Ely State Prison 2

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March 10. It's 1 A.M. Yesterday started at 3 A.M. when I awoke having to urinate badly, had some trouble pulling myself out of bed, began huffing and puffing as I moved to the bathroom, was afraid that I would dribble all over, too breathless to stand and search for my urine stick that seems able to hide easily these days and about whose orientation in space I have little knowledge--It's About Schmidt for me at this point in my life. I have not taken enough hytrin and the bladder remains full without any flow and I'm still huffing and puffing and hoping that something will begin to dribble out and relieve the pressure and finally it comes and a I'm able to slow down my breathing and relax and let things flow. Urination? has achieved a place in the pantheon of major concerns. Urination?Yes! has achieved great standing. At 5 A.M. and 6:30 A.M. there were minor replays despite my use of some extra hytrin.

Ely State Prison 2
Thinking back on my time there, I am struck by the organizational efficiencies demonstrated in the privatized system of medical care at Ely when compared to what I have seen in the past three or four years in a State-run system in California. The Nevada prison was small enough to match an expected general practice for a family physician. This means that a relationship was possible and much more likely. In a bigger prison with multiple physicians, there will be temptations to manipulate by physician shopping. Even when caseloads are assigned, inmates realize that they can receive emergency treatments by the strength of their complaints and by their knowledge of symptoms which can be woven into the story of illness.
In California there is a lot of micromanaging of medical and psychiatric care. Some of that has to do with improving standards of care, but a good bit of it is plain "Cover Your Ass" beforehand. An example is the family Tricyclic Antidepressants (TCAs). There are no more effective antidepressants and they have been around since the 1950s and 1960s. However, they can be used to overdose and this can be done with a 2 to 4 week supply if hoarded and taken at once. In California, these drugs were taken off of the Psychiatrist's formulary some years ago and could no longer be prescribed for depression.
In Nevada, Tricyclic Antidepressants are just as lethal but were continued safely by crushing each dose, mixing it with liquid, and requiring the inmate/patient to drink medication while the nurse observed. I found the class of TCAs sometimes useful for treatment of Attention Deficit Disorder without resort to amphetamine-like drugs that are likely to be abused in prisons. In 4 years at Ely I never saw a TCA overdose.
Eric Stokmanis M.D., an internist was the Medical Director. He was excellent. In addition to Internal Medicine, Eric had an overall curiosity about all of medical practice, particularly minor surgery and orthopedics. He was able to handle the full range of outpatient department complaints from the prisoners. He also knew when patients needed to be shipped out for local surgical or tertiary care.
The medical observation rooms and the infirmary at Ely State Prison did not distinguish between psychiatric and medical cases. The same staff of nurses and mental health technicians cared for both. I think this is a huge strength. It makes it harder for a medical department to look at bizarre behavior and automatically attribute it to a psychiatric condition rather than a delirium. There were seldom more than 2 psychiatric patients behaving badly at the same time and our overall incidence of physical restraints declined while I was there. In Nevada the process for using psychiatric medications over the objection of patients was based upon a Supreme Court Decision.
http://en.wikipedia.org/wiki/Washington_v._Harper
The Supreme Court ruled that the patient was entitled to a full institutional review and not to a court hearing. This is a much more efficient mechanism than is currently used in California. In California, three lawyers will be paid for each hearing--a judge, an attorney for the inmate, and a California attorney who will prepare and file the papers for the State.
The Death Row
Death row housing is done at Ely although executions are carried out in Nevada State Prison in Carson City.

http://en.wikipedia.org/wiki/Capital_punishment_in_Nevada

I generally visited the death row once or twice a week. There were several patients who received antidepressant medications and some suffered from anxiety attacks. These patients were seen on a regular basis for medication evaluations and changes. Any of the inmates could request a mental health visit and generally these were screened by 1 of 3 mental health professionals, after which the therapist would discuss the case with me before I followed up.
The atmosphere on death row was very calm. Nevada is a state that is in no hurry to execute anyone. You are more likely to die of natural causes than executions unless you decide to forego your appeals. The warden designed the schedule on the Death Row with an eye toward maintaining a low-key atmosphere. There were live weights on Death Row but not elsewhere. The men were allowed out of their cells for considerable periods of time during the day. There was no evidence of racial animosity. Many of the inmates continued to work on their "cases."
One of the first of the inmates I got to know was Lawrence Colwell, Jr.
http://en.wikipedia.org/wiki/Lawrence_Colwell,_Jr.

My first impression of Mr. Colwell was an empty cell that was so neat and tidy that one would expect that a monk was living there (at least Sohr's interpretation of how such a monk's room would appear). He was initially receiving some medication. When asking him about the future, he told me that he expected to be executed--that he had committed a horrible crime for which he had no real explanation. He believed that justice demanded his own execution. As you can see from the Wikipedia article, he appears to have represented himself in such a way to guarantee his execution. Although Colwell had committed a heinous crime there remained for him a need to face and own his own behavior, rather than to deny or mitigate his actions. He saw no alternative but a life for a life.

In contrast to Mr. Colwell was another death row inmate who had come to Ely State Prison with depressed mood, failure to maintain hygiene, difficulty sleeping, difficulty thinking, weight loss, etc--the classic signs of a major depressive episode. He was maintained on antidepressants for about 6 months until he adjusted to the death row and stopped medications. There was definitive video evidence of his crimes. However, when I interviewed him a year after arrival, he was no longer depressed. He was angry and complaining of the way his "case had been handled." He expressed outrage that he had been "in the marines to protect his fellow countrymen" and they had the nerve to give him a tainted trial for his multiple murders. He was able to separate himself from his actions using the vehicle of his "case." This is one of the weaknesses of our adversarial legal system--the case takes precedence over the admission of responsibility and the possibility of rehabilitation.

Here is some recent activity with respect to the Nevada Death Row:
http://ccadp.org/nevada.htm

What do you think? Penpals anyone?

