|SAN FRANCISCO CHRONICLE
GENERAL, LIFE AND DEATH AT SAN FRANCISCO'S HOSPITAL OF LAST RESORT
Tension Permeates The Psych Ward — A Refuge For City's Most Fragile Minds
Mike Weiss, Chronicle Staff Writer
Wednesday, December 11, 2006
Editor's note: The names of patients have been changed to protect their privacy.
Among the 350 or so patients jammed into San Francisco General Hospital's beds on most days, the most common diagnosis upon admission is psychosis.
Schizophrenia is second, followed by delivery of newborns, HIV, hypertension, pneumonia and depressive disorder. In other words, three of the top seven reasons people are admitted to General are psychiatric. Among the nearly 18,000 patients admitted last year, about 1 in 5 suffers from mental illness.
Amelia is one of those patients; she is chronically depressed and suicidal. And on a sunny, breezy afternoon in late spring, Amelia was up a tree -- a white birch on the seventh floor patio where the patients from 7A, one of the four locked acute-care wards, had been taken for fresh air and sunshine. The 32-year-old with the arresting, pale blue eyes sought refuge there because tension was heavy in the unit. Three days earlier a patient named Reed slugged a night nurse and was forcibly subdued.
No other hospital in the state houses so many psychiatric patients. In San Francisco, when it comes to involuntary admissions -- people unable to maintain, or acting in bizarre ways that pose a threat to themselves or others -- General has all but 35 of the city's beds. The other beds are at a private hospital downtown, St. Francis, and according to Abbie Yant, a St. Francis spokeswoman, they are kept half empty because such patients are a drain on profitability.
The truth is "that nobody else wants our patients," said A. Sue Carlisle, associate dean at the hospital. She says that UCSF would go broke if only 10 percent of its patients were on Medi-Cal, but at General the number is more like 40 percent.
The hospital also houses the city's only psychiatric emergency room, where last year 7,400 people were seen, most of them brought in by the police for 24-hour observations. In a separate rehabilitation building that opened in 1996, 140 more men and women are housed, some of them free to come and go, others not.
So the 99 beds in General's four psychiatric wards, including the 22 in Ward 7A, fill an enormous and otherwise unmet need.
For the caretakers of the mentally ill in those wards, the current question is developing an approach to violent patients. "The big issue in the psychiatric world right now is violence in psychiatric settings," Sharane Darlington, a clinical nurse specialist at General Hospital, was saying a few days before the assault on the night nurse that had unsettled Ward 7A. Darlington is tall and has gray bangs and long fingers that she knits and unknits as she talks.
Darlington said that previously when a patient became angry and violent, "the prevailing wisdom was strap 'em down and give 'em meds." But recent studies have led to a different conclusion. "Staff are far more likely to be injured while physically restraining a patient, and so are patients. Out of that came: 'We need not be putting hands on these patients,' " Darlington said.
An initiative to avoid restraints and locked seclusion was begun this year at General, modeled on procedures already in place at Bellevue Hospital in New York City. Ward 7A implemented it first.
One potential roadblock to implementing the new approach is that the psychiatric nursing staff is getting older; the average age of a nurse is 48. "Many of them have been hurt," Darlington continued, "and say, 'God, I just don't want to be on the floor again.' We're just edging our way into this."
George Moissant, for example, is ambivalent. A 64-year-old nurse with 24 years of experience and a long doleful face that seems stamped with the afflictions life has tossed his way, Moissant said, "The stress here is the thing that kicks your ass. The stress comes from balancing trying to help your real complex patients versus keeping yourself safe. Self-preservation. I get so tired sometimes." Nurses are in short supply, and often the nurses on 7A work double shifts.
"And sometimes," Moissant said, "I'm in fear of my life."
The tension on 7A that led to Amelia climbing the birch began to ratchet up on May 12, when a patient lunged at a nurse-practitioner and stabbed her in the cheek with a pen, seriously injuring her.
Because so many patients are what the staff calls "frequent fliers," in and out of 7A all the time, the help givers and their patients are all in the same pool, emotionally speaking. When the waters are roiled in the ward, or bloodied, nobody escapes the turbulence.
Six patients were admitted on the weekend of May 19-21, the ward was short-staffed and nurse-manager Jean Horan had her hands full. One new patient was a young woman who heard voices telling her to bite off her finger, so she could get into the hospital and find help. She obeyed the voices.
"This is the sad part of this work. People so psychotic they can't even get to the hospital without doing something terrible to themselves," said Horan, an energetic gray-haired woman with an air of invincible competence.
Another patient arriving in 7A was Reed. He was slightly built, with pained, distant eyes and clumped brown hair. He did not look especially threatening but had a long history of sudden violence. He had left the ward two weeks earlier, bound for one of the city's board-and-care homes for the mentally ill; when he hit a worker there, he was sent back to 7A and permanently barred from the home.
