Life, Death, Madness

Confronting the raw reality of the emergency department

Gary Weinstein
Magazine Issue
July/August 2008
Life, Death, Madness

My pager is a tiny sound-knife, slicing into my sleep. I sit upright, disoriented. What? What! It’s Sunday, 2:30 a.m., and I’m the clinical social worker on call for our upstate New York public hospital. “They need you,” says Liz, the overnight Emergency Department clerk. “There’s a trauma and a lot of family. They need social work.”

I dress in the dark and jump into my car. The streets are empty, abandoned by a sleeping world. Traffic lights blaze for no one; the street lamps are strung like jewels. As I pull into the ED parking lot, I see a mass of police cars, Emergency Medical Transport vans, and flashing lights. An African American family mills around the entrance, while perhaps a dozen others—friends, other relatives—pace frantically nearby. I’m waved through the door by security and walk quickly to the trauma room, where I see 20-some medical staff intently pumping, infusing, and cutting. Bloodied clothes and sneakers litter the floor.

As I step back out, the charge nurse, Bette, greets me. “What do we have?” I ask.

“We need you with the people out front,” says Bette. “No one’s been able to talk with family yet. We need the patient’s parents, a wife, or a significant other inside. Nobody else—no young children, no friends. Can you sort that out and accompany them in?”

There’d been a picnic. A hot summer day and a neighborhood dispute had turned to shooting. A young man named Cyrus Johnson had been shot point-blank in the chest. Now half the neighborhood is here, pacing, cursing, nearly frantic.

I feel wide awake, pumped up. I prize this feeling—a razor-sharp sense of purpose, laced with something like fear—in the moment I confront a new situation, a new family. I came to this regional public hospital four years ago, assigned first to the inpatient psychiatry unit and then to the Emergency Department, where I now work. One of 30 social workers among 6,000 hospital employees, I’m called on in the midst of emotional crisis, when family or patient turmoil becomes too intense for medical staff to handle. It’s psychotherapy in the moment, with people I don’t know and may never see again—people facing some of the most terrible moments of their lives.

I’m not new to crisis work. Before coming to the hospital, I spent nine years counseling county prison inmates, men who regularly dissolved into rage or tears, threatened suicide, or vowed to kill someone. Earlier, I directed a Salvation Army shelter for teen runaways who required 24-hour care. And now, at 3 a.m. on a Sunday morning, I’m standing beneath blazing fluorescent lights in a hospital hallway and readying myself to meet a distraught family. I feel in my bones that this is vital work; I want to do the best I can for the people I’m about to meet.

At the same time, I want to flee. I want to burrow back into bed and escape all this tumult and pain, this unrelenting test of my ability to be of any use. I’ve been doing crisis work, in one form or another, for nearly 30 years. I’ve confronted a number of forks in my professional road, opportunities to take a less demanding route. But I’ve chosen to continue on this path, accompanying others who’ve been suddenly, often brutally, cast out of life’s safety zones. The reasons I stay aren’t simple, and they continue to shift and surprise me.

“This Isn’t Happening!”

As I step outside the ED entrance and greet the murmuring crowd of relatives and friends, all eyes fasten on me. Seconds slow and divide. I know that the next words I speak will turn their world.

“I’m social work,” I say, using the hospital vernacular. “Cyrus is still with us. I just saw the doctors working on him. They’re giving it everything they have.”

I hear a collective exhalation of breath. He’s alive.

“Does Cyrus have parents here? A partner? The doctors would like them to come inside.” I pause. “I’m sorry. This must be awful for all of you.”

A girlfriend and an ex-wife emerge from the night crowd, hand in hand. They point beneath a street light across the lot to Cyrus’s mother, Claudia. She’s pacing, alone, her voice piercing the night. “It didn’t have to happen! You save my boy! I told the cops to watch them people! How many times I call them?”

A cousin and grandmother approach, arm in arm, looking beleaguered. “Please, sir,” says the grandmother gravely. “We have to be with Cyrus. We need to pray over him.”

“I’m so sorry, ma’am. I can’t let you in.” I’m a bouncer, a traffic cop of grief and shock. In self-defense, I feel myself turning to stone.

Three young children hover nearby with an aunt, their eyes wide and worried. “These are his children,” says the aunt, as if by virtue of their innocence and pending grief, Cyrus will be spared. Look, he has these sweet souls to care for. Please don’t let him die.

Then Cyrus’s parents appear, and I usher them, the girlfriend, and the ex-wife inside and into the ED’s designated family room. After settling them in, I step out briefly to check on the patient.

I poke my head through the curtain of the trauma room to see white coats completely circling Cyrus. I can see only his uncovered feet. One resident I know turns, catches my eye, and gives me the subtle frown and headshake I recognize immediately: things are dire.

Returning to the family room, I hear anger, raised voices.