http://nevadaprisonwatch.blogspot.com/2011/09/costs-of-nevadas-death-row.html

Guilty But Insane
Nevada was one of a few states that eliminated a plea of "Not Guilty by Reason of Insanity," (NGRI) and instead permitted a plea of "Guilty But Insane." In most states, a patient found NGRI would be committed to a state hospital for treatment. However, in Nevada, patients found Guilty but Insane were very likely to come to Ely State Prison and be included in available mental health programming. This meant that a Schizophrenic man who had killed his parents and offered passages from the bible as justification would likely be one of our prison patients during the first few years subsequent to the crime.
Uncertainty in Medicine
The Guilty but Insane plea is at the heart of one of the most bizarre experiences I have had as a physician. Sometime around 2000 we received a patient from the prison mental health center near Las Vegas. He had pled guilty but insane to a murder charge. As I recall, he was in his early 30's and arrived with a diagnosis of schizophrenia. A part of the narrative that came with the patient was that the transfer to a prison had been "pushed" by the family of the victim who demanded that the patient be treated like everyone else and spend the first year of incarceration at the maximum security center at Ely. It was also curious that there were some newspaper articles that quoted the judge in the case as believing that the murderer/patient was malingering his mental illness.
When the patient (I'm going to call him Mr. C) arrived in Ely he was already on an antipsychotic medication, called Clozaril, that is frequently the medication of last resort because of a side-effect profile that can lead to the loss of key parts of the immune system and death from infections.
When evaluated at Ely, Mr. C was able to communicate reasonably well. He endorsed previous membership in the CIA. He expressed sorrow and remorse about having killed a young woman and an antidepressant was added to his medications. Mr. C remained at Ely for several months. He was seldom any trouble and he continued his Clozaril without incident. He spent several weeks in the infirmary over the years and I saw him frequently. There was no doubt in my mind that he suffered from Schizoprenia, but probably of the paranoid, higher functioning type.
Shortly before I left Ely, Mr. C asked to talk to me. He related that the Courts had overturned all pleas of Guilty but Insane and that the District Attorney had stated that Mr. C would be retried. If C pleaded guilty he would be given Life in Prison without the possibility of parole. The District Attorney said if Mr. C pleaded Not Guilty or Not Guilty by Reason of Insanity then the state would seek the death penalty. Mr. C asked me if I knew of any psychiatrists who might be willing to look at his case. At the time, Jasmine was board certified in Forensic Psychiatry. I gave Jasmine's work number and thought no more about it until about 2 years later.
In 2003 Jasmine received a phone call from a lawyer for Mr. C. He asked if Jasmine would meet with him to discuss a case. Jasmine was in Las Vegas every other weekend and so an appointment was set up using the office for my private practice. Two attorneys appeared. They summarized the case against Mr. C and then asked if either Jasmine or I were interested in participating in the case. Either Jasmine or I asked for the most damning information from the case and our jaws dropped open.
As a part of the plea of Guilty But Insane, Mr. C was required to identify the location of the body so that it could be autopsied and returned to the family. Mr. C provided a location and a forensic team retrieved the body. The problem was that it was a body other than the victim's.
Jasmine and I looked at the lawyers. "You've got to be kidding! How could anyone willingly provide testimony that might lead to Mr. C's release. Life without Parole seems like a rather light sentence for a person who appears to be a serial killer."

Uncertainty--the Goddess of the Universe

Ely State Prison 1

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March 8. It's 1 A.M. as I start this. I am four weeks past my last chemotherapy and today the fuzziness in my head seems completely gone. I'm having a little bit of difficulty with word finding. My mood is very good. Current meds are dexamethasone 4 mg daily (more than twice what the body generally needs), hytrin 5 mg once or twice a day to battle my prostate, omeprazole 40 mg a day to keep from making stomach acid and decreasing my risk of developing an ulcer from the dexamethasone, and Levaquin 500 mg a day to treat what is probably a pneumonia that has been around for a week or so.  I'm having some pain from the left diaphragm from tumor fluid and I took a short-acting fentanyl a few minutes ago.


Ely State Prison
Jasmine and I had met in 1997. Her fellowship in Forensic Psychiatry ended on June 30 of that year. She had originally planned to return to her home in Orange County but decided to accept employment at Atascadero State Hospital instead. I was already committed to Atascadero for the forensic fellowship. She moved in with me in Morro Bay and we had a wonderful first year of romance. For me it was an opportunity to observe a Zen master. For her it may have been something analogous to a Jane Goodall field study.
Unfortunately, "lived happily ever after" was not an option at that time--the world was rapidly changing. Although the youngest in her family, Jasmine is the matriarch of her family of origin and provides needed medical services to various family members. She had delayed her return to LA from 1997 until 1998. However, her 89 year-old father had stopped driving and was becoming more frail. Both her dad and step mother had ongoing medical problems and needed assistance on a regular basis. She believed that she had no choice but to return--out of love for him.
There is a phenomenon that I call the illusion of independence, where the elderly stay in their own home but require a mountain of assistance in order to do so. Her father was at this point in his functioning and it was not something that was going to change.
Atascadero State Hospital was changing, also. After the Polly Klass murder, the legislature had passed a statute that required certain types of sexual criminals, Sexually Violent Predators (SVPs), be committed to a state hospital for treatment upon completion of a prison sentence. Atascadero State Hospital had been designated as the treatment site for all of these cases until a new hospital, Coalinga State Hospital, could be constructed specifically for the needs of these "patients." Neither Jasmine nor I had any real interest in doing psychiatric work with that population.
I was unable to imagine myself living in the bustle of Los Angeles. (Jasmine would always tell me that she lived in Orange County, not Los Angeles--but it all looked the same to me.) Sometime in May I received a job offer from the old company, Correctional Medical Services. The position as psychiatrist at the maximum security facility for the state of Nevada was available. It was a job with medical benefits but no retirement plan. However, the contract offered twice the hourly rate as my position at Atascadero...it was an offer I couldn't refuse.
Jasmine and I scoped the job. We flew to Salt Lake City and rented a car and drove the 250 miles to Ely, where we took a tour of the medical facilities in the prison and had a meal with the medical and mental health staff. It was very convivial. The next day, I met the warden and I was impressed. He was an enormously big man--both large framed and carrying an extra 100 lbs. He was articulate and opinionated enough to make me comfortable that his decision-making was likely to be clear and decisive. I didn't see anything not to like.
The job required that I spend 35 hours at the facility per week when averaged over a month. This provided an opportunity for a great deal of flexibility in scheduling. However, a key to that flexibility was the relationship with the medical director, Dr. Eric Stokmanis, a young internist who had been at the prison for a couple of years. Given my background in Family Practice and prison medicine, I could actually provide him with medical coverage and permit him time away from Ely several times a year. It turned out to be a great arrangement. We were both capable of examining one another's patients and discussing the cases by phone in order to develop a reasonable treatment plan. We did this for the next four years.

Ely Nevada. Low resolution shot that captures the mountainous feel to the place.

Ely is in a beautiful location at about 6500 feet above sea-level with a high desert climate. The summer weather is next to perfect with very dry days in the mid-80's with intense sun. Although it was not unusual for night-time winter temperatures to dip to zero, the average daily temperature during the winter months was in the 40's. I found it much more comfortable than Billings MT.
http://en.wikipedia.org/wiki/Ely,_Nevada

Aerial View Ely State Prison: The 8 squares are housing units.

