Photo courtesy of NAMI
(6-9-21) This is the second installment of a three part series about Patty as told by Los Angeles’ Skid Row doctor Susan Partovi. You can read part one here. As with all guest blogs, the opinions are that of the writer.
Marinating
By Susan Partovi, M.D.
I wasn’t going to give up on Patty.
I began putting her in motels paid for by Homeless Health Care LA while waiting for her to get into interim housing. She stayed in one for a month but eventually was kicked out due to damaging the TV and having “inconsiderate” friends.
She tracked me down and I put her back at the original hotel where I’d housed her. I didn’t give her any antipsychotics this time, due to me being too tired and thinking if she wasn’t using, maybe she wouldn’t act out. Five days later I received a call from the manager saying she was “crazy,” but he didn’t speak English very well, and I didn’t take the time to try to understand what he was saying.
The next day he called me again, saying she had to leave. I said that I would get her in the morning. When I arrived, her door was open, her bed and bed frame were on their side, there was trash everywhere, the TV was shattered, the pictures were off the wall and destroyed; it was a disaster zone!
Patty’s Gravely Disabled: Where Will She Go?
“Dr. Partovi, this place is filthy; there’s feces inside the walls; there are sensors and cameras detecting my every move; they’re raping me, “ Patty said, while crying hysterically. I started to clean up the motel room, mostly just because I didn’t know what else to do. The manager complained that he hadn’t slept in 2 nights because Patty had been pacing non-stop around the motel and bothering the other residents.
I knew that if I took her back to skid row in her condition, she would get beaten up. She had proven that she could not provide (nor sustain) shelter, one of the criteria for California’s legal definition of “Grave Disability.” We are allowed to hospitalize someone against their will if they are a danger to self, danger to others, or gravely disabled. Grave Disability is defined in California as “one with a mental disorder who is unable to take care of oneself in that they are incapable of providing oneself with food, clothing OR shelter.”
Today, after working on the streets of LA County for 17 years, I have learned how difficult it is to hospitalize someone against their will…even if they do meet criteria. Mostly, because there are few available housing to place people for long term psychiatric care, because neither Medicaid nor Medicare cover the cost. There is no funding to care for our brothers and sisters suffering from chronic severe mental illness. And so, they stay in the streets suffering from their demons, vulnerable to potential violence, further psychiatric decay and disease, often in and out of jail.
“Patty,” I said, “Look, you’re having a bad day, a hard time. Let’s go to the hospital so we can talk to someone.”
“I’m not going to the hospital,” she announced between yelling at people who were only in her mind.
“Patty, this is your choice: you either come with me to the hospital or I call the police.”
“I’m not going to the hospital!” She was getting angrier.
I called 911.
Why did I call the police? I could have called the Psychiatric Mobile Response Team (PMRT), which is a division of LA County’s Department of Mental Health. But my experiences with them was that a team could take hours to respond. I didn’t have that much time. The team also often didn’t agree with my definition of what constituted grave disability. That’s why I called the cops. Patty was escalating and, quite frankly, I didn’t know what else to do during what clearly was a psychotic break.
The dispatcher must have asked me five times if Patti had had a weapon,
“No!” I kept answering. In about 15 minutes, LAPD officers arrived and calmly walked over to speak to Patty, approaching her cautiously.
The Police Arrive – Who Else Could I Have Called?
“You’re not in trouble; we just want to talk to you and check in with you,” an officer said.
Patty actually began to calm down. She started telling the officer about the feces in the walls, being raped, demons, etc., while the other officer spoke to me. I tried to explain “the story” and why I thought Patty was Gravely Disabled and potentially a danger to herself because of how pugnacious she was and how she could easily provoke someone into harming her.
This officer listened politely to what I had to say and was very sympathetic. I knew that the officer would call the Mental Evaluation Unit, the highly trained officers who make decisions about who can be placed on a 72 hour hold. I also knew based on previous encounters, that they wouldn’t think she met criteria. I thanked the officers for being so kind and caring with Patty. They actually had helped calm her down. Most of the police I have met in working with the homeless and mentally ill are exceptionally skilled and truly are caring, but they are not mental health care experts.
I continued to clean and put her things in my car. I apologized multiple times to the manager and asked Patty if she would come with me to speak to a doctor. As I drove out of the parking lot, instead of turning right towards skid row, I turned left where I drove her to Harbor-UCLA’s hospital Emergency Room, where they have a Psychiatric Emergency Department and Inpatient Hospital. I put my county badge on because I thought it might help when I tried to get her admitted. It was so obvious that Patty was out of control. She was demonstrating potential harm to herself and she was Gravely Disabled but there was a high chance the hospital would turn us away.
I told the ER Nurse Practitioner “the story.”
