Monday, January 31, 2005

Ethereal Day

Yesterday, two friends and I made a transcendent climb up Mt. Monroe to the ceiling of New England. The route begins near Crawford Notch, often a vortex of bad weather but mercifully mild yesterday (15-ish). In high spirits we tromped through mystic woods draped in snow shrouds and hemmed by coal-black waters bubbling round white-ice swirls in the small Ammonoosuc River. A mile in the trail grew suddenly steeper as we headed into the Ammonoosuc Ravine. Up, up, the snowy staircase, kicking steps in with our boots, watching the valley below grow smaller. At a frozen stream crossing a spectacular wall of ice appeared above, glowing iridescent pale turquoise. To me it looked like a solid wall of microcline, my favorite mineral. Staring at it brought on a sense of rapture and I found it hard to tear away.

Climbing further the trees gradually shrank to knee-high krumholtz, the views opened on three sides; the headwall of the ravine loomed in front and above. Mount Washington, just to the left, played in and out of its own personal cloud, which wisped around the summit in a stiff western breeze. From here on, New England seemed to recede away. The open expanses, the snowfields, the rock, the ice, the twice-normal-sized sky— none of it fits with what we experience down below. Thoughts wander to days in Wyoming, or Alaska, or pages from guidebooks of never-visited Patagonia. The mind, usually entrenched in daily boundaries, suddenly bulges to expand in every direction at once.

As ice replaced snow we put on crampons and removed ice axes from the packs. Navigating ice with crampons feels foreign at first, and as magical as walking on water. You almost can’t believe you’re getting away with it. Then, a sense of liberation rises up, as you strike off across the otherwise-impassable terrain. Even more so than in summer, winter above treeline presents a sense of boundlessness.

We stopped in the lee of the boarded-up Lakes of the Clouds hut to have lunch. I found I’d left my sandwich on the kitchen counter—classic winter mountaineering error. But I had a big bag of cashews, and a thermos of hot tea with maple syrup. Friends shared their cookies. The wind was more pressing here, and the chill began to creep into us, so we started moving again towards the summit of Monroe. Oddly, as we approached the top, the ice thinned, until at last there was none. Despite several feet of snow lower down, the summit looked little different from its summer appearance. We each ate a York Peppermint Patty to get that sensation of a cool mountain breeze. It was cold, but the sun had come out in blazing beauty, and the sky was a deepening azure. We descended as we had come, but twice as fast, chit-chatting, happy, and very alive. A day like this, every day, I believe would preserve us all sane forever. This peak marked my 37th in pursuit of climbing all 48 four-thousand foot peaks in New Hampshire in the winter.

Today, a bit giddy from the mountains, I returned to the hospital to find the usual morass of problems—patients who quit their medications, patients assaulting each other, staff out on leave due to mental strain. I wish I could take them all up above treeline with me. I think it would help. But I’m not sure any would want to go. There are no smoke breaks there.

Thursday, January 27, 2005

Shrinks and lawyers, Part II

Yesterday a distraught man named Juan Manuel Alvarez planned to kill himself by parking his SUV in front of a commuter train in L.A. At the last moment, he changed his mind and abandoned the vehicle on the tracks. The train hit his truck, derailed, and smashed into an oncoming train. 11 people died. Mr. Alvarez was arrested at the scene, and has been charged with murder, carrying the possibility of a death sentence.

Strange thing #1: Had Mr. Alvarez met me before this all happened, he likely would have wound up in a psychiatric hospital. We would have expended enormous resources and (likely) taxpayer money in an effort to reduce his suicidality and keep him alive. If, as his psychiatrist, I failed to keep him alive, there would be inquiries and investigations.

Instead, however, the L.A. County D.A.’s office will now expend enormous resources and taxpayer money to convict Mr. Alvarez, and possibly execute him. If they succeed in executing him, they may be praised for their hard work and skillful prosecution.

Strange thing #2: What does it mean that someone wants to die in his SUV?

Wednesday, January 26, 2005

One more oxymoron?

Judge recently heard to refer to a patient's self-injury as a "Well-reasoned suicide attempt."