On my second or third day on the job, I was still within the facility in the afternoon after the departure of Dr. Stokmanis. I was called to one of the housing units. When I arrived, there was a man lying on his back outside of a cell. There was a very ragged cut that extended from one ear almost to the other. The man on his back was dead and had been for a while because the body was cool.
On the floor alongside the man was a coffee can lid with sharp edges. It had been folded over and rolled slightly to provide a handle. Home made prison knives are called "shanks." Most are constructed to "puncture" and penetrate rather than slash. Generally shanks do their damage by piercing vital organs in blows to the neck, spine, and chest. The shank I was looking at was more sophisticated and specifically intended for use as a blade to slash the trachea, jugular veins and other vessels in the neck, like the carotid arteries.
Inside of the open cell, a naked inmate was on his knees, cuffed in the back, and pressed against the wall by two correctional officers. This was the cellmate. The body had been discovered during the afternoon "count." (Several times a day, a count of all prisoners is performed--to ensure that all that should be there, are in fact there.)
About an hour after pronouncing the man dead, the warden invited me to a conference room where a recorded telephone conversation between the dead man and his mother was played. The victim had been scheduled for release on parole within the next days. His mother was a card dealer in Vegas who spent several minutes informing him how important it would be to obtain credit.
It was suspected that the victim had been unwilling to comply with a request from a gang.
Despite the murder in the first week of work, I have never felt safer working in a prison.  Movement of inmates was strictly controlled. Patients brought to the medical unit were shackled at ankles and wrists. There was also a "belly" chain to which the shackled wrists were attached. And then there were either one or two escorting officers who walked beside the inmate and maintained a  hand grip on the upper arm.

Oregon Assisted Suicide

March 6..

I promised to look into the Oregon Physician Assisted Suicide situation. I don't mean to complain but it seems like such a very small step forward in the direction of providing as much assistance as my dog, Archie, will be able to receive to help him with his terminal illness and pain. If somehow I attempt to take a lethal dose of oral medication, like Seconal, and I am unlucky enough to vomit too much of it and survive, there is no legal way in the U.S. for a physician or anyone else to start an IV and give me the lethal dose that I need to exit.
To benefit from the Oregon law, one must be 18 years of age, a citizen of the state, and have a documented terminal illness. The patient must be competent to make medical decisions. The patient must request assistance in writing. I'll just provide some of the information from the statute. The complete statute is here:
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

127.805 s.2.01. Who may initiate a written request for medication.

(1) An adult who is capable, is a resident of Oregon, and has been determined by the attending physician and consulting physician to be suffering from a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner in accordance with ORS 127.800 to 127.897.

127.810 s.2.02. Form of the written request.

(1) A valid request for medication under ORS 127.800 to 127.897 shall be in substantially the form described in ORS 127.897, signed and dated by the patient and witnessed by at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is capable, acting voluntarily, and is not being coerced to sign the request.

(2) One of the witnesses shall be a person who is not:

(a) A relative of the patient by blood, marriage or adoption;

(b) A person who at the time the request is signed would be entitled to any portion of the estate of the qualified patient upon death under any will or by operation of law; or

(c) An owner, operator or employee of a health care facility where the qualified patient is receiving medical treatment or is a resident.

(3) The patient's attending physician at the time the request is signed shall not be a witness.

(4) If the patient is a patient in a long term care facility at the time the written request is made, one of the witnesses shall be an individual designated by the facility and having the qualifications specified by the Oregon Health Authority by rule. [1995 c.3 s.2.02]

127.815 s.3.01.Attending physician responsibilities.

(1) The attending physician shall:

(a) Make the initial determination of whether a patient has a terminal disease, is capable, and has made the request voluntarily;

(b) Request that the patient demonstrate Oregon residency pursuant to ORS 127.860;

(c) To ensure that the patient is making an informed decision, inform the patient of:

(A) His or her medical diagnosis;

(B) His or her prognosis;

(C) The potential risks associated with taking the medication to be prescribed;

(D) The probable result of taking the medication to be prescribed; and

(E) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control;

(d) Refer the patient to a consulting physician for medical confirmation of the diagnosis, and for a determination that the patient is capable and acting voluntarily;

(e) Refer the patient for counseling if appropriate pursuant to ORS 127.825;

(f) Recommend that the patient notify next of kin;

(g) Counsel the patient about the importance of having another person present when the patient takes the medication prescribed pursuant to ORS 127.800 to 127.897 and of not taking the medication in a public place;

(h) Inform the patient that he or she has an opportunity to rescind the request at any time and in any manner, and offer the patient an opportunity to rescind at the end of the 15 day waiting period pursuant to ORS 127.840;

(i) Verify, immediately prior to writing the prescription for medication under ORS 127.800 to 127.897, that the patient is making an informed decision;

(j) Fulfill the medical record documentation requirements of ORS 127.855;

(k) Ensure that all appropriate steps are carried out in accordance with ORS 127.800 to 127.897 prior to writing a prescription for medication to enable a qualified patient to end his or her life in a humane and dignified manner; and

(L)(A) Dispense medications directly, including ancillary medications intended to facilitate the desired effect to minimize the patient's discomfort, provided the attending physician is registered as a dispensing physician with the Board of Medical Examiners, has a current Drug Enforcement Administration certificate and complies with any applicable administrative rule; or

(B) With the patient's written consent:

(i) Contact a pharmacist and inform the pharmacist of the prescription; and

(ii) Deliver the written prescription personally or by mail to the pharmacist, who will dispense the medications to either the patient, the attending physician or an expressly identified agent of the patient.

(2) Notwithstanding any other provision of law, the attending physician may sign the patient's death certificate. [1995 c.3 s.3.01; 1999 c.423 s.3]

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Well, that was my promise to provide more info about Oregon. At the end of this process, you will receive a prescription for a lethal dose of a medication. It would be nice if there were a refill available in case you screw up and vomit the first try. The law does make it easy to receive other medications that will be of help--for anxiety and for nausea.

There is an ongoing, active, negative campaign by opponents of end-of-life rights as exemplified by this Fox News article: http://www.foxnews.com/story/0,2933,392962,00.html

For this particular case above, I would like to see the original letter that the patient received. To notify the poor patient of a rejection of insurance coverage and in the same communication to offer assisted suicide is poor form, to say the least.

The safeguards outlined in the Oregon statute appear reasonable when considering that we intend to end a human life. The capacity to make the decision must be established. Pain must have been addressed aggressively. Depression should be ruled out or treated vigorously. Second opinions are a minimum precaution. Stretching out the process over two or more weeks reduces the probability of an impulsive decision.
Hopefully these safeguards become the foundation of a system that provides more in the way of help. No matter how carefully an individual prepares for the moment of departure, there is the possibility of a misstep or error, in which case a backup of actual euthanasia administered by an experienced practitioner would be highly desirable. So--Oregon seems like a "start."

Rationing

In another post I have mentioned rationing. It has always existed in the delivery of health care and to begin a serious conversation about the future of health care costs without recognizing its presence dooms the discussion at the outset.
I like the thoughtful presentations of Daniel Callahan in Setting Limits. Throughout human history, survival of the family, group, and clan depended upon pooling of resources and, at times, decision-making about the distribution of resources, like available calories immediately available to the group. I believe that one of his vignettes depicted an Eskimo family in which the grandparents decide that they are too much of a burden to make the next "hop" in their hunting and they stay behind as the family leaves without them.
In our own society, how should health care resources be distributed? If we all agree that a heart transplant at age 40 is reasonable and that a heart transplant at 100 is not, what about the ages in between? Is there a magic age? As fewer of us pay for health care out of pocket, how will health insurers, including governments, make decisions about the distribution of benefits? We have 300 million different value systems to apply to such questions but serious discussion is hidden behind sloganeering.