Reed, Horan explained, "is a young man with nobody in this world. He's a lost, lost soul, he's really psychotic and impulsive, and you have to be careful around him."
When he arrived on Sunday night, a psychiatric technician named John Collins tried to get Reed to take his medication. Taking meds voluntarily -- mainly anti-psychotics, anti-depressives and anti-anxiety pills -- is an essential step toward being released.
According to another patient who saw the incident, Reed "kind of batted them away, and John got upset and went up in the patient's face and he punched John, and then John jumped on him and kept pounding him, and then the other staffers jumped in." Another patient said that during the confrontation, near the plate-glass window of the dining room, "John nearly slammed him through the window. It seemed excessive," he added. Patients were screaming, or scrambling for safety. A woman ducked under a chair, rocking and trembling.
Collins had a different understanding of what had happened. As a veteran of nine years on 7A, he knew Reed to be violent and unpredictable, he said later. So when Reed hit him in the head, he grabbed hold of him and wrestled him to the floor before the patient could do further harm. "I was angry," Collins said, "that I had to put my hands on a patient -- how was I going to be perceived? But I had to do it to keep myself safe, and the other patients safe. I didn't know what he would do next, and I didn't want to get punched anymore."
When patients complained about how Reed had been manhandled, Jean Horan began an immediate investigation. Obviously, the new, hands-off policy was not implemented in this instance.
"Staff are still unclear this can be done," Sharane Darlington acknowledged. "And the night staff involved in both the assault and the restraint have not gone through the new training. That might have changed the way it was handled."
A different outcome resulted when a patient decided to walk out of 7A.
The unit is U-shaped, with a nursing station at the bottom of the U. Along the two corridors are bedrooms, where patients sleep segregated by gender; bathrooms; a shower; the locked medication room; staff offices and meeting rooms. Patients have the run of the unit, including a day room and the dining room situated to either side of the nursing station. The locked door is south of the nursing station. It is not uncommon for patients to make a run for the door when it is opened.
Ignacio would not take his meds, and bolted. He has jet-black hair that stands straight up and a pugnacious jutting jaw. He tends to give strangers the evil eye. His plan to escape was thwarted by the locked door, but he refused to budge and kept shouting that he had better be let out.
"There was a time," said Darlington, "when people would have goose-stepped him into a seclusion room and locked the door." Instead, a panic button was hit and about 20 staff people arrived on the run, including the director of behavioral health and the deputy chairman of psychiatry.
For 15 minutes, while the staff surrounded Ignacio but did not advance toward him threateningly, he was encouraged to take his medication and come away from the door. Somebody even went and bought him a pack of chewing gum. In the end, he submitted to having his medication injected, and was guided to an unlocked room where he could be alone and decompress. Success.
Despite his pugnacity, Ignacio is nowhere near the threat that Reed is. As one nurse, Johnnie Chavez, said of Ignacio: "If you're small and in the street, the best defense is be belligerent."
When Chavez arrived at S.F. General 16 years ago, he was part of what was called the goon squad, wrestling patients into submission. He's taken a wait-and-see attitude toward the new approach. The intervention with Ignacio, he said, "felt good because it didn't feel like my butt out there all by myself. Back many years ago when we did something like that it was called a show of strength. Now it's called a show of support.
"But, you know, I didn't become a psychiatric nurse so I could retire on disability. People see us as guards but we're human beings, neither more nor less. Most people go to work and are annoyed because the Xerox machine isn't working. We come here and be called everything but a Christian in a 12-hour day and still try to retain that sense of compassion.
"I stop every single day on my way in at the chapel on the second floor. I never come in here without praying."
The day after Reed slugged John Collins and was aggressively subdued, the ward was manic. A patient named Steve -- he has a buzz cut and wears a leather vest cut off at the shoulders to display his tattoos -- boasted that he had sex, which is strictly forbidden, with two different patients, a man and a woman. Then he cut himself.
"We're all terrified," Amelia said. Wards like 7A do not do therapy; they exist to stabilize seriously ill people and provide a safe haven. But nobody felt safe.
Overnight, Reed clobbered another patient, Steve said he made a third sexual conquest and was transferred to a different ward, and Amelia sliced her abdomen with the razor-thin metal eraser-end of a pencil.
"I cut myself because I'm afraid of leaving and being alone," she said in a voice as small as a single tinkling bell, holding herself tight around her middle. "They wrapped me in a blanket and threw me on my bed and tried to talk with me. They were really very sensitive."
There were some staff who were, as Darlington acknowledged, "really pissed off" at Amelia, who soaks up a lot of staff attention. "There is resentment by some staff who think, 'If she's going to kill herself, why doesn't she go ahead and do it?' "
Darlington said. "They feel manipulated, and then betrayed -- they're working well with her, and three minutes later she has a pencil in her stomach. We always need to be reminded there is a genesis, people don't choose to behave this way."
