Albuquerque and Psychiatry 1994

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It is Thursday Feb 9. I'm pain free using fentanyl patches. I have completed the course of radiation on my left ribs with good results. I'm continuing daily radiation for my spine and I'm much better able to lift my leg. My chief problem is shortness of breath. This does not appear related to the amount of lung tissue that I have remaining and is likely the result of some chemical product of the tumor itself.
Dr. Palchak has convinced me to give Alimta another try. I have moved my therapy from Stanford to a town 25 miles away and I will receive chemotherapy there tomorrow.
The weather in Morro Bay is perfect. It is about 70 degrees at 4 PM and I'm about to go sit outside and enjoy the late afternoon.

Albuquerque and Psychiatry 1994

In June 1994 I moved from Pocomoke City, Maryland to Albuquerque, New Mexico to begin a residency in psychiatry at the University of New Mexico.  In the five months prior I had made three trips from the East Coast to New Mexico--to sign a contract for a house, to do an inspection on the construction, and to move a car and a few belongings into storage.

It had been 24 years since I had completed my internship--my last formal year of medical training. I was to begin as a second year resident  in psychiatry on July 1, 1994 and the program length was three years. I had always been curious about the Southwest and had looked forward to an opportunity to live in the region since the 1950s and 1960s when my Uncle Earl worked as a hospital administrator for the Indian Health Service. Normally he was stationed in Washington, D.C., but when he returned from Albuquerque, he had gone native with the cowboy boots, the Stetson had, the Indian String ties, and the Turquoise watch band. Cool!
Perhaps the best decision in my life was to return to a training program in my early fifties. When I had started medical school in 1965, one of my instructors was a psychiatry resident who was 65. He had been a family physician in Frederick Md for more than 30 years. He radiated happiness and enthusiasm. After starting my retraining, I had many wonderful experiences both medical and life experiences. I also learned quite a bit about myself including my interpersonal scripting that had guaranteed problems in relationships with women. Mostly, it was an opportunity to learn by reading and doing. Perhaps the most important force was exposure to the young and really listening to their various takes on the practice of medicine.

The usual general psychiatry residence programs in the United States require four years of training before completion. Each of these four years is a "Post Graduate Year" (PGY). The first year of training is called PGY-1, the second year is PGY-2, etc.The program at New Mexico promised to get me out of training and back to work in 3 years by giving me one year credit for my internship of a quarter century before. I was expected to begin at PGY-2 level rather than PGY-1. 

Although the pay for residents was very bad, about $30K per year, the cost of living in Albuquerque was moderate. The climate was wonderful. Although I was not used to spending so much time at temperatures over 100 F, Albuquerque at a mile altitude, is very dry, and there is generally a little bit of a breeze. I found that I was almost always comfortable in open shade on the hottest of days.

The low humidity enabled general use of evaporative cooling for the house and eliminated the need for expensive air-conditioners on all but 5 to 7 days a year. So utility bills were reasonable as well.

I was joining an existing group of residents--primarily the first year residents who had begun their postgraduate training the prior year--1993. I believe that three of us were new, one of whom was Roger O, an internist a few years younger than myself. By coincidence, Roger had practiced in Montana at Butte. Roger and I are still in touch. He is also struggling with Stage IV Adenocarcinoma of the lung. I had been attempting to visit him around the time I received my own bad news.

A week before the year was to begin, a camping trip scheduled for all newly arriving psychiatry residents. Most of these folks were the incoming PGY-1 folks, fresh from graduation from medical school. So, my first contacts with the program were with these youngest members, a very lively and diverse group. The camping site was near Los Alamos. The days were spent hiking and exploring Bandolier Park with cliffside Native American dwellings of the past. As we hiked and camped we were given an orientation to the residency program.

A big change for me over the next three years was an enormous increase in the amount of walking that I did on a daily basis. The parking lot was quite a trek from the County Mental Health Building. In the evenings I began walking a few miles several times a week on the mesa west of town, not too far from my house. Hiking was wonderful in New Mexico. There was a lot of insensible sweat loss which meant personal evaporative cooling and a sense of coolness. However, the water loss has to be replaced and ongoing hydration was important.

Albuquerque is situated at about 1 mile in altitude. The Rio Grande River runs from North to South through the town. A few miles east of the river, the Sandia Mountains rise to over 10,000 feet and most of the population of the city lives between the mountains and the river. On the west side of the river stretches a long mesa, often depicted in the cable TV show, "Breaking Bad." There are five small volcanic cinder cones easily visible and running in a line north-south parallel to the direction of the river.

I purchased a little house on the West Side of the River. I built a little ramada in my back yard which had excellent views of downtown and the Sandia Mountains. I spent many evenings relaxing in my yard watching the Sandia (Sp. watermelon) turn colors during the sunset. Then, at nightfall, I could see the lights of the tram as it ran up and down the mountain at the North of the city.