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My enrollment in hospice has been completed. In the past 5 days I must have gotten 25 phone calls from various disciplines in the hospice agency including nursing, social work, pastoral, administration, etc. Apparently Medicare requires that each offers me their services.
The hospital bed was delivered on Monday and set up in the middle of living room.

View from the head of my bed

The picture is before sunrise. The sea is out there but I guess you are going to have to trust me. The most distressing symptom is severe shortness of breath when I change positions, like getting up out of a chair and walking to another room.
There is a lot of fluid and crud in the base of my left lung. It is lying on the diaphragm, the dome-shaped muscle that does a lot of the work of breathing. The diaphragm is a structure that migrates during the fetal period. The nerves that innervate the muscle come from the cervical spine, C3 and C4. The epaulet area of the shoulder is also innervated by C3 and C4, where I am sometimes experiencing breakthrough pain, like right now as I write.
Today Kirk and I were busy. He spent the morning editing a cooking show while I worked on refinancing and taxes again. Then we took the RV to the beach. I took in the sun while Kirk and Archie had a great walk. Then a lunch at a restaurant on the water. I wasn't hungry so I drank a beer and ate some sourdough (I am really living it up!). Then a drive to Los Osos to the pharmacy to pick up some supplies. Then to Autozone to get replacement bulbs for headlight and rear running light...then replacement of bulbs courtesy of Kirk...then a nap. A great day. Somewhere in there we bought a very expensive single malt whiskey.
This was a treasured day. I hope yours was as well.

I recently wrote about my increased interest in observing human faces--I noticed that I was smiling back in response to seeing smiles both in my environment and on television. When I mentioned it to David, a psychiatrist friend, he threw out a comment about mirror neurons. Such neurons might be a key to empathy and permit us to walk a mile in another's shoes without leaving our living rooms.
http://en.wikipedia.org/wiki/Mirror_neuron

March 4

February 28
Yesterday I called Dr. Palchak's office and opted out of my chemotherapy session set for Friday. I don't think that it is doing much for me. I was very fuzzy-headed for quite a spell after my last session and I want to be as clear as possible for the next phase of illness.
One of the things that I have noticed is a tendency on my part to enjoy watching people smile--this can be in real life or on television. I am also much more aware of length of life when it is mentioned in a news brief. Yesterday, I came across an article about George Kennan who lived to be 101. I thought.."wow...another 30 plus years beyond mine...what would that have been like?"
Dana is my youngest brother, born in 1959, 16 years after me. He is incredibly smart and started his own newspaper when he was 19. The paper was called "It" and was initially directed at students and faculty of the University of Maryland and expanded to other colleges and night spots around the D.C. area. The paper was not a successful commercial venture but was an important failure for his professional growth. He had some time after the demise of the newspaper and I invited him to visit me in Billings to write a manual for a software program that I was developing with Ed Puckett. We spent two or three weeks working and hiking together. We got close and have stayed close ever since.

Dana and Wife, Therese

So, we've had two long rides of about 8 hours each in the past week with the opportunity to talk about a number of things, particularly our current sense of impending loss.
Our Las Vegas reunion included 7 families who came from New Jersey, Maryland,  Virginia, Colorado, San Francisco, Berkeley, and Mazatlan. My brother, Kirk (b. 1956) was a primary chauffeur and made several airport runs.
It was wonderful to have all of my siblings and their children together at the same time.

The Sohr Kids: clockwise Sue, Dana, Kirk, Geoff, Eric--September 2006

Las Vegas was an amazing value. The Station Casino buffets at Green Valley Ranch and at Boulder Station were remarkable for the variety and the price, particularly if one acquires a "rewards" card. The Bellagio buffet on Saturday night was also bargain when factoring in variety and quality. I particularly liked the Sushi, the variety of seafood, exquisite pizza, fresh vegetables and fruits, and pastries. (As you can see, the only thing that is working for me these days is my Alimentary tract.)
There were a couple of moments for tears. On Sunday morning I was sitting at the breakfast table with 20 family members and I was watching all of the wonderful interaction. I thought how much my mother and daughter would have enjoyed being there with everyone--and I was experiencing my loss at seeing most of my family for the last time.
Other good times over the weekend were spontaneous with folks piled into one hotel room or another shooting the breeze and telling family stories--several of which you would have recognized from previous posts. I have accumulated a couple of dozen bottles of wine over the years. If I do drink, it is never more than about 1/2 glass. Jasmine doesn't drink. So it's open a bottle of wine; use no more than a drink;  then cook with it and wait for it to turn to vinegar. My wine cellar for the past few years has been cardboard containers under my bed so as not to waste space in cabinets. This trip allowed me to create space and fight the dust bunnies.
As the room filled with people, the bottles of wine slowly disappeared, voices were raised in merriment, and laughter supervened.
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As you might imagine, as my time ticks down I am increasingly focused on my plans for the last few hours of life.
"What do you want done with your ashes?" It doesn't seem crucial to me. The nicest place to scatter them would be the graveyard on Smith Island.
"Do you have any requests for your service?" To quote Bob Hope when asked where he wished to be buried, "Surprise me!"...but no, I don't have any requests right now.
There are some apologies I owe where there is no longer any possibility of making amends. I do have to get started on some of those.
There are letters I need to write to others and I'm still hoping for some honest conversation with family and friends.

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In addition to last few days, I have concerns about last few minutes and last few breaths. This brings up the issues of right to die and euthanasia.
I happen to take the position that we have the right to be in control of our passing from this life. Although I think that there can be value in suffering, that value is diminished when in the embrace of a terminal illness. I fully believe that some safeguards to prevent action in depression or in pain be in place, provided the safeguards are not constructed exclusively by those who are opposed to the right to choose the timing of one's death..
For those who do believe that we are justified in exercising that control over the future, we have to make certain decisions about the timing. If we are planning on an assisted-suicide, there is less need to be concerned about our physical abilities because we are ceding control to another. However, if we are intending to act without assistance in pulling the trigger (a preferable way in most states to avoid possible charges of assisting another to die) we need to pick an exit time when we still possess the necessary physical strength and mental ability to be successful. We'd like to only have to do this once.
My knowledge of the literature on the topic is limited to Final Exit by Derek Humphrey and To Die Well by Wanzer and Glenmullen. Plugging these titles into Amazon will bring forward some other candidates.
Naturally, I was most interested in the chapters specific for self-directed departures. The focus in both books was on two methods--lethal medications and inert gases. Barbiturates are the medications that have a long history of "successful" use as a toxic agent. The short acting agent secobarbital (Seconal) is increasingly more difficult to find. It is an old-time sleeper and has been replaced by newer sleeping agents that are much less toxic. The lethal dose is as variable as human genetics. 9 or 10 grams is considered a certain lethal dose.
A possible scenario for obtaining Seconal is to "start early" in acquiring a supply. I would approach your physician with an inquiry about his/her stance on your right to determine your time of departure. If an equivocal response, network among other cancer sufferers to find a more open physician. You might want to check out the physicians associated with your local hospices. Your next move is to request medication for sleep. I would mention that in the past you had used a few sleepers and that Seconal appeared to work the best for you. The physician is more likely to ask you to try something safer and to prescribe a few alternatives. Smile and accept all the alternatives. Wait 72 hours and call the physicians office for another appointment because the sleepers didn't work. Hopefully, after two or three tries, a prescription for seconal is forthcoming. As for a month supply. It will take three months of 30 tabs of 100 mg to acquire the lethal dose. The copay for seconal is especially heavy at $50 a clip with my insurance.
The books recommend that one eat pills as fast as possible in order to get 90 down before falling asleep. An alternative is to open the capsules and mix the powdered drug with applesauce and to down the small amount of applesauce in lieu of swallowing pills. This makes more sense.
Here is the procedure I would follow for seconal.

