Finding a Bed in Bedlam
Jo Marie Reilly
There's a full moon tonight.
"That's when crazy things happen," my superstitious mom always says.
I'm a family physician doing weekend call at my urban community hospital. My pager rings incessantly. As I answer yet another call from the emergency room downstairs, I think, Maybe Mom has a point.
"Got a suicidal patient with nowhere to go," the ER physician yells into the phone, against the background commotion. "This guy John has been here for three days. He's casted on both feet and can't walk. The insurance company's authorization nurse says she can't admit him because it's not medically indicated--but if a doctor gives her an indication, she'll authorize it. Can you do it?"
Dismayed, I trudge downstairs to investigate.
The ER is a cacophony. People strapped to gurneys, crying, "Ayudame, ayudame! (Help me, help me!)" Women in labor, moaning. Children restless and shouting as they dodge the paramedics rushing in with the next crisis.
I'm not sure who I expect to find. Certainly not this clean, intelligent-looking man maneuvering his wheelchair here and there to make room for other patients. His dark brown eyes look hauntingly sad.
This man has been here for two-and-a-half days? I think. This is inhuman. He's already suicidal; now we've given him post-traumatic stress disorder for sure.
I introduce myself, move us to a quieter room and pull a flimsy curtain around us for privacy. I sit down.
"What brought you here?" I ask gently.
"Two weeks ago, I tried to kill myself," he replies. "I took some pills, jumped out a window and broke both my ankles. The orthopedists at another hospital pinned the bones, casted me and put me in a facility to recuperate. But the place couldn't give me the care I need, so they transported me here. I just need somewhere to convalesce for a month. I hoped that this hospital could do that, but--"
A nurse bursts into the room and rips open the curtain. "Out! I need this room immediately!"
A paramedic races in and plops a limp, ashen three-year-old boy on the gurney. The ER team begins CPR.
"I'm so sorry," I tell John. "Let's move to another place."
The problem is, there is no other place. Every nook and cranny of the ER is crammed. I point him to the exit alcove, and we continue.
"As a teenager, I was diagnosed with depression," he says. "I've tried to kill myself many times. I've had a gun in my mouth, been through multiple cuttings and overdosed with drugs from my parents' medicine cabinets. Then, six months ago, I was diagnosed with bipolar disease. Since I've been on lithium, my moods have been more stable, and I've been much less suicidal."
An ambulance pulls up: the paramedics rush past us with a man in coronary arrest.
"John," I say, shaking my head in disbelief. "It's remarkable that you're so calm in the midst of this. I can't imagine being here for three days."
"I've really reached a low point," he answers.
"Do you feel like you'd hurt yourself now?"
"Well..." He reflects. "I'm not sure how I'd do it. I'm pretty incapacitated."
"Tell me more about who your supports are."
"I don't have many...My mom lives in Texas. I have no idea about my dad. My brothers and sisters are all over. I've worked as a songwriter in the recording industry. I was doing pretty well with it, then my wife and I moved. Work was tough; everything fell apart, and we divorced."
He pauses, sighs, and goes on. "I went through a pretty bad time--trashed a bar during a manic spell and ended up in court for it. The judge offered me a choice between jail or living in a clean-and-sober facility, so I chose the facility. It's not like substance abuse is my big issue, but I got a safe place, a diagnosis and medications. I'm actually doing a lot better."
"Then why the suicide attempt?"
"Ironically, I was working on songs about my own story," he confesses. "I got so caught up in it that I went on a couple days' composing jag and didn't take my lithium. I sank into a depression. I felt so low that I couldn't crawl back out. Killing myself seemed like the only option."
I don't know where to begin.
"Wow," I say. "That must have felt so painful."
The nurse who dislodged us comes over, looking apologetic. "I'm sorry I kicked you out--it was my only choice. That child had to be coded."
Drawing me aside, she adds, "If you admit John, at least we can keep an eye on him while they find him psychiatric placement."
"You're going to take him, aren't you?" the ER doc shouts from across the room. "Can't get a bed anywhere in this city!"
I go back to John. His troubled eyes stare at me.
"What can I do to help you most?" I ask.
"Please, all I want is a place to rest so that I can get my legs better, stay on my lithium and go back to my living facility. They're holding a bed for me."
"Yes," I agree, trying to sound hopeful. "I don't know that one of our beds is the ideal place, but I'll get you upstairs and do my best to get you a better placement."
"Thank you," he says.
It is the end of a long weekend. I am exhausted from too many calls and too little sleep.
Ideally we would find John a rehab facility where his legs could be cared for, he'd receive his bipolar medications, and everything would be paid for by insurance. But since he's underinsured, I know that's an unlikely scenario. I'm compelled to do as the ER doctor and nurse have asked. Although John is not acutely ill, I admit him to the hospital with the diagnosis of bipolar depression, suicidal ideation and bilateral ankle fractures.
Upon reflection, I'm not sure who is more grateful for this admission: John or me. He feels thankful for having a safe place to stay, and I feel grateful that I've been able to arrange the care he needs, despite insurance and institutional hurdles. And all on a night when the moon is full.
John stayed on our family-medicine service for two days while we worked with the social workers and discharge team to find him placement. We were able to work with our state affordable-care plan, which ultimately covered his convalescence until he could return to his living facility.
About the author:
Jo Marie Reilly is associate professor of family medicine at the Keck School of Medicine of the University of Southern California (USC), where she is director of the Primary Care and Community Medicine program and associate director of the Introduction to Clinical Medicine program. She is also a member of the Pulse Advisory Group. "Writing heightens my awareness of the power of humor, joy and compassion in the work that I do, and in doing so helps me stay connected with my professional life, patient care and family."