“There’s gotta be some payback!” cries Rhonda, Cyrus’s ex-wife.

“Don’t you talk that way, Rhonda! You honor Cyrus and hold your tongue,” warns his father, Fred.

“And let the shooters walk away?” counters Keisha, the girlfriend. “We can’t do that!”

“Folks,” I say. I wait for them to calm down. “I just looked in. They’re still working hard in there.” I realize I’m dispensing happy talk, something vaguely positive but fundamentally evasive. I’m offering hope even though I have little, or perhaps none. Is this wrong? What on earth should I say?

They’re nearly silent now. Fred sits hunched over, his head in his hands. Claudia stomps her feet and mutters. The two younger women sit shoulder to shoulder, arm in arm, rocking. Just then, two physicians appear at the threshold. Dr. Roonig, a trauma specialist, motions to me. “We’re ready to tell them,” she whispers. I lead them into the family room and make swift introductions.

“He’s gone. I’m sorry,” she says. Her voice is neutral, factual. Everyone gasps. Keisha collapses to the floor, while Rhonda clings to her on the way down. Fred is bent over, his shoulders heaving. “Not my boy!” Claudia howls, her voice hoarse with rage and pain. “Oh, mighty Lord, no!”

Keisha’s mouth is agape. “He’s gone? No, you didn’t say that!” she pleads. “I’m carrying his baby!”

In the coming year, I’ll get to know this face, the stunned human face in acute grief, eyes searching for solace, pleading for a second chance. In this moment of catastrophic knowledge, time seems to stand still. The hospital continues its madly swirling pace: tech staff roll equipment by, phones ring, visitors stroll past. But for us in this room, time has stopped.

After a few minutes, the physicians exit. I want to leave with them. I feel a hot, prickly anxiety. Now it’s just me. What can I, or anyone, say when faced with people who’ve lost all hope?

I remind myself that this family doesn’t need any words from me, at least not right now. I breathe deeply and sit quietly with Cyrus’s family as they cry, shake, and try once again to seek refuge in disbelief. “This isn’t happening! He was doin’ so good!” I stay with my breath, listening, meeting their eyes. Finally, Keisha looks up at me. “Now what do we do?”

But my pager is vibrating. The ED needs me to help place a psychiatry patient. Quickly, I gauge how much more time I can spend here without letting the psychiatry patient wait too long. I ask what might be of help right now. A clergyperson? Glasses of water? A phone? “I’ll bring you to Cyrus soon,” I tell them. “I’ll help you through this in the coming hours.” Then I excuse myself, promising to return quickly. It’s nearly 4 a.m. I walk down the hall to meet my next patient.

Talking in Code

Dorothy is sequestered in a locked, barren ED room, on watch. She’s a slight woman in her mid-fifties, her salt-and-pepper hair disheveled and her jeans street-dirty. They’ve taken her shoes; in her stocking feet, she paces rhythmically.

As I introduce myself, she spews a cascade of non sequiturs, accusations, and suspicions, interlaced with demands for water, another blanket, to go home, to call her lawyer. She’s been here before. She knows the drill.

“You know why I’m here, don’t you? Tell them—you’re the robot!” she scowls at me. Actually, I do know Dorothy from numerous previous psychiatric admits. And I wager she does recognize me through her harrowing and debilitating psychosis. “You never liked me, I know,” she growls. “You and the rest. When the washer is broken, the parts are sent here!” She thrusts a pointed finger at the floor. “You know what I mean, don’t pretend!”

Psychiatry staff will confirm that Dorothy needs inpatient care, but what I can’t bear to tell her is that our psychiatric unit is full. We may have to transfer her to another hospital, perhaps more than 50 miles from here. Worse, she may be transported by police, subjecting her to more stress. Our community still sometimes treats the mentally ill as inherently dangerous, or as potentially criminal. I object to this largely unfounded assumption and will try my best to avoid this fate for Dorothy.

I spare her the details. She’s confused and afraid enough. As it happens, a bed will open upstairs on our psychiatry unit later in the day. Meanwhile, I try to reassure her, using her own language, trying to match her code. “Dorothy, yes, we’ll fix things for you. Whatever’s broken, we’ll fix it. I’ll find someone who likes you. We won’t pretend.”

I excuse myself and walk quickly back down the hall to the family room, where Cyrus’s people still sit, weeping. I spend the rest of the night with them.

Listening to Chopin

My encounter with Dorothy brought back intense memories. When I’d first come to the hospital, four years ago, I’d been assigned to the psychiatry unit. Having spent the previous decade in prison social work, I’d celebrated the move to a hospital setting. I’d no longer be the lone clinical practitioner in the brutal, hardened world of incarceration; instead, I’d be part of a bright, nimble medical team, working with diverse families and helping shape transformative hospital care for the mentally ill.