The Bernalillo County Mental Health Center

The county mental health center was located on the campus of the University of New Mexico and it was the primary teaching center for the department of psychiatry. There were 4 wards for inpatients including two adult wards, an adolescent ward, and a geriatric unit. In addition to the inpatient units, there was a psychiatry emergency room that was open 24 hours a day, and several interview and conference rooms for outpatient work. Finally, there was office space for some of the faculty. The Department of Psychiatry had several other teaching assets, including a Children's Hospital, and a main office building that housed much of the faculty and residents' offices.

My first rotation was on the adult inpatient ward of the County Mental Health Center. The usual census was about 20 patients and the turn-over was fairly rapid. The purpose of inpatient treatment was stabilization so that treatment could continue outside of the hospital within the patient's general living situation.

The day started in the Mental Health Center with a staff meeting scheduled for 8 A.M. during which all of the admissions since the end of the last work day were reviewed. Each ward had an "attending psychiatrist" and two assigned residents. Frequently there were medical students assigned to a ward. All were expected to attend the morning meetings--generally up to 20 participants.

The morning meeting exposed me immediately to a different concept of time prevalent in New Mexico. Some of my friends described it as the "mañana" syndrome, where any specific mention of time is only a suggestion. The meeting seldom started before 8:10 and occasionally started as late as 8:20. Some of us out-of-staters were quick to point out that some of this thinking applied to New Mexico driving habits as well. For example, the yellow light at an intersection meant to speed up rather than try to come to a safe stop. We also noted that the common practice of entering an intersection immediately after the light had changed to red was frequently practiced in Albuquerque under to the dictum of "fresh red." Our resident Judy complained that the natives used bread wrappers and rope rather than trailer hitches to attach their trailers to the vehicles.
The Locked Ward and Violence
My previous experiences on a locked psychiatric ward occurred in medical school, more than 25 years prior. Then, as a student, I did not have keys to the doors. In Albuquerque we were issued keys to the wards on the first day of residency. 
In medical school, I had been assigned to a rather laid-back locked ward and never saw any violence. Things were much rougher in Albuquerque. People were committed from the street with a variety of problems, from acute drug withdrawal to severe paranoia. The staff of nurses and psychiatric technicians were expected to use listening skills, medications, and force if necessary to maintain safety within the ward.
I drew call duty for the county mental health center on the first weekend of July. I was responsible for emergency visits and admissions of patients from Friday night until Monday morning. As I recall things were hopping. Charles, a patient with severe bipolar disease, had been brought to the hospital by police after they arrested him on a golf course where he was trying to run people down with his Toyota truck. While the police were there during his admission interview, Charles had permitted one dose of medication. But after the police left, he refused to continue it. He was scary, being a very large, strong young man who was paranoid and isolating himself in the bathroom. Early Saturday evening, he stripped naked and remained in the bathroom lathering up his body. He was yelling and screaming curses at the nursing staff and daring them to attempt to restrain him.
The nursing staff had to do something about "slippery" Charles. They called for backup and used a mattress to contain him to the point where they could apply restraints. His attempts to punch staff made him a "danger to others" and an immediate candidate for chemical intervention.

Dr. Hammond's Ward

I was fortunate to do my first rotation under Lee Hammond, M.D. a bright, sensitive, quiet and competent psychiatrist. He was self-deprecating and spent some of his free time working with the homeless mentally ill at the Salvation Army. He was a very trim man, not an ounce of fat and apparently able to wear the same clothes that he used in college. His pants had a slight flair at the bottom and he wore short sleeved shirts with a tie. His particular academic interest appeared to be neuronal migration and the neuropathology of schizophrenia. I don't recall his specific title but he was acknowledged as the chief of the inpatient services. He was very quiet but the wit would shine through at times in conversation.

I particularly enjoyed watching him begin to establish a diagnosis for new admissions. There are two particular incidents that I recall--I think of them as "birds of a feather" and "he wouldn't have been able to keep the secret."

Birds of A Feather

You might be surprised that an inpatient mental health unit would be of any interest to people without mental disorders. However, it was very common for there to be one or two people on the ward who were hiding from police in the sense that they were avoiding questioning. 

There were also addicts and alcoholics who were not interested in specific programs for addictions, but wanted the 24 hour support from an inpatient hospitalization to dry out or detox or even to avoid detoxification. They would generally present as the "suicidal addict," claiming to need help to prevent them from giving in to their overwhelming desire to kill themselves. It was common for their behavior to be motivated by drug seeking.

