West Again 1997

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It is Feb 21 at 4:30 AM as I start this.
My pain situation is pretty good. I am having occasional left chest pain in the area of the ribs that were irradiated. There have been 2 occasions in the past three days where I took a short-acting fentanyl for breakthrough pain. They come in a tablet that is absorbed through the mucous membranes.
My head has been fuzzy and my thinking seemed slower going back to my last chemo on 2/10. It feels a little clearer this morning and gives me hope that I can write a little bit.
My left ankle and foot have begun to swell. That hasn't been a problem before and may indicate a number of things that I'll take up with Dr. Kolb's office today.
I'm scheduled for a CT of the chest today to "stage" the disease...to see what the changes have been since the last CT done 5 weeks ago.

Going West Again
In the Spring of 1996 I was completing my 2nd year in Albuquerque which left me a year away from completing the program. Dr. Lauriello had tipped me off about Atascadero State Hospital (ASH) in California.  The hospital was always advertising for more staff in various psychiatry journals. So, I called the hospital and arranged a recruiting visit. The facility was enormous, something close to 1000 beds, entirely devoted to mental health and criminal justice issues. It was particularly surprising to imagine 25 psychiatrists all living in a county of about 250,000 souls.
The interview process went well and I was given two employment options: a forensic fellowship or a position of staff psychiatrist. Both of them paid the same salary of about $100 K. In addition to the salary, there were health and retirement benefits from the state. There were also opportunities to take call at the hospital and to earn additional money in that fashion.
The fellowship guaranteed more time for learning and reading and I left the recruiting interview determined to start the fellowship in the Summer of 1997.
During my last year of residency, I was also entitled to 4 months of elective time. As soon as I returned to Albuquerque I began to make arrangements to do that elective in California at ASH. My plan was to work my final day in New Mexico in February and move to Atascadero to begin March 1.
Hurdles Leaving Albuquerque
Immediately after my job interview in California, I applied for a California Medical License. This turned out to be  a tedious process. Without a California license, I could not be hired at Atascadero. When November rolled around and I remained without a license, I began to look at other options as a back-up plan. Finally I received a phone call to come to California to sit for an oral examination of general medical practice. Three cases were presented to me:

1. a delirium occurring on the third hospital day which was probably related to alcohol withdrawal after admission to the hospital
2. a fungal infection in a young man that was almost certainly HIV related
3. depression in a post-menopausal woman

After receiving the license from California, Atascadero State Hospital informed me that when I came for an elective, I would have to be on the payroll of the hospital, not the payroll for the University of New Mexico. The wonderful news was that ASH was going to pay me $8K per month as opposed to $3200 per month that I was making as a psychiatry resident in New Mexico. 

The University of New Mexico objected and requested that the State of California pay them the $8K per month while New Mexico continued my usual salary. I became involved in the discussion and pointed out to the University of New Mexico that it should have expected to have been on the hook for my entire salary for the four months of my elective time in California and that my arrangements with ASH were actually saving them $13000 in resident salary, health insurance payments, etc. ASH was also firm and would not negotiate the salary--to work as a resident in the hospital, I would need to be counted as an employee.

At the end of February, I removed all of the seating from my Acura Legend except the driver's bucket. I packed what I thought I would need for few months and I was California bound.

I love the variety of Western scenery between Albuquerque and Atascadero. One goes West past the Navajo Sacred Mountain of the South, Mt. Taylor.

http://en.wikipedia.org/wiki/Mount_Taylor_(New_Mexico)

Forgive me for cheating with the photos...but these are your tourist opportunities as you go West from Albuquerque.

Mount Taylor: Navajo Sacred Mountain of South: Tsoodził, the turquoise mountain  : 

 Further west is Gallup with miles of gorgeous red rocks 

In Arizona, The Painted Desert

The Meteor Site in Arizona

Flagstaff, AZ

Needles CA and Colorado River

Mojave, CA:  Windmill Farm and Plane Graveyard

I rented a studio apartment in Atascadero and reported for work on Monday, March 3 1997. There are about a half-dozen pictures preceding this text. A common denominator for them could be roomy, vast, big, expansive. They reflect one of the principal attributes of Western scenery--the immense scale.

Well--here's another kind of immense scale. Below is a google Earth photo of Atascadero State Hospital. If you look sharp, you can see the security fence that appears as a light-colored line around the edge of the central "hunk" of the photo.

Red Stipe on Patient Yard which is 320 feet long

I went and marked a red line on the patient yard which is the size of a football field. Notice how this yard is dwarfed by the surrounding structure.
The two-story hospital is divided into "units," a euphemism for "wards." Each ward has a team of professionals that consists of psychiatrists, psychologists, somatic physicians, social workers, nurses, psychiatric technicians, clerks, occupational therapists, nurse practitioners--sorry if I've left anyone out. There are hospital policemen who work in the facility, but they are rarely involved in physical interactions with patients. (The formal role of the hospital police force was never clear to me.)
Each ward may have anywhere from 25 to 40 patients. The hospital has been organized by the particular "forensic" issue, for example, competency to stand trial, not guilty by reason of insanity, California Prison Inmate in need of inpatient mental health treatment, or an inmate paroled to the care of the forensic hospital.
There were also "admission units" where staffing was robust as new arrivals were evaluated with respect to risk of violence to self or others.
The patient uniform was khaki. This meant that khaki and brown colored clothing was off-limits for staff. This is a standard type of rule in many facilities--staff must wear colors different from those of patients.
Staff entry to the facility was through a sally port inside the main administration building. All staff wore badges and these were scanned upon entering and leaving the facility. As the badge was scanned, the security system displayed the employee's picture, name, and data. The security officer checked the live face on the other side of the glass with the face that showed up on the TV screen during the scan.
The sally port emptied directly into the main corridor of the hospital which is about 50 feet wide. On the morning that I started traffic was heavy. Several staff members and many patients in one's and two's were on the move. There may be entire wards of 30 men marching in a formation reminiscent of 3rd grade with 3 or 4 staff in attendance to accompany them. There is a remarkable sense of freedom within the hospital. The appearance of regimentation only occurs when groups are in motion.
My First Case
Sometime in the first week I was assigned to spend a day in the "Admissions Unit" of the hospital. I watched one of the veteran psychiatrists go through the paperwork and the interviewing process for inmates who were being sent from the prison system to the State Hospital for a higher level of care than could be provided within the prisons. After observing two of these admissions, I was instructed to try one on my own.
Everything was very straightforward as I collected the most basic information...date and place of birth, reason for incarceration, medical history, family history, and then the interview got away from me and the patient began describing what had been happening to him in the prison where he had a terrible urge to swallow the hair and feces that accumulated next to the drains in the men's shower in the prison.
Suddenly I knew that I was in a very different place than I may have imagined! It was only later that I learned that in California, three lawyers and two psychiatrists would be required to implement a court order for involuntary medication in cases such as these.