Us vs. Them

Every Wednesday morning is Court Day here at the hospital. A judge from the District Court comes across the river, presides over our in-hospital courtroom, and hears the cases of patients who want to leave the hospital before our team feels they’re safe to go. I avoid keeping people here involuntarily whenever possible, and only go to court seeking commitment when the case appears convincing. For that reason, we usually “win” the hearings—which has led patients to refer to the process as “kangaroo court”. They feel the outcome is pre-ordained.

By the nature of the selection, most of the folks who wind up in court are significantly out of touch with reality. Many misinterpret the court proceeding and feel that they are on trial for some crime. The problem is furthered by the adversarial nature of the hearing. Although we have a relatively low-key courtroom (the judge, for example, does not wear robes), it is divided in two like a regular court—with the hospital staff and attorney on one side (like prosecutors) and patient and attorney on the other (like a defendant). During the hearing, “our” attorney will ask questions of me designed to show that the patient has a mental illness, and that the hospital is providing necessary, appropriate treatment. This usually involves detailed description of the patient’s poor ability to care for himself, or threatening behaviors, or poor judgment, or other aspects of severe illness. In most cases, the patient disagrees with virtually every word of my testimony (also known as “lies” or “perjury”) and becomes visibly angry while I speak. It is extremely hard to sit and listen to someone who appears to be listing off all your character flaws. It also isn’t pleasant to be the person doing the listing.

Later, the patient’s attorney will ask me questions designed to cast doubt on my professional abilities, grasp of the facts, and treatment decisions. The patient often sees this dressing-down as just revenge for my previous lies. The lawyer becomes the patient’s champion, protecting him against the Bad Doctor. One patient got so excited that he jumped up and down and applauded as his (particularly ferocious) lawyer needled away at me.

Finally, the judge will decide either to release the patient, or allow the hospital to continue an involuntary commitment. In the latter case, a huge problem follows: the patient is furious for days. Rarely does the patient see the judge’s opinion as one worth considering— rather, he may see it as further evidence that people are indeed out to get him, and that the system is rotten to the core. One patient recently declared that the judge was actually family member in disguise, trying to put her away to get her money.

Most distressing to me, however, is the damage done to the doctor/patient relationship by the adversarial legal process. Usually, I’ve just spent weeks trying to gain the trust and cooperation of a suspicious, angry, or withdrawn person. Now, in their minds, I’ve “turned against them”, embarrassed them in public, and lied for the purpose of incarcerating them. They’re mad as hell. It may take days or weeks for the person to begin to work with me again towards discharge. Sometimes, the damage to our relationship is permanent.

I’ve spent hours, late at night, mulling this problem, trying to find ways around it. In court, I now go out of my way to emphasize (to the extent that I can do so truthfully) each patient’s positive attributes—intelligence, wit, humor, artistic skill, bodily strength, whatever I can find. I try to prepare patients before court, warning them that they may not like what I say, that my concerns don’t mean I dislike them as people, asking for their forgiveness ahead of time. I try to meet with people right after court to undertake damage control. But none of this is highly effective. Are there other strategies? The suggestion box is open.

Friday, January 14, 2005

Need Not Apply

At a staff meeting a year or two back, a hospital administrator passed around a new policy barring the hire of psychiatrists who had not been seeing patients within the past 12 months. Several of us thought this was a foolish policy, primarily because at the time (and before that time, and since that time) we’ve had unfillable vacancies on our medical staff. In short, it was delusional to think we could be choosy. Any shrink with a pulse and a legitimate or well-forged diploma should have been (and should still be) hired immediately.

But beyond that practical aspect, some of us had other objections to the policy. Our one female psychiatrist (since illegitimately fired, worsening our staff shortage) questioned why we would refuse to hire a doctor if he/she had taken a year off from practicing to raise a child. Another colleague asked if he’d be barred from returning to work if he got cancer and was ill for a year. Or if he had a research fellowship.

The administrator stammered, explaining that such was not the intent of the policy. “The point,” he said, “is that we don’t want people who have been sitting around on the beach sipping margaritas for the past year.” This phrase became locally famous and oft-repeated. Whenever the shrinking business got too stressful, which was just about every day, we’d say “Well, maybe it’s time for me to go sip margaritas on the beach.” If someone was heading for vacation, we’d joke that he’d not be welcome back if he went anywhere near a beach or a margarita.