A neighbor of mine—a psychotherapist well acquainted with the hospital—joked that I must be a masochist to jump from a prison yard to a psych unit. Her comment still burns. I can’t help but wonder what continues to draw me to these extremes of psychotherapy.

I do have a sense of what led me to the work. Growing up in middle-class New Jersey, I felt loved and cared for, but carefully protected from major upsets. My gentle parents edited out the raw footage of life; I have no memory of seeing a dying person, or real rage, or raw grief. I was kept safe but spared the experience of being fully alive.

Consciously or unconsciously, crisis social work has delivered me to the walled-off side of life—to the heart of human suffering. When I step into the hospital in the middle of the night, it’s as though curtains are drawn back: the actual curtain to the treatment room and the figurative curtain hiding the wounded world from me. I’m a first responder. I feel myself waking up, growing up.

It’s tough work. The river of grief, rage, and fear of those I work with runs so deep and wide that I sometimes can’t imagine how I can help them navigate it. The stakes are high; what if I blow it with this desperately fragile individual? Unlike office-based therapy, I may not see this person next week, or ever, to follow up. But if I’m honest, I’d say that the hardest thing about my work is what I’m forced to see each time I accompany my clients in their devastation. A part of me doesn’t want to know that life can get this bad. My illusions of life’s safety are smashed, daily.

When I try to fathom what keeps me here, I sometimes think of Dominick. Not long after starting work on the psychiatry unit, I heard someone playing Chopin in the music room. Pausing at the door, I saw a large bear of a man sitting at the piano. His eyes were closed as he ran his hands lightly over the keyboard.

At age 50, Dom lived with his aging mother and had bounced in and out of group homes for 20 years. Years back, with his schizophrenia in remission, he’d developed crippling obsessive-compulsive disorder. He rarely dared to leave the house for fear he’d lose hours obsessively picking up bits of trash in neighbors’ yards, risking trespass and scorn. His tormenting compulsion had recently flared up, and his mother had brought him in for inpatient treatment.

During my stint in the psych unit, I heard that Chopin piece often. The fractured etude floated through the hall to remind us—and perhaps Dominick himself—that he was more than his illness. He played, I imagined, to remember his life intact, a youth full of music lessons, school, and friends; a life on track until illness derailed him.

Dom and I would stroll the halls, speaking of local neighborhoods we both knew, his pleasure in music, and his struggle to get through each day. He was achingly polite, thanking me after each encounter, shaking my hand and apologizing for his perceived intrusion. At the same time, he seemed to hunger for conversation, for simple connection. He was one of my favorite patients. I was drawn to his honesty and gentleness, and nourished by the knowledge that a companionable walk up and down the hall might make his day.

My Patients, Myself

But those moments with Dom were reprieves from the disorder and distress that saturated the psych unit. Brad, a young man with flaming red hair, tattoos, and body piercings, stalked the halls in a palpable rage. One day, he tore 40 felt hammers out of the piano. I arrived the next morning to see them collected in a plastic bag. I felt sick.

Seth, clearly psychotic, also roamed the halls. Boundlessly needy, he knocked at my door 15 to 20 times a day before being accompanied away by nursing staff. Once, early on, when I allowed him in, he ended up on the floor under my desk. He crawled about, slithered up into my chair, and began to sift through my drawers.

I wasn’t prepared for this level of personal invasion. The madness and threat I’d known in my prison work had been contained by steel doors, concrete walls, and vigilant guards. My office had been a separate haven. On the psychiatry floor, my office was simply one among numerous patients’ rooms. When I wasn’t intervening with them, I was fielding directives from insurance companies, physicians, nurses, administrators, and case managers, and family members. Family members were often the toughest lobbyists, each a relentless advocate for his or her particular vision of a relative.

“Release my wife!” “Keep my sister in!”

“Someone has to find my brother housing!” “Hold him until his Medicaid comes through; he’s still suicidal!”

“She still hears voices!” “She’s just manipulating.”

Several months into the work, something crumbled inside me. I was swept by waves of anxiety, accompanied by depression and terrible insomnia. It was as though my patients’ anguish and neediness had poured into me; irrationally, I began to fear that mental illness was contagious. I felt fragile and wracked. I wished I’d never taken the job.

My wife, Trina, listened to my despair through long, troubled nights. A close friend, Robin, told me of his bouts with psychotic depression during an especially difficult job transition. Several coworkers revealed vulnerabilities, and even breakdowns, that they’d endured and survived. I was astonished and comforted by the willingness of so many people to be with me in my pain, and to share their own. As winter yielded to spring, the days lengthened; I got my hands in the dirt and gardened. I began to feel better. The air and sun helped, but I knew I couldn’t have survived that dark season without the presence and caring of others.