1. Mix 9 grams of seconal powder with applesauce--I'd give 4 oz a try.
2. 2 hours before departure time, use an anti nausea med (antiemetic preparation). I like Odansetron (Zofran), or Phenergan or Compazine.
3. 1 hour before lift off, use a dose of lorazepam (Ativan) 1 mg for uninitiated--your usual dose if it's something you already take like valium or serax. 
4. It is well known that Alcohol increases the effectiveness of barbiturates. One hour before might be a good time for cocktails with your supporting group. Don't drink so much that it increases your risk of nausea.
5. At 1 hour before departure, you might consider a little more opiate, like morphine or whatever you are currently using, but not so much that you increase vomiting risk.
6. Remember that our goal is to get down a lethal dose of seconal without any reflex vomiting occurring after you have fallen asleep from the medication effects. You need to keep down the lethal dose.
7. At departure time, eat the applesauce. Don't dawdle because you will go to sleep fairly quickly and you need to get the medicine all down.

The above mentioned books provide many more details about Seconal. Both also cover the use of "inert gases" primarily helium which is readily available in disposable tanks intended for balloon filling. As part of my research, I ordered 2 tanks online. With shipping, etc. each was about $64. The authors of Final Exit and To Die Well describe the use helium as representing a potentially painless way of exiting. Their argument goes like this--our respiratory drive is associated with our sense of smothering. If we look at the information on waterboarding, it only takes a few seconds before the smothering supervenes. The sense of smothering is triggered by sensors in the brain that detect carbon dioxide and oxygen, but that it is primarily carbon dioxide that accumulates rapidly and initiates the sense of smothering. The authors claim that low oxygen does not cause distress. As long as one can continue breathing, it blows off the CO2 and prevents its accumulation. So the breathing of helium replaces oxygen without disturbing CO2 and allows the brain to shut down from oxygen lack in a minute or two without distress. As one continues to breathe helium, the brain suffers from anoxia, consciousness is lost quickly and brain death occurs within about 15 minutes. There are diagrams in the books demonstrating a helium hood that can be fashioned from readily available materials.

Well, I really liked hearing about the helium method. After reading the books, I decided that it would be my first option should I see it to be necessary. That's why I ordered the gas. However, since both of the authors were still alive, I decided to check out the painless claim with a friend. We gerry-rigged a tank to my cpap machine and did a trial run. The goal was for me to demonstrate oxygen deprivation by failing to maintain a hand signal and to do so without experiencing air hunger. I failed--the air hunger kicked in within 20 seconds. Both authors who recommended the method were still alive. I decided to try again using a medication for anxiety before the trial. I was unable to find any ativan. So I used additional fentanyl quick-acting. I doubled my breakthrough dose and waited about 25 minutes and tried the helium again. Maybe I went a bit longer, but the result was the same--absolute terror. Conclusion: this method leaves a lot to be desired for me.

After my experiment with helium, I decided that I'm going to give a call to folks in Oregon tomorrow in order to find a place where I might go to get some help. I'll do my best to keep people posted. It appears to me that there might not be a fail safe method for me that doesn't potentially compromise my friends. Given the current situation, I would have to elect to use seconal. However, if I were not dead within an hour or two, I would want to add the second method--i.e. the helium. I will be far below sufficient consciousness for my respiratory drive. The use of helium to eliminate the oxygen should end things very quickly. However, it would take someone else's hand--and that is too much to ask because of the possible legal burdens.

March 4. It has been a very tough weekend. I awoke on Friday with a fever and a headache. My pulse was generally around 130. My oxygen saturations were in the high 80s. My brain was very fuzzy. The most likely cause of a fever for me is a pneumonia. I felt so crummy I was hoping that this would be a terminal event...no such luck...just a miserable couple of days. The fever went away on its own and I decided to take an antibiotic. I could live pretty well with my days from last Wed and Thu. On Friday I ended up stuck in my recliner in recline and was too weak to get up when the doorbell rang and rang and rang. I was finally able to get up for the hospice nurse and she went through the intake procedures and  left a comfort kit of senna for constipation, morphine for pain, lorazepam for anxiety and nausea, phenergan for nausea, and decadron as a steroid. A hospital bed and walker and were ordered for me.
Today Luis and Desiree came by with the baby and moved furniture around in the front room to accomodate a hospital bed. It will be nice to have everything I need on one floor. Generally I use the TV room, bathroom and bedroom downstairs for recreation, work, toileting, and dressing--but that has gotten harder to manage...
Jasmine has been overworked handling her day job, doing errands, filling rx's, getting me food and drinks, rearranging furniture, etc. She asked me to ask my family for help--to have someone around when she is at work because she worries. We called my brother Kirk and he said he would be here tomorrow--pretty amazing! Thank you, Kirk, and thank you for letting him go for awhile, Claudia. This is so helpful.
My canine partner has decided to wind down from the busy week.

