment. When my colleague leaves at 8 p.m., I will be the only psychiatrist in the building.

Later that night I will evaluate, among others, a man who was preaching naked in the street, a young woman who was going to jump off the Coronado Bridge but decided to call the crisis line instead, a 12-year-old “child” who broke a few windows during a temper tantrum and finally threatened his mother with a screwdriver, an inmate from Las Colinas County Jail who had managed to cut her left wrist with a piece of glass, a man who said he would kill himself unless he received a prescription for a narcotic pain medication, and a friendly elderly woman who has run out of her medication and says, “I just don’t do well without it.”

Not all the patients I see on this Friday require hospitalization, of course. Many are well served by other forms of treatment. And when there is no bed available for those patients who need to be in a hospital, I keep them in the ESU. But what happens when there is no space left in the ESU? Such problems make the emergency psychiatrist’s job among the least envied in the county.

Some people come for food and shelter. They are not really mentally ill but do not function well in today’s society and have learned to show a few symptoms of illness so they can be in a hospital rather than on the streets.

On this evening, I also answer many phone calls, being the only psychiatrist available in the county system after the usual working hours. For example, a board and care home asks for advice regarding a disruptive resident; an emergency room director expresses concern about my having placed a patient on a waiting list rather than accepting an immediate transfer, and a psychologist in private practice states he has a patient who feels angry and should be hospitalized.

When midnight comes, I’m glad to see my relief. Driving home, I feel badly for not having immediately accepted some of the transfer requests. But I know it would not have been safe to bring any more patients into the screening room when five very ill patients were already there; the room only measures 15 by 25 feet. But it is hard having to cause another health professional and his patient such difficulties. After all, the Hillcrest hospital is the facility of last resort for acute psychiatric situations.

I’m also concerned about how the patients feel, being crowded into a small area, when it is hot and malodorous. Often they are too confused to express discomfort, but still, they do have feelings, sometimes more than the healthy. I worry about becoming insensitive toward the patient’s needs and think that if it ever stops bothering me to see people suffer, I will need to find other work. I admire the staff’s ability to remain sensitive and see the patient’s well-being as their prime mission.

The many inspections and surveys during the last months and all the subsequent changes in procedures and paper work have made it difficult to remember the prime mission. All the criticism published in the media, some of it reaching the level of insult, has not helped either.

I’ve always considered myself a perfectionist, but quality is no longer the issue at CMH. Yes, it was a problem last year, but no longer; the real issue is quantity. The Hillcrest hospital has a fine program, but there is not enough of it. Better quality care is not necessary, but rather a larger amount of resources for the mentally ill. Given the resources, almost any professional could meet patient needs at a high level of quality.

So I wonder who really is interested in the patients and who views the situation surrounding CMH as a means toward political accomplishment. Human beings like Richard, Harry and Sally, who can find psychiatric care only through the county mental health systems, are not able to speak for themselves.

I know some people think that professionals working for the county must be of a lower level--otherwise they would be working elsewhere. An interesting attitude. People who view the patients at the county as being the worst of the bad and below their dignity may also view professionals who work with them as also being of a lower class. These patients are the most difficult and ill of all psychiatric patients, and they truly are a test to the staff working with them. But what really separates the staff of the county mental health system from “higher class” professionals is their idealism.

I do like my work and enjoy the challenge, and I’m not too concerned about what outsiders think of me. Everybody tells me I have the toughest job in the county, but I disagree. The staff in the many county programs who struggle daily with the crisis and pain of their clients have it no easier--neither do the law enforcement officers we encounter or the families of patients.

On this Friday night, I go to sleep with the evening’s events on my mind. Later I will dream about a representative from an undeterminable licensing agency explaining the right color of socks to wear for proper patient care, and about a private physician--or a politician--dressed as a magician, with a caducean rod in one hand and a dollar sign in the other. Is he right- or left-handed?