“Patty has to get tested for COVID first before we see her,” she announced.
COVID: I held her down
Ok, first hurdle, I thought. A very tall nurse named Mike met with us next. I told him “the story,” hoping to get as many allies on my side as possible. Patty started dancing and laughing. She was not making much sense. Mike told Patty that he was going to check her for COVID.
“No!”
We tried telling her that she could swab her own nose or let me do it. Patty was like a toddler, so eventually I held her down and Mike quickly swabbed her nose. I was not letting a friggin Q-tip keep Patty from getting the care she needed. We waited three hours for the results. For two of those hours, she was yelling and screaming at people who weren’t real. She would sob uncontrollably. I asked Mike if an ER doc could give her something to calm her down. I again told “the story” to the ER resident who appeared sympathetic. She was very kind and understanding.
“Patty, do you want to take something to help relax you?” I asked.
“No, I have to keep my wits about me,” she retorted. But then she said, “Well, I’m willing to take the medicine you normally give me.” Knowing they wouldn’t have that particular medicine in the ER, I quickly replied: “How about something similar?”
“Ok.” It took Mike twenty minutes to fetch the medication and within a half hour, Patty had calmed down and was curled up on the bed sleeping soundly.
The Covid test came back negative.
Will Patty Be Admitted? I Almost Started To Cry.
A different nurse came to interview me. I told Patty’s story with more emphasis, knowing that I had to convince this psych nurse that Patty required a bed. The nurse listened without interruptions and seemed caring. She disappeared back into the Psych ER and after a long period, returned with a Psychiatry Resident. I knew this resident would be deciding Patty’s fate and I was ready to give it my all. I had practiced what I needed to say many times. I told him “the story.” I explained how I’d spent 17 years working with people experiencing homelessness and mental health issues. I told him how I have been studying the California Laws on what qualifies for “a hold.” I told him how Patty was clearly a harm to self and was Gravely Disabled because of….
“Oh yeah,” he said, cutting me short. “We’re putting her on a hold. She is definitely Gravely Disabled.” I almost started to cry. He had agreed to admit her. I gave a brief sigh, knowing there would be more hurdles ahead, but at least we had time for her to calm down while I started looking for a place for Patty to go afterwards.
I emailed La Tina Jackson, head of the Full Service Program (FSP) at LA County’s Dept of Mental Health (DMH) and with her help, I reached Victoria, the Director at Portals, a DMH agency in downtown. I spoke with Victoria on Friday at 5 pm and she said that she would work on finding a place for Patty. One of her workers called me on Saturday asking for “the story,” which I gave her. The plan was to interview Patty on Monday to enroll her into the program.
The only trick now was getting Patty to agree to participate in the county’s treatment program. Just to make certain that Patti wasn’t discharged before we had everything in order, I contacted the Chair of the Psychiatry Department at the hospital. He happened to be an old colleague of mine and I told him “the story.” He assured me that Patty would not be released until she was stable and had a discharge plan. I told him how grateful I was for how Patty and I had been treated at the hospital.
When Monday rolled around, a different Psych ER resident called me. I told her “the story,” she listened and agreed that Patty needed to remain at the hospital until suitable housing was arranged. Again, I was almost in tears because someone actually understood the repercussions of having someone who can’t take care of themself be released back to the streets.
Looking for a safe place.
“I’m putting her on a two week hold,” the Psych resident told me. Finally, I had some peace of mind. I made a few more calls on Patty’s behalf to help secure a safe place for her to live.
The next day, I received a call from the Inpatient Psych resident at the hospital asking me for “the story.” I repeated it and after hearing it, he said, “Yeah, we’re going to let her marinate here for a while.”
What a great metaphor, I thought. People experiencing acute psychosis might calm down in 72 hours (the first “hold”) but really, their brain needs more time to stabilize. Two weeks is a good start, but many need months to stabilize. It doesn’t mean they have to be in a locked facility for that long, but definitely need major support.
Patty called me from the hospital a week later. She was cheerful and asked me for her daughter’s phone number. She grumbled that the hospital wouldn’t let her smoke, asked me to bring snacks because she was “not getting enough to eat,” and said that she had been thinking about how it might be better if she began getting the injectable long acting shot each month. She wanted to be discharged but understood that we needed to find her someplace safe for her to go from the hospital.
“We want to keep you safe,” I told her and she thanked me.
Families left in the dark most times.
Working to stabilize Patty gave me a glimpse into what it must be like for a family member or other loved one trying to navigate the system and help someone in psychosis who needs both acute and long-term care. What made Patty’s story different was that everyone was willing to communicate with me, I suspect, because I am a doctor. I knew that family members often are left in the dark regarding a treatment plan and patients are also often discharged without family member’s being notified.