Atascadero State Hospital

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It is Friday Feb 24 as I begin this post. I'm waking up in Las Vegas. About 6 weeks ago I began making plans to see my family for a small reunion of my siblings and their children. Las Vegas offered the most convenient venue for good air service and reasonably priced hotels--bargains if you are not a gambler.
My brother Dana flew out to Morro Bay on Wed and we got up at 2 A.M. on Thursday and drove the RV to Las Vegas. We experienced some engine power problems as we approached the California/Nevada border but managed to make it to a dealer in Las Vegas and had the fuel filter changed out. We'll see today if that was the culprit.
My family will all be here on Saturday. About 25 people will be going and coming for the next 48 to 72 hours.
My CT of the chest on Tuesday looked terrible to me. I know that medical imaging is not my forte but I'm very sure that I see a lot of progression of tumor or tumor effect in my chest. It also appears that my heart is wrapped up in this mess as well. I think that may be a partial explanation for my breathlessness--that my heart is unable to expand to the degree necessary for a good stroke volume. Normally the heart can increase blood output in two ways, by expanding and increasing the filling volume to squeeze out more blood with every beat and by increasing the number of beats per minute.
I am only able to walk about 25 paces on level ground before stopping to catch my breath. At home I am unable to climb the stairs and must rely on the elevator that the builder had installed for his own wife--what a lucky find.
So, my time appears to be very short.
***
It's now about 2:30 PM. There was a lunch buffet at Thai Palace at 935 E Sahara...best Thai restaurant ever...Following that, Robert Granieri, who was my office manager when I practiced in Vegas,  and I went to look at comparable office spaces to the building we are currently renting out. Jasmine and I bought the building where I practiced in 2004 (a converted 2700' house). We have been renting it since leaving Vegas in 2007 and the leases come due in September. There are two suites in the building and neither occupant is interested in taking responsibility for the entire building.
***
I'm back in the hotel room and making myself some coffee brought from home. I'm dying for the real thing. While I was boiling the water I had a flashback to Billings in January 2011--staying in a motel room and making coffee when I went to visit Shirley Gunnels who had been told that her breast cancer had involved the lungs and liver. At the time, there were three friends with cancer and lung involvement--I felt connected to them all and was really much closer in some ways that I could have guessed.
Shirley died in late summer but was unable to avoid a spinal surgery for pain 2 weeks prior to her death. She was in her high seventies or early eighties and was active enough to paint parts of the outside of house and to do a lot of cooking and running around at the senior center. There is nothing like cowgirls. We spent the afternoon at the movies. Our choices were Black Swan and True Grit. I would have gone to Black Swan but there was no way Shirley was going to a movie about ballet.

Atascadero State Hospital
The hospital was established in the 1950s and is the city's major employer. The town itself has a very interesting history.
http://en.wikipedia.org/wiki/Atascadero,_California

One of the requirements for working in the hospital is attendance at several weeks of training to teach each new staff member the set of expectations for conduct. A part of this training is physical--to teach the ins and outs of restraining patients safely. All disciplines are expected to participate and respond to alarms that indicate a problem on a ward. When an alarm sounds, staff from neighboring wards are expected to run to the problem and immediately boost the number of staff available to handle the situation.
Physical confrontation with patients was a last resort. Training was focused on identifying situations that were escalating and providing techniques for calming things down.
Alarms are inherently dangerous. People are running at full speed and must get through heavy steel, locked doors that separate the wards from the main corridor of the hospital. Injuries during alarms are common and more likely to be accidental than due to physical confrontation with the patient himself. Staff are more likely to be injured by patients when a punch appears out of nowhere--the patient having planned such an assault and waited for an opportune time.
The hospital has been adopted by the town and vice-versa. It is not unusual to talk to employees who are the third generation of hospital workers.
The State Psychiatric Hospitals are much more dangerous to staff when compared to psychiatric facilities within prisons. The U. S. Department of Justice became involved in the State of California's psychiatric hospitals in about 2002 and there has been turmoil for the last decade. I know that the "consultants" to the state (actually the original inspectors as well ((?talk about conflict of interest)) ), have made a very good living from California.
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I am quickly running out of time and have to prioritize what I think I can actually get written in the next few weeks--so for the time being, I am going to skip away from my work history and focus more on illness-related matters, a summing up and reflection on certain relationships, and my day-to-day kind of progress or lack thereof.

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.

Albuquerque II

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I'm beginning this on Thur 2/16.
I had my last chemotherapy, Alimta, on Friday 2/10 in Dr. Palchak's office in Arroyo Grande CA. It was a very short infusion--about an hour or so. He convinced me that the Alimta was unlikely to be the culprit from the prior round which whipped me so badly--that it was more likely to have been from the Zometa, a drug that is used to prevent bone fractures.
Dr. Palchak was right. The chemo last week was reasonably mild. On Saturday I was able to drive my RV down to the beach where Archie and I parked in the Sun and watched the activities around the Morro Rock. My friend, Bob, joined us for an hour or so.
By Sunday I was becoming more tired and out of breath. On Monday I slept for 17 of 24 hours. Tuesday was the worst day--no wind and no energy. When I awoke that morning and looked in the mirror I was shocked to see the face of death or at least the absence of life.