Afterward, I thought seriously about leaving the job. If there’d ever been a time to switch gears and seek easier, calmer work, this was it. But once I’d regained my balance, I found myself feeling new compassion for the patients sitting across from me. How thin is the membrane between adept functioning and crippling dysfunction! The psych unit is widely seen as an alien place, the butt of degrading jokes about odd and unknowable “others.” Yet, some years back, one of my closest friends had been hospitalized here. Several acquaintances were admitted during my two-plus years on the unit. Hospital staff and their relatives, university professors and students, community leaders—all took up residence on this hall while I was on staff. How tenuous the line we draw between our patients and us! Today I sit here in a tie and badge. Tomorrow I may wear a gown and a bracelet.

Someone to Accompany Me

So I stayed. In time, I was reassigned from Psychiatry to the hospital’s Emergency Department, a different kind of encounter with wounded people. Here in the ED, homeless men must have their sneakers cut from their feet in the dead of winter: I sit with them in their befuddlement and their odor, searching for words that will allow them to trust me enough to speak. Here, a young mother and father arrive with their infant found white and lifeless in her crib: SIDS has taken their 5-month-old, and for the next seven hours, I’m one of several staff who accompanies them in their grief. Here, a beloved great-grandmother who’s fallen while shopping is brought to us with a life-threatening head injury: three generations of family are present, sobbing and in shock. Here, I sit through the night with Cyrus’s family.

I thought, at first, that ED work might be beyond me. Trauma and death pass through these doors in the most urgent crises imaginable, short of war or natural disaster. But almost from the start, I found myself immersed, able to forget myself and my small anxieties in the much larger human enterprise. Trauma response seemed to bring out the best in me.

Something has shifted in me, too. My own crisis of spirit has yanked back another curtain for me—the curtain that separates human beings from each other. I know, now, that we’re really all in this together. The ED is a nexus, a portal from a predictable life to sudden, random catastrophe. It could be any one of us. And in that moment of facing the abyss, who doesn’t yearn for someone to accompany them, a simple human presence to sit beside us and be unafraid of our pain? My real work, I think, is to be worthy of that wish.

Psychotherapy of the Moment

The unmistakable stillness of the deceased fills a room. It commands the attention of the living. Twenty minutes from going home, after sitting with Cyrus’s people in the ED and confirming a room on the psychiatry unit for Dorothy, I’m asked to assist Elizabeth, whose 83-year-old mother has just died. She sits alone at her mother’s bedside, her red hair descending in a braid down her back, her freckled face flushed and wet with tears. She’s bitterly angry with her brother. “Damn him! “Mr. Special’ asks me if I want him to come back to the hospital now, since he was already here once today!”

I sit down next to her. “His mother is dead and he won’t even come back!” she continues, sobbing. “It’s typical. I do everything alone!”

Her mother is cadaverous. Her dentures have been removed, leaving her mouth collapsed, agape. Her scalp is hairless and her face is without eyebrows, making her appear genderless, universally human, and dead. I take long, contemplative looks at her as Elizabeth speaks.

Her rage alternates with tears and relief, and then, a moment of quiet pride. “My mom was the last of eleven brothers and sisters,” she tells me. “I’ve buried most of them. I think they’d be happy with how I’ve done by them. They were farmers; we go way back.” She’s silent for a moment, then murmurs, shakily, “It’s really the end of an era.” Six months or a year from now, Elizabeth may sit with a psychotherapist to uncoil her grief and rage. But I’m here, now, at this very moment of loss. I feel privileged to be with her.

After a while, Elizabeth begins to speak of her mother’s final months, how she was paralyzed below the neck following a fall, unable to feed herself or even sense her own body. “It’s best she’s gone,” she says, calmer now. As we quietly inhabit the room, the three of us, a thought arises: This will be me some day, sitting with my deceased parents. Will I be alone, or will someone be here with me?

Soon, this body will be wheeled to the morgue. Elizabeth will drive home into the night. Someone in the ICU will take a final breath. The Emergency Department—that ever-lit, fluorescent planet that knows no clock—will accept two more motor-vehicle accidents, a teenage shooting victim, and a suicide attempt. Cyrus’s family will have found their way home through the dawn and begun to make funeral arrangements.

On the psychiatry unit, Dominick will sit in his room, anxiously awaiting his mother’s next visit. Nearby, Dorothy will sit cross-legged on the hallway floor with a cup of cold coffee, deriding staff and mocking her long-deceased husband. Two new patients—a manic, disorganized young woman from a local college and a psychotically depressed, 40-year-old man who’s convinced the world is scheduled to end on Friday—will be admitted to the unit.

This much I know: the world won’t end on Friday. But today has. I walk out of the hospital and into the night, a world brimming with people just one breath removed from emergency.


Gary Weinstein, L.C.S.W., has practiced social work for 30 years in Syracuse, New York. He last wrote for the magazine on his work with prisoners in the March/April 2003 issue.