Based on what I was experiencing with Patty, I came up with a list of seven observations:
Having a loved one being part of the care plan is important. I knew Patty’s background, what she had been through, and other key parts of the puzzle and thus was able to paint the complete picture when I met with those whose resources Patty needed. California privacy laws do not prohibit family member involvement (unless implicitly stated by the patient) but those laws do leave the final say to the mental health provider. Unfortunately, this leads to family members rarely being contacted. They don’t have an opportunity to tell the complete “story” or to be part of the care conversation. That’s wrong. Families are key for a successful treatment plan and outcome.
Secondly, every provider I came in contact with was extremely empathetic to Patty’s case and thus used common sense (which is actually supported by the law) to do what was best for this person’s chance to live a healthy life.
Thirdly, the doctors followed the law. They heard her case and saw that she met criteria even if there is a shortage of long-term care facilities.
Fourthly, police, though can be very caring and can help with potentially violent people suffering from psychosis, are not the best choice. A mental health expert needs to come in a timely manner and assess and help with the situation.
Five: We need a funding stream for long term psychiatric care for better stabilization. If I was someone who was hit by a car and suffered a spinal cord injury, Medicaid would pay for the hospitalization AND the months of rehabilitation needed post hospitalization. Why don’t they pay for psychiatric “rehabilitation?” This seems discriminatory to me. Furthermore, we need to beef up our Board and Care facilities. So many have shut down due to not being paid adequately for their residents’ care.
Six: Drug users often have severe mental disturbances. It doesn’t matter which came first. The mental disturbance needs to be addressed first. Then the drug issue can be addressed adequately.
Seven: We need to address drug use adequately.
All this takes time, energy, collaboration and cooperation, but it is how we can start making a dent in the homeless numbers in L.A. County and in the U.S.
Patty is discharged – what’s next?
Patty stayed in the hospital for ten days until she was discharged. She was sent to a hotel through Project Room Key in Century City on a Tuesday. She left the hotel Wednesday after breakfast before the Full Service Program worker arrived to check on her. She also missed her hotel curfew at 7 pm. The next day, she came to see me and asked me to place her in a different hotel.
I told her that she needed to return to the hotel and give it a few days. I also tried to convince her to take the long acting injectable medication – reminding her that at one point she thought it was a good idea. I also called the hotel to ensure that her room hadn’t been given to someone else and she could come back. Next, I called the Full Service Program worker assigned to her case. While I was making these calls, Patty announced that she wasn’t psychotic. She said, “I just had emotional issues. I think the demons have brought you onto their side.” She walked out.
I let out a sigh and second guessed myself. What if I’d found her a board and care facility where she could have had more support than being discharged directly to a hotel? I had spent enough time with her, to recognize that she didn’t have any insight into her condition making it difficult for her to adhere to treatment. What if she’d been discharged to a longer term facility that she wouldn’t have been able to leave so easily? Perhaps some kind of step down facility that would keep an eye on her, engage her in activities, allow her to smoke and eat what she wanted, connect her to her family, address her drug use and keep her safe?
Was that too much to ask?
To be honest, I’m not sure if this type of high-level community care facility actually exists. Who would pay for this? Each time I tried to help Patty, I became more frustrated. No one ever asks who pays for her when she goes to jail or gets hospitalized over and over again. I knew that she was costing the county much more than if she’d gotten stable and was able to control the symptoms of her mental illness and beat her drug addiction. I was getting angry too. Civil libertarians insist that Patty has the right to refuse treatment, even if she doesn’t quite understand that the refusal results in constant suffering from her demons, increased risk of dying and incarceration.
Yeah, I thought, that’s the more humane thing to do.
Where was Patty now? And how was I going to get her off the streets and stabilize her?
(Friday: Part Three of the series about Patty.)
About the Author: Susan Partovi, MD, is Medical Director for Homeless Health Care LA. She completed her undergraduate work in psychobiology at UCLA and earned her medical degree from Thomas Jefferson Medical School in Philadelphia, PA. During her undergrad years she spent her Saturdays working with a Physician’s Assistant attending to squatters living on a dump site in Tijuana Mexico. She completed her residency in Family Medicine at the County Hospital, Harbor-UCLA Medical Center in Los Angeles where she focused on working with the uninsured and the poor. She spent six years on its faculty before moving to a community clinic where she was introduced to Homeless Medicine. That led to her working almost exclusively with the homeless, creating street medicine programs throughout L.A. In 2004 she started working for Homeless Health Care Los Angeles beginning a “career” in wound care and working with homeless heroin users of skid row. She soon became Homeless Health Care Los Angeles’ Medical Director and continues to be part of their innovative creations in best caring for the homeless…especially the mentally ill and drug users.
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