Some Hair is Growing Back

There was no hint of any sparkle in my eyes--just a flat brown. I am increasingly aware of how sick I appear. Maybe it's paranoia but I catch people doing double takes--even people I know seem more curious than usual about my appearance. As a result I am becoming more and more self-conscious and would prefer to keep away from others.
These feelings and thoughts were particularly acute on Tuesday. The weather was miserable. There were scattered showers throughout the day but the rain became serious while Archie and I were in the Albertson's Supermarket Parking Lot. I have been wearing Crocs as my full-time footwear and I was concerned about slipperiness and falling, so I grabbed a grocery cart to use as my support and walker. We don't have a KFC or PopEyes in Morro Bay. The closest take is Albertson's fried chicken--really quite good. So I picked up a bag of chicken and wended my way to the self-service checkout line. The store was very crowded and all of the checkout lines were packed. The line for self-service snaked around a bit through a mass of humanity.
So, I'm waiting at the end of this crooked line and a young family of three pulls in behind me. The man and his wife appear to be in their early to mid-twenties. They have a five year old boy who is rolling around on the floor and ignoring their entreaties to do something else. Suddenly, in a loud voice, the young man points out that I am using a full size grocery cart to hold a lunch bag worth of fried chicken.
"The truth is that I'm sick. This grocery cart is my walker. It's holding me up." As I am giving this explanation, I can feel anger welling up that is directed at this blabbermouth. His eyes are opened pretty widely now and he is becoming more uncomfortable. I find that as he appears to be more frightened I feel more angry. Then he hits upon the real magic, "Why don't you calm down?"
Surprisingly, that didn't help. "Why don't you mind your own damn business!" popped right out without thought or restraint.
People are looking at us now. I'm embarrassed. Suddenly a checkout machine comes open and others in line are very quick to point it out to me. So, I go to the machine and I'm determined to demonstrate to the world that I am in control and possess complete mastery of grocery technology in my home town. I scan my chicken. I deposit my $10. My change is $6.01. Cooly I scoop up the penny. I grab the bag of chicken and leave the store and the $6.00 in bills behind!
I've spent the last two days in an effort to refinance our home mortgage to a better interest rate. For those of you who have missed such an exercise in tedium, it involves finding a ton of documents and scanning them into PDF files and then uploading the data to prospective lenders. I know I'll feel better when this is sorted out. Jasmine is working full-time and looking after me by cooking and squiring me to doctors' visits. Doing chores is a normal part of life--and we're still a partnership.
Today was my last scheduled visit for radiation to my spine for pain control. There was a timing glitch and I was asked to wait for a few minutes in a little examining room while the patient ahead of me was processed. While I was waiting, Dr. Stella walked in and was surprised to find me there. This is his medical practice and it was the first time that we had an opportunity to talk outside of a scheduled office visit. Normally I detect a little bit of an emotional distance when we meet, but there was none of that today. He asked me how I was handling all of this and I pointed out that I been lucky to have had so many teachers in the course of a life time of medical practice. He came over and shook hands with me and said that he was sorry that this was happening to me. I told him how much I appreciated all of the help with the back pain. I told him that the pain was much better but wondered if there was more that could be done to allow me to lift my left leg without pain. He pointed out that a lot depended upon the stability of the vertebrae and the amount of strong bone that remained. I enjoyed seeing him this morning when he had his guard down and we met as two people.
Albuquerque II
After my rotation on Dr. Hammond's ward, I moved over to Dr. B., one of the laziest physicians I've ever encountered. At the time, I was 51 years old, exactly one year older than the head of the department. Dr. B was in his thirties and the son of an internist. Dr. B had a very high opinion of his medical knowledge and capabilities. I only saw self-deception.
One of the perks of being in a teaching program is the ability to utilize residents and medical students to do the medical work of the hospital. In return, the attending physicians, like Dr. B., are expected to teach, to guide, to mentor. In addition to being lazy, Dr. B. was caught up in the great frauds of the era--satanic ritual abuse and dissociative identity disorders (multiple personality disorders). Dr. B always had two or three "multiple personality disorder" patients on his ward and he took a special pride in their presence. He spent a great deal of time with these patients reaffirming the "split" in their concept of self. Almost all authorities recognize that this is counterproductive or even destructive.
Sandra
Although diagnosed as having multiple personalities in 1995, the County Mental Health Program had been treating this woman for more than 15 years. The veteran nurses were quick to point out that Sandra's claim of witches' gatherings and torture had only surfaced in the past few years while she was being treated as the long-term therapy patient of one of the faculty. Prior to developing such a popular psychiatric diagnosis, Sandra had been diagnosed with  Borderline Personality Disorder with self-injurious behaviors. Halloween occurred during my rotation on Dr. B's ward. Sandra was admitted as a precaution for Halloween.
With Sandra, there was evidence in her own medical records that the diagnosis had expanded from a personality disorder and that she relished the attention and control that she was able to exert as a "multiple personality."
Patient Dumping and Cobra
There were some serious administrative problems in Albuquerque when it came to mental illness inpatient care. In general, hospitals would prefer that the uninsured and poor go elsewhere for care. Otherwise, the hospital itself becomes responsible for providing the care. In the 1980s certain hospitals became quite adept at "dumping," i.e. physically transporting patients to other facilities, typically large, urban public and charity institutions. Congress responded with a bill known as "Cobra" during the mid 1980s which made dumping illegal and subject to fines. Transfers between institutions had to be cleared on both ends and data collected at the first hospital had to be provided to the second one in the path.
Although these regulations had been in effect for more than 5 years nationwide, they appeared not to have made it into general awareness in Albuquerque when it came to mental illness. While working on call at night in the mental health center it was fairly common for ambulances to roll in from other hospitals and emergency rooms without prior notice. Despite complaints to the Department of Psychiatry nothing appeared to have been done about it.
Drawing A Line in the Sand
One Friday I was working on Dr. B's ward. The other resident was either off or sick and this left me responsible for all the patients for the day. Rather than work, Dr. B. decided that he was going to give me some personal instruction in the treatment of Alcohol and Drug Abuse. He had just passed his subspecialty certification examination. (At the time it was possible for a psychiatrist to be labelled an expert in addiction medicine by paying to take an examination and passing it. The pass rates were very high. The process looked more like the exchange of a credential for a sum of money.)
Of course Dr. B's personal experience with drug and alcohol treatment was rather limited. I had done full-time work in the field for more than a year in Baltimore with opiates. While I was in Billings I had been one of the attending physicians at the alcohol detox program. (In Billings, subzero temperatures are the rule during the winter months. One cannot discharge an inebriated patient to the street in severe weather. Therefore, Billings had developed a model alcohol detox program that guaranteed anyone a bed for the night. The sleeping space was monitored by RNs and a physician arrived in the morning to re-examine the patients to minimize the risk that there were medical problems other than alcohol intoxication that contributed to the clinical picture.)
After listening to Dr. B for an hour I went back to work and he disappeared. Since I was alone, I was responsible for all the admissions, discharges, and rounds. It was very busy but doable if I could just keep plugging away at the workload.
The nursing change of shift occurred at around 3:30 P.M. and I was still very busy. The charge nurse identified a problem that she believed I needed to address promptly. I thought it was less urgent than some of what I was doing and I promised to get to it as soon as I could. She bugged me about it again and I firmly put her off again. Shortly after 5 P.M. a medical student approached me with the nurse's request--again!
Rather than just ignoring the nurse's behavior, I took it personally and read her the riot act. I'm sure my face was flushed and my voice was up and I expressed particular displeasure in her manipulation of the medical student.
Gradually my anger passed and I got back to work and walked out of the ward at about 8 P.M. instead of the more usual 5 P.M.
The following week, I was called into the office of the training director, Dr. Morrison. She wanted to know the circumstances behind my outburst. She knew that I had been seeing a local therapist and that I was taking an antidepressant. She asked me an open-ended question. "What's it like working at the Mental Health Center?"
"Generally it is okay during the day. Being on call is very difficult. I feel like I am in a 50 foot hole trying to shovel it out. Over top of me are a series of sewer pipes, each one leading from an Albuquerque hospital. At night the pipes open and it gets flooded in the hole."
"Is there anything positive about working working there?"