There were also patients who were totally overwhelmed by their life situation and who lacked the emotional and problem-solving resources to overcome their circumstances. Some of these were too afraid to consider the use of shelters or food lines and preferred the security of an inpatient facility. Sometimes these patients were the ones who would resort to cutting on themselves if not admitted. 

The diagnoses were generally sorted out pretty quickly, but some of the difficult cases were the patients whose behaviors were particularly impulsive and self-destructive. For these patients one had to consider severe mood and anxiety disorders as an alternative or accompanying diagnosis.

Dr. Hammond pointed out to us that patients often sorted themselves out by diagnoses. He noted that the two refugees from the criminal justice system were spending their free time together as were many of the patients with personality disorders. It was a lesson that has been useful to me for many years.
He Wouldn't Have Been Able to Keep the Secret

Kenny was living on social security disability for mental illness. He had a history of many acute hospital admissions for psychosis. During these episodes, he would be stabilized on a medication for his psychosis and eventually released whereupon he would avoid further treatment.

He had been living in a motel in downtown Albuquerque. One day the landlord entered Kenny's room because of a complaint of noises. The room contained 40 tires that had been patiently gathered from around town. In addition there was a large quantity of uneaten and spoiled food neatly stacked in containers around the  baseboards of his room. Kenny was very agitated, was screaming at the landlord, and he continued screaming at the two policeman who had been called to the scene.

Kenny was brought to the Bernalillo County Mental Health Center. He was heavily sunburned. His lips were fissured and cracked. He weighed 20 lbs less than on a hospitalization the previous year. 
In the first few days after Kenny's arrival, the staff engaged in discussions about his underlying illness. Was it a bipolar disorder with psychosis or was it schizophrenia? If it was bipolar disorder, a drug like Lithium of Depakote was indicated in addition to whatever was required for his psychosis. If the illness was Schizophrenia, he would likely improve with anti-psychotic medications and have no need for the Lithium.
Dr. Hammond's belief was that he was schizophrenia. His argument had to do with the nature of bipolar illness and its effect on relationships. A manic patient is often "intrusive" and may take liberties with the social space of others with unwanted touching or invasion of personal space or the revelation of secrets. Dr. Hammond pointed out that Kenny had managed to bring 40 tires into his hotel room without anyone being the wiser. Since a manic patient was unlikely to be able to manage such a task without telling several people about it, it was more likely that Kenny was best labelled as Schizophrenia.
Kenny and Close Enough
Finally, Dr. Hammond intervened on my behalf in the treatment of Kenny. Kenny had been committed to the hospital with a condition called "grave disability."  This leads us into a little discussion of the criteria for "involuntary hospitalization." 
In order to take away the right to freedom of movement and to place an adult in a mental hospital, there must be a demonstrable of probable cause that one of the following risks is present:

• danger to self
• danger to others
• grave disability

Danger to self is the suicidal patient. Danger to others means a current risk of serious injury to another. Grave disability is the inability on the part of the patient to utilize the essential means for preserving life, such as taking fluids and nourishment, seeking shelter from elements, or navigating known and common dangers in the environment such as busy highways.
In the case Kenny, he was not threatening others or self. However, his sunburn and dehydration indicated that he was not paying much attention to his physical well-being. The spoiled food in his room buttressed this argument and demonstrated that he was not able to utilize food in a safe fashion. He was judged to have "grave disability" and he was placed on a mental health "hold," a commitment to a psychiatric facility based upon sworn affidavits from two mental health professionals. This "hold" provided the legal basis for placing him in the locked facility. Within a few business days he would have a judicial hearing where a the judge would listen to testimony and decide whether Kenny could be held involuntarily for 90 days.
Although patients could be held in the hospital involuntarily for several months, an initial court order for commitment did not allow psychiatrists to administer psychotropic medications over the objections of the patient unless there was imminent danger to self, to others, or grave disability--our familiar criteria.
In the case of Kenny, his admission to the hospital itself had relieved the grave disability. He was being fed three times a day. The sun wasn't shining inside the hospital. Although he attempted to hoard food in his hospital room, the nurses kept cleaning it out.
Kenny was an imposing man. He was about 300 lbs. He was agitated, loud, and religiously preoccupied. He paced the halls at night and got less than 3 hours of sleep at night. His speech was rapid and there was a flight of ideas. He sometimes "dogged" nursing staff and made them nervous.
Kenny was assigned to me as a patient and I was not getting anywhere after a week or so. One afternoon he became increasingly religiously preoccupied and more argumentative when I tried to change the subject. He walked up to me and shouted "My god is going to blind you and kill you!"
Dr. Hammond heard him and ordered the staff to medicate Kenny. 
Kenny knew the law pretty well: "I didn't say I would do it. I said my God would do it."
Dr. Hammond: "That's close enough!"