Natividad Medical Center
Salinas, California
July, 1978
I attended UCLA Medical School from 1974-1978. I started with an attitude that I could be a student forever; I ended acknowledging that it was time to move on—but move on to what exactly.? I found something to enjoy in virtually all of my clinical rotations but the least-liked was psychology. I had more than one attending physician in the various other specialties roll their eyes when I suggested I would match with a Family Practice residency. Their concern was that I couldn’t make a decision but in truth, I wanted to do it all. There is irony in that by choosing Family Practice, I would find “psychology” as one of the three most important specialty skills I would need for my career. Natividad Medical Center in Salinas, California is where I matched. What follows reflect my first clinical experiences there.
Monterey County is not a heavily populated county, but the mechanism of its county bureaucracy rivaled that of much larger counties. I was one of six new residents starting at Natividad Medical Center as new county employees and I was fourth in that group alphabetically. Using a formula doling out assignments for the next three years, with no exceptions, the cogs churned out the following: we were on call every sixth night, filling in for a designated partner every third when needed. My alphabetical location in the six new residents paired me with the first, who turned out to be the weakest of our group—he was out after just one year. It also meant my first night of call would be on July 4th—on which day, four days into residency, I would not have a normal staff to back me up and I would be the lead doctor taking admissions to the hospital and managing any problems on each floor—-and that would be for two years in a row, given it was a leap year. Lastly, it assigned me to Psychiatry for my first clinical rotation. I wanted the familiarity of the internal medical floors, the promise of learning technical skills on the surgery floor, or delivering babies; I was assigned to the only “lock-up” unit for mentally ill people in the county.
This lock-up unit found me unprepared, having received only out-patient psychiatric training at UCLA. This was no modern facility; the core building of Natividad looked and felt like something from the early days of FDR’s administration. In fact, it had been a Tuberculosis Sanitarium prior to becoming the county hospital, and because of that, every patient, regardless of admitting diagnosis, received a Chest X ray during the intake process of admission.
The lock-up unit was on the top (third) floor and once in, having passed a very secure metal door, there were two corridors, linoleum floors, no art on the walls, a lounge with a TV where group meetings were held, a few offices, and a not so “padded room” which had a metal bed with arm and leg restraints. The color scheme was khaki-mustard.
On the wall, there was a touch activated heating element for lighting cigarettes protected by a metal grid; only cigarettes could fit between the metal bars to reach the lighter. There was always a crowd of patients circling this wall ornament. Smoke fill the ward routinely.
I learned of my first patient at morning rounds. “Crazy dude was scaring people downtown and the police brought him here. He was thought to be a danger to himself so he is in on a 72 hour hold.”
I asked if he had a medical problems and the response was casual: “He creeped me out and could not give me much information but I don’t think so. There were no calls about his labs.”
I reported to the floor; the lead physician (Taylor) and I were talking about the staffing and patients to be evaluated when the phone rang. He put it on speaker and the radiologist asked us to come down and see the Chest Xray of my patient. The radiologist squinted at the name on the Xray, “Well, as you can see, Ken has a problem.” I looked at the film and could indeed see the problem: a sprinkling a white dots across both lungs which should have been mostly dark. My psychiatric attending asked, “OK, Randy, so what are the most likely causes for a 20 year old to have metastatic cancer spread to the lungs?” He sensed that I was not ready with the answer and let me know which is pretty astounding given my experience with psychiatrists at UCLA. “This boy, Ken, is going to have a testicular cancer.”
We went back up to the third floor, got access to the lockup unit and we introduced ourselves to Ken who made an impression: Ken was six two and weighed maybe 135 pounds. He had a shock of Christopher Wolken hair and icy blue eyes that looked right through you. His very clingy T-shirt had the sleeves cut off. Borrowing from A Clockwork Orange, he had used scissors to cut away the fabric over each breast as well.
I looked in Ken’s chart: no genital exam had been done when he was admitted. Looking at him again, I thought, “No shit!” This guy scared me and the, “routine” thorough physical exam on admission took a hit that night. I considered the likelihood we would have discovered the diagnosis without the unusual requirement for the Xray, regardless of medical status. In the light of day, we asked him to drop his trousers and he did so with no resistance whatsoever. He indeed had a large fixed mass on his left testicle. Taylor, was a good teacher in this unit—he “walked the talk”. Despite Ken’s psychological impairment, Taylor addressed him by name and very clearly and succinctly laid out the problem we had encountered and what next steps we would take to help him. Ken’s response was inscrutable—and then he asked if he could smoke on the ward.
Smoking: Yes! In 1974, psychiatric patients could smoke in the public places in the unit with staff present. Most the staff smoked. Staff meetings sometimes held eight people in a 12x12 room with the door closed so as to allow open and frank case discussions. It took just a few such meetings for me to capitulate and smoke with them; the smell was easier to tolerate if I joined in.
Ken had his smoke and we worked a referral. His appointment for intake and a treatment plan would take a couple weeks. In that time-frame, Ken got taken down by a fellow patient—a young man had been admitted with a PCP psychosis. This was not unusual in 1978; he had been stabilized medically and was in on a 72 hour hold that was extended when he did not clear. On his first day on the unit, the magical attraction of psychosis allowed the two of them to go nose-to-nose, posturing and activating the other patients who like teenagers after school, circled round to see what would happen next. Ken leered and moved aggressively but made the mistake of actually touching Mr. PCP who struck him a glancing blow to the head. Ken was down like a ton of bricks and stayed down.