Thinking more about it, though, a person who spent the last year SMOTHB may be the ideal candidate for this job. The burn-out rate is high-- at three years, five months and 14 days, for example, I have the longest tenure of the current medical staff. Perhaps a year spent doing something completely different would give one a running head start? When I interview people for a job here (not that any have come by lately), I’ll look to see whether they’ve ever explored something different, expanded their sense of possibilities, and relaxed their brain ligaments. The last thing you want is a shrink stuck in a routine and about to crack from the tedium.

Vaguely related Question of the Day: Which of these is closer to “reality”, and why?

1) Driving to work, getting coffee, working, driving home, going to the supermarket, paying bills, going to a movie, going to bed.
2) Standing naked on an island in the rain with a piece of plastic tarp and wondering what’s going to happen next.

Wednesday, January 12, 2005

Unequivocal oxymorons

In my few years in this business (not the blog business-- I mean my job that pays my VW repair bills so I can get to my job that pays my VW repair bills) I have discovered that virtually everyone is ambivalent, all the time. People think they know what they want. Often they'll march right into the office and tell me. Usually, however, they're wrong. They want something else, but don't feel permitted to say so. Or can't express it. Or aren't even aware of it.

In our society, it borders on sinful to lack brightly-lit awareness of one's wants and goals. How often have you heard "He has no idea what he wants" used as a compliment? We're all struggling (admit it) to keep up the cosmetic front of consistency that belies the shifting sands of our opinions and desires.

I've been thinking, lately, that oxymorons are the societally acceptable expression of our innate amphibological state. Everyone knows oxymorons make either no sense, or less sense than a more precise phrase. Nonetheless, we seem to tolerate them in the language. People point them to each other, not in the way you'd correct someone's spelling, but more as a form of amusement. No one likes to let a good oxymoron slip by uncelebrated. Perhaps they let us, just for a moment, relax into the soothing mire of our own sticky contradictions.

Just a few that I've heard lately...

"In the event of a water landing..." (aboard flight to NYC)

"It turned up missing..." (A favorite expression in these parts-- this morning, regarding a patient's missing pack of cigarettes)

"Rudy Maxa, our travel writer in residence..." (on NPR this morning)

Thursday, January 06, 2005

Experiment in Frugalitation

Every year, one of my friends half-starves himself for a week just before Christmas. As a protest against the dietary excesses of the "holiday season", he eats nothing but rice, cous-cous, and fruit juice for seven straight days. I joined him in this pursuit twice. Neither of us has much extra weight to burn, and we both work in hospitals-- where the nursing staff tends to flood the break rooms with cookies, cake, and candy around Christmas. These two facts added to the challenge for us. What I learned from this experiment:

1) The process was not as easy as it sounds. My hand reaches for cookies without my brain's permission. More than once, the cookie was in my mouth before I remembered I wasn't supposed to eat it. Constant discipline was necessary to avoid eating items not made of rice or cous-cous.

2) I eat as much for entertainment as for nutrition. It was a boring week, eating the same bland thing over and over. Each "meal" (loosely defined) became a challenge to get calories into my body before my brain, exhausted from the tedium, revolted and "closed the hanger door" prematurely. By the end, I could see how spices were worth fighting wars over (not lately-- I mean back in the Dark Ages and all.)

3) Being short on calories led first to grouchy irritability. Next, around day three, came unpleasant dizziness and fatigue, which interfered somewhat with my work as a shrink. I hoped that my friend, a surgeon, was not having similar symptoms. Finally, though, came a real sense of lightness and liberation. By the end of the week, a bowl of rice looked almost as good as a brownie sundae. Almost.

4) I really missed beer and coffee. A lot. And pizza.

I have no wish to repeat this experiment again. But I'm thinking of a different one: trying a week of eating on some fixed, minimal amount of money. The idea is not to eat less, nor to live ascetically-- rather, to see just how delicious (and nutritious) a week can be coaxed out of, say, $25.

The Rules as I envision them:

a) Must be a self-contained experiment (no using leftovers, no sneaking pinches from the spice rack, no free eats at friends' houses, etc.)
b) Must pay for everything straight up. No pro-rating one cup of flour out of a five-pound bag or one squirt of ketchup out of that big bottle.

Obviously, I won't be eating organic kiwis for breakfast. But with some creativity, perhaps they won't be missed. Anyone want to join in this venture and compare notes?