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Mary’s first baseball game at Turner Field. Braves vs Reds - we lost in overtime.

Meet Theresa, one of Grady’s 5+ unbelievably high tech computer programs that store patient data. MS-DOS lives eternally at Grady.

I finished off intern year with a bang – ten overnight shifts in the PES, or Psychiatric Emergency Services at Grady. Ironically (or appropriately?), the PES resides on the 13th floor of Grady, separated from the main emergency room by a loooong elevator ride. In practice, the main ER feels even further away, especially in the middle of the night. The PES consists of two main areas: the triage area, or waiting room, and Temporary Observation. Patients are seen first by security, who comb through their belongings, and then they walk through a metal detector. They are registered by the triage staff before being seen by the triage nurse. The triage nurse (usually) records their vital signs, asks for their medications, assesses the appropriateness of their chief complaint, and instructs them to sit down on one of the smelly vinyl chairs in the waiting room. Thereafter, patients are seen by a MHA, or Mental Health Associate. The MHA’s invite the patient into an interview room, complete with a (hopefully) functional panic button. They collect a battery of information on the patient, from their demographics, medical and psychiatric history, and HPI, or History of Present Illness. The MHA’s then find a physician and present the information they have collected; we in turn interview the patient and determine a diagnosis and treatment plan.

There is a more direct route through this system. If a patient is acutely psychotic, agitated, suicidal, homicidal, et cetera, they will often get a direct ticket to “Temp Obs” or “the Back,” our colloquial terms for the Temporary Observation unit. These patients are taken immediately to a single windowless room, approximately 30 by 50 feet, I would guess, staffed by a nurse and a couple of MHA’s behind a desk. In this confined space, as many as 30 people have been kept, sleeping on chairs. In addition to the one large space, there are two seclusion rooms, a couple of bathrooms, and one room with two stretchers, where patients can stretch their legs in rotation. A security guard monitors the situation most of the time from a small attached room with a window overlooking the environs. It is in this room that the dilapidated state of Georgia (and America’s) mental health system is most poignantly visible. The room was initially intended for 5 to 10 patients to spend a few hours while transportation arrived to take them to a state or private hospital. However, since I’ve been at Grady, patients spend as many as 150 or more hours in this confined space, awaiting a bed. State hospitals have been closing and the number of uninsured patients growing, leaving the patients to fill Temp Obs.

The conditions in Temp Obs are at best, intolerable. Patients will be wailing from a seclusion room, being tackled by a multiple security guards and given a forced injection of medication, defecating on the floor. They sleep in chairs for several nights in a row. It is difficult for me to imagine spending an hour as a patient in there, much less a week. Certainly it is not a therapeutic environment.

Patient’s presentations run the gamut in the PES. For many, we serve as their primary care center. They will come monthly to get a prescription for their psychotropic medications, and we will do our best to address their hypertension, diabetes, and back pain and make appropriate referrals to other clinics where they may or may not follow up.  These cases are presented as “med refills” but are rarely a simple visit for a prescription. Other patients come in for referrals to substance abuse programs or come because their substances abuse program or shelter wanted them to be evaluated by a psychiatrist.

Recently, we see more patients who are suffering from depressive symptoms resulting from their social and economic circumstances. People come in tears, explaining how they have lost their jobs, their cars, their houses. They may be newly homeless, or have spent their savings to survive. Their relationships with partners and children often suffer, as does their view of themselves. In the face of these overwhelming life circumstances, my response is one of helplessness. A diagnosis of depression means little in this situation and an antidepressant a near-placebo for their suffering.

The “fun” psychotic patients are perhaps the most memorable. I wrote a post documenting some of my favorite psychosis patients before realizing (after an email conversation with Emory’s legal department) that it would be violating their privacy for me to post it. The delusions I witnessed and heard about were horrific, beautiful, intriguing, imprisoning and nearly any other descriptor you can think of. Some were so grandiose that I hated to take them away; others so painful that I wished I could will them to sanity.

On my first round of night shifts, I was tormented by the suicidal, drug abusing, malingerers. Night after night, patients would tell me that they wanted to kill themselves, kill someone else, and they often threatened that if I didn’t hospitalize them or “put them in the back” they would follow through on their threats, but not until after they had written their suicide note citing my name.

The craziness and inhumanity of the PES was a huge shock to all of my co-interns. We held meetings to brainstorm what we could do to help. We even thought of holding a bake sale outside Grady to raise money for a renovation of Temp Obs! I think it haunts most of us, but at the same time I feel somewhat powerless against forces I don’t yet fully understand related to state and federal government, resource allocation, and probably stigma around mental health as well. There is so much more I want to say about this….

From the City of Atlanta Jail:

“Suspect advised that when he saw the officer chasing after him he got scared and defecated in his pants. Nurse at City Jail advised he needs psych treatment.”

Wanted to post some photos of Mary’s new haircut, just in time for the beginnings of hot Atlanta summers…

Before (left) and after (right) photos:

We returned Wednesday from a three day mini-vacation to Charleston, a beautiful old city that felt European at times, with pointed church towers seen as you drive into the city; an attractive suspension bridge, modest by Danish standards, but impressive nonetheless; and cobble-laden roads lined with colorful row houses. I was deeply envious of the houses and gardens along King Street, albeit wary of the many good ol’ boys with Southern drawls, not to mention the…ahem…lack of ethnic diversity.

There is something about these old Southern graveyards that I find, well, morbidly charming.

I was eager to buy a sweetgrass basket but putoff by the sticker shock.

We stayed on the beach (Isle of Palms); here’s some sunset photos:

I’ve been finally taking some of my vacation time the last few weeks, first to make a trip back to Texas to visit my parents. In addition, my cousin Niels, his wife, Alice, and their 14 month old son, Christian, were in Texas visiting as well (from Denmark) - I last saw them in May of 2008, during my last trip to Denmark (posted here). My maternal instincts are evident in the photos I took over that weekend; there is not a single photo of anyone besides Christian! Here are just a few of my favorites.

A follow-up from my March 29th post:

It would seem that I have a black thumb.

To commemorate ten years together, Ken and I decided to acquire a new piece of art. We found our new piece at Outsider Insider Art in Atlanta:

We named him Dix in honor of the event. He was created by Debra Ryan, a self-taught artist who makes these “spirit dolls” entirely from hand. Initially I found the dolls haunting, but with time a sweetness in their face becomes more evident.

Or so it seemed, before it got cold and started raining late last week….

These pics are from last weekend, when Mary “helped” me plant some flowers on the balcony. She promises not to eat them.