Dr. Emily Lee is the only attending psychiatrist on 7A, although the unit is budgeted for three doctors. Amelia, said the diminutive doctor who unwinds at home by rolling around with her three small kids, "was shattered by childhood trauma, and always had this death wish." Amelia says her mother let her boyfriends have their way with her. "She is truly suicidal, she sees no way out of things," Lee said.
"When I'm out in society I look like the last person who will end up in a place like this," said Amelia, who has been admitting herself to General since 1998. "I look conventional, I'm well-dressed, I have a job. But let's face it, I'm never going to be OK. Medications don't help me. I'm in and out of the hospital."
She is married, but only because she was helping a foreign-born friend get a green card, she said. Now she said she has a plan to kill herself so her husband -- the father of her child -- and his new girlfriend can take over caring for Amelia's 17-month-old daughter. "I'm in a big rush to do it before she's old enough to have memories of it," she said.
When Amelia was a child herself, Lee said, she would sometimes escape from what her mother wanted by hiding in a tree. On the day after she sliced herself, Amelia climbed that white birch. "I just wanted to get away from everybody," she explained. "It was fine there, the wind was blowing. I felt happy."
Lee said Amelia is "like lots of people we see only when they have a crisis. They're always living on the edge. You ask, what would happen to these patients if General Hospital went under? A lot of them would go under, too. It would be chaos -- I don't know who would pick them up."
In 16 years as a nurse, Jean Horan thought, she had never known 24 hours as horrible as those that began with Reed's assault and ended with Amelia cutting herself. After work, Horan attended a concert and went home and sat on the couch and stared into space. When she went to turn on her computer, it froze. She laid her head on her desk and sobbed.
Horan finished her official investigation by concluding that John Collins, the nurse who had subdued Reed after being punched, had not done anything wrong. "I was so relieved," the nurse-manager said. "It's hard to believe we have an abusive person on staff."
Two sheriff's deputies cuffed Reed and escorted him to the jail ward. He walked silently between the much larger deputies, an angry red welt under his eye. The reinforced metal door clanged closed behind him.
Later, charges were dropped, and Reed, who is uninsured and whom no other hospital wants as a patient, was back in another locked ward on the seventh floor.
Following her rescue from the tree and her discharge, Amelia managed to stay off the wards for a few weeks. On a number of occasions she showed up at the psychiatric emergency room and remained there until she felt strong enough to face her life. But she spent much of the late summer back in the hospital.
Darlington thinks a lot about Reed and Amelia, and also about why, at 42, she left a job working for a labor union to become a psych nurse. In the mirror, and all around her on 7A, she sees not a single nurse or doctor with a carefree or relaxed face. Just before she took a vacation this summer, she was "having a really hard time. The weight of human suffering takes its toll, the weight of the human condition."
Reed "is somebody who had a real severe history of childhood trauma but is also schizophrenic. I find him really sad," Darlington said. She closed her eyes for a moment. "He is in some ways the creation of this system. He came from really bad foster homes, and bad child treatment centers but because he lashes out, his treatment's going to be focused on punishing. They'll medicate him heavily, he'll be sedated and confused."
General Hospital will, in effect, become his home and his prison, isolating him and protecting him from whatever harm he might otherwise do.
"This is not as a San Francisco General practitioner I'm saying this," she adds, but for Amelia, "there is suicide. She has gotten what the mental health system has to offer and the decision to suicide would be a much more existential decision."
Just like the white birch into which she had escaped and become stuck, 7A was also Amelia's refuge and prison. And not just Amelia's and Reed's. The locked wards are that for many of the city's weakest and most tormented people.
And as for Darlington, and the other nurses and doctors? What keeps them on 7A day after day?
"Oh," she said, as if the answer were obvious. "The work that goes on here doesn't get done any place else in the city, and the people we see don't have any place else to go. It's tremendously difficult. And truly, truly rewarding."
EMERGENCIES OF THE MIND
This is how and why 10 patients ended up in San Francisco's only psychiatric emergency service on the morning of June 10.
-- by police, paranoid-delusional
-- from St. Luke's, arsenic ingestion
-- by police, suicidal, intoxicated on cocaine
-- by paramedics, hanging from I-280 overpass
-- by police, waving knife on street, bipolar
-- by friends, suicidal
-- self-admitted, cut left wrist
-- by family, suicidal; in custody, threatened jail staff
-- by police, crack, alcohol, started fire in hotel
-- by police, naked and screaming in Laundromat
SUNDAY: Dr. Andre Campbell's trauma team battles to save a 14-year-old gunshot victim.
TODAY: When violence erupts on a psych ward, staff and patients get caught in the turbulence.
TUESDAY: Four generations of the Soccaras family have come to lean on the strength of their family doctor.
WEDNESDAY: The hospital's chief executive, herself a former patient, leads the fight to rebuild General.
E-mail Mike Weiss at firstname.lastname@example.org.