"Where else could I learn to create multiple personality disorder?"
This incident contributed to my reputation as a somewhat "prickly" individual.
This was reinforced a few months later when I was on call for the V.A. hospital one evening. I was paged and told that there was a young airman who needed to be involuntarily committed to the V.A. hospital for a mood disorder. I drove out to the V.A. hospital and met the young man and proceeded to do a psychiatric evaluation. The airman was irritable but not disrespectful. He was not suicidal and denied any intent to harm others. He was not gravely disabled. In short, there were no findings to suggest that he met criteria for involuntary commitment.
We began a discussion. The airman told me that his superiors were trying to create "a mental health jacket" so that it would be easier to transfer him on. He pointed out to me that if I committed him to the hospital, I would be violating his rights. He asked me not to do so.
As I thought about it, I had to agree that I didn't have a basis for committing him. As a licensed physician, I was responsible for my own medical decisions. I could not avoid responsibility by claiming that I had been ordered to do something by military authorities. I told the patient that I would have to discuss the case with superiors and that it was unlikely that I would be the physician with the final word on his situation.
I left the airman and called the faculty member responsible for the V.A. for that month and told him that I had examined the patient but could find no rationale for a commitment. The faculty member told me that the commanding officer for the base and hospital had ordered the airman committed-- and I was urged to admit the patient. I told the faculty member that it was my medical license and my judgment and that I could not oblige. I offered to remain at the hospital until some higher authority arrived to relieve me and take responsibility for the patient. I was told to go home.
The reaction among the young residents was interesting. They generally believed that it had been my duty to obey the order and saw my resistance as arrogance.
Kathryn
The case of Kathryn was one of the most blatant that I witnessed. She was a patient of Dr. B. She had a confrontation with a police officer in the parking lot of supermarket. The officer reached into her driver side window to grab her keys. As he did so, Kathryn sped away with the police officer trapped in the window for several feet. She left the parking lot and headed for the Mental Health Center with the police in pursuit.
By coincidence, Dr. B was outside the entrance to the mental health center. Dr. B, Kathryn, and the police all arrived at the same spot at about the same time. Immediately Dr. B began to address "Kathryn" as "Jane," supposedly the "bad-ass" alter and made a commitment to an immediate hospitalization for Kathryn that allowed her to avoid immediate responsibility for her actions with the police. To me it looked like Dr. B showing off to the police and choosing to be an idiot.
Teaching and Peter Thompson, M.D.
I believe that the quality of teaching in New Mexico was very good. The weakness was a lack of overall structure--we were thrown onto the DSM-III and DSM-IV, laundry lists of diagnoses and criteria. One of the rotations was the outpatient clinic at the Mental Health Center. At about 3:30 or 4:00 PM one or more faculty members would come to the clinic and begin to review the cases for the day. Whenever I was available at that time, I attended those sessions and learned a lot.
One of the teachers whom I totally misread was Peter Thompson, M.D. He arrived in Albuquerque at about the same time as I did. There appeared to be a touch of arrogance (and I'm sure that would fit me as well.) A few months later, I was assigned to the outpatient mental health service, where Dr. Thompson was in charge.
It was during this time that I had become interested in John Money's idea of lovemaps (discussed in at least one previous post). A lovemap is a guide to an individual's personal preferences with respect to sexuality and sexual expression. The fact that lovemaps were dynamic was especially stimulating. After all, at age 6 my blonde friend, Nora, was "hot." At age 51, such thoughts of "hot" would be suspicious for pedophilia. So, how did this evolution of lovemaps occur?
One morning I was scheduled to see a young gay female who had been taking prozac for relief of depression and anxiety. She was having some problems with hair loss, probably due to the prozac. The scheduled visit was for medication evaluation and renewal. It was not for psychotherapy. However, I believed that I had established a good rapport with the patient and I decided to talk about "lovemaps." I explained that in my own life, I was aware that changes had occurred from the age of 6. I inquired about the patient's experiences. From the expression on the patient's face, I knew immediately that I had made a mistake. The right thing to have done at that point was to immediately grab my supervisor to try to right the ship. Instead, I just clammed up and wrote the prescription for prozac.
A few weeks later, I received a copy of a letter that the patient had written to the Department of Psychiatry. She apparently believed that I was confiding to her that I was a pedophile and related her recollections of our prior meeting.
Naturally I was mortified. I went to see Peter Thompson. He was wonderful.
"Eric. Everyone in psychiatry has a letter like this in their file. It happens to everyone. It is one of the principle reasons that you go through training programs."
A year later, I managed to get small monograph published, The Difficult Patient. Peter Thompson was the only faculty member who congratulated me on the accomplishment.
The Wonders of New Mexico
I loved my time in New Mexico--the scenery, the history, the culture, and the food--particularly the food. One can go to any little town in New Mexico and eat like a king. The New Mexico question is "Red or Green?" This refers to your preference to green chile or red chile.
Hatch, New Mexico is the chili capital of the world.
http://en.wikipedia.org/wiki/Hatch,_New_Mexico
In the autumn, thousands head out from Santa Fe and Albuquerque to Hatch to gather their chilis for the year, bushels of green chilis of different heats. There is a method for measuring the heat of various types of peppers.
http://en.wikipedia.org/wiki/Scoville_scale
In the autumn, large chili roasters can be found in the parking lots of many supermarkets in Albuquerque. The smells are wonderful. The roasted product is taken home, peeled, and frozen in order to provide the next year's supply of the base material for so many New Mexico dishes.
Used Cars
One of the pleasures of New Mexico was used car hunting. When I first moved to New Mexico, the independent Volvo mechanic called over his two employees to show them what happened to automobiles on the east coast. The rust was amazing to them. The dry climate of New Mexico preserved the past. Along Coors Boulevard on the West side of the Rio Grande there were a couple of areas where cars were parked with "For Sale" signs. I was an enthusiastic follower of this market. During my time there I bought a 1978 4 cylinder Toyota truck for Brian and a 1980 Celica Supra for Keith. I traded one Volvo to my mechanic for work done on the other car and purchased a used Acura Legend with 150,000 miles for about $3000 that I drove for three years. I still miss looking at the used cars.
The Next Step
As the second year of my psychiatry residency wound down, I had to begin to think about my own plans after residency. Much as I liked New Mexico, it would be a hard place to make a living. Almost all psychiatrists ended up in the larger cities, Albuquerque, Santa Fe, and Las Cruces. Salaries were low and there were service taxes for those attempting to work on a fee-for-service basis.
At the time that I had begun looking for a residency, I had thought to return to the Eastern Shore of Maryland and to join the group that included the psychiatrists that I had worked with in the prison.
However, while a resident in New Mexico, I had the opportunity to observe psychiatrists interacting with patients who were felons or standing trial. It appeared that the physicians accepted many statements at face value with very little work exerted to expose weaknesses in the stories. Having spent years dealing with inmate medical complaints in prison, I knew that was terribly naive.
One of my psychotherapy supervisors, John Lauriello, M.D. suggested that I consider "forensic psychiatry" as a career. Forensic psychiatry is the intersection between psychiatry and the legal system and issues such child welfare, competency to stand trial, not guilty by reason of insanity, capacity to handle one's affairs, etc. John told me that Atascadero State Hospital inc California paid a very good salary for those who decided to spend a year training there in Forensics.
When I went to the California map to find Atascadero, California, I was suprised to find that it was within about 15 miles of San Luis Obispo. Curiously, I had spent time there on New Years Day 1995. While living in New Mexico, I decided to spend Christmas 1994 in San Francisco. I got a good price on a great hotel for a week and headed that way. Unfortunately, I had recently traded in my Prozac for Venlafaxine, a relatively new antidepressant.  Venlafaxine made me predictably sick each afternoon, but I had no idea of the cause. I had a great hotel room but I was not feeling well-enough to enjoy the wonderful food of China Town in San Francisco.
A couple of days prior to New Years, I started back to New Mexico. The first leg was down the coast through Monterrey and Big Sur. The tight turns in the road made my sickness worse and I checked into a motel at San Simeon in mid afternoon. It was a very mild day with a slight breeze. I'll never forget the sensuous delight of a gentle breeze through my motel room that evening. A couple of days later, I was sitting in an outdoor cafe in warm sunlight in the middle of San Luis Obispo and I was taken by the charm of this mission town.
Atascadero was only a few minutes from San Luis Obispo and only 17 miles from the ocean at Morro Bay. Beginning in the summer of 1996, I started to make arrangements to move further west to Atascadero.