A day later, they were inseparable, friends for life.
Late in July, I covered the unit for a weekend (which was unusual; Taylor had to be out of town and there was no back-up psychiatrist to cover any emergencies). I dutifully did rounds which were mostly to check in with the nursing staff to make sure there were no medical issues with existing patients or meet and evaluate any new admissions. I wanted to be thorough. The chart reviews and quick check on people revealed no problems. I was getting away with murder—this was too easy. Ken and Mr. PCP casually asked if they could speak with me in private. I learned a good lesson that day; my “social” self disregarded my place and purpose. I walked into their now shared room and Mr. PCP closed the door behind him.
“Doc!” Ken announced. “You have got to let us out today on a pass. The army is having a regional boxing match and we want in.” I smiled knowingly and took the bait.
“Well guys, a regional Army boxing match would be for Army guys. Neither of you is in the Army. Why do you think you would get in? And do you want to box or just watch the matches?”
“Doc! The matches are down at Camp Roberts and I know we can get in and yes, we want to box!” They stood shoulder to shoulder— between the door out of the room, and me. They were not threatening in any obvious manner. They seemed guileless, and totally focussed on this delusion but implacable and not moving until they had the answer they desired. Our conversation went in circles and I began to get annoyed, which is to say a little anxious.
This casual setting and the circular discussion did give me time to think, and I thought of a distraction, identifying the bruise Ken had on his temple and asked him to come over to the window so I could look at his wound from their meeting. No longer side-by-side, I was able to “lay hands” on the wound and make an exit.
Ken was transferred after an evaluation in Monterey by an oncologist and reported to the Community Hospital of Monterey County for treatment.
My wife Kernie was an oncology nurse; I had uprooted her from a solid hospital day-shift on a medical/oncology floor at Cedars Sinai Hospital to Monterey County. Channeling Beverly Hills and Cedars, she found a job at CHOMP: the Community Hospital of Monterey Peninsula. This remains a beautiful community hospital set in a forest near Carmel, California. The indoor lobby sported a pond with with coy. The nursing staff were issued cards with which they could charge the gourmet meals prepared in the hospital ( and which would be deducted from their paychecks). Deer grazed just outside the floor-to-ceiling windows of patient rooms on the ground floor. Kernie worked the oncology floor.
She came home noting, “I had the most interesting experience with a most interesting boy today. I was helping with chemo and this very weird guy looked at my name badge and asked, ‘Moeller; are you any relation to Dr. Moeller in Salinas?’” She paused, “I put two and two together and realized this was your crazy patient who got in the fight on the ward.” Kernie reminded me of something I had learned from the famous Dr. Gorney of UCLA: “If you think someone has a mental problem, but you are not sure what kind, if they make the hair go up on the back of your neck when you interact with them, they are probably schizophrenic.” Ken had made Kernie’ s hair stand up.
Ken also, in a rage, trashed the Infusion room at the hospital. I got the word that Ken was transferred to Napa, one of only six State managed institutions for the insane. By now, I had moved on to a radiology rotation and Ken was just an interesting memory. I dwelled a bit on the implications of a schizophrenic not being able to cooperate with chemotherapy for a cancer. Did that assure them of non-treatment and a death sentence? Testicular cancer statistically is one of the more treatable cancers, so just how hard was the state or any advocate for Ken going to push for further cancer treatment? Did being twenty years old make a difference? How important did that seem to me? It was interesting stuff but not my problem and I was more than busy enough worrying about my day-to-day in the hospital.
Late winter, Kernie came home one evening, having taken the long way: through Castroville and the artichoke fields. She looked flustered. She settled in and told me the ongoing story of Ken. She had been writing nursing notes on the evening shift and the hair on the back of her neck sat up. She looked up and there, staring through her was Ken. She greeted him and had a short discussion before contacting security. He told her Napa was a drag and he had walked out! “How did you get here?” She asked.
“I hitch-hiked.” Ken still had his Christopher Wolken hair, gaunt appearance, and thousand yard stare. It is a credit to Christian charity or the the foolishness of Californians that Ken got the rides needed to hitch-hike the 155 miles from Napa to Monterey.
Ken had no plan; CHOMP is a pleasant place and he somehow knew that something important was there for him and so he came. Neither of us ever heard of him again.
I was not done with the lock-up unit, however. All of us residents felt about the lock-up unit as we thought of the dialysis unit: it was a place where our skills were deficient and the specialty work on the unit had to take care of itself. There were exceptions, however. People could suffer heart attacks and strokes in dialysis, and a “code blue” would be announced over the PA system with a location identified. We were obliged to help in those situations. People did not suffer heart attacks in the lock-up unit; they suffered from a loss of control. When this happened, a “Mr. Man” was proclaimed over the hospital loudspeakers. This unit had attendants that were chosen in part for both their stature and their demeanor. They were not people anyone, “in their right mind,” would tangle with. But the point was, this was the place where that equation broke down. I learned after my initial first-year eagerness to carry on with my work elsewhere when the “Mr. Man” was proclaimed. If the call went out a second time, I would call to be sure all was well in hand. I never expected to attend the take down of a wildly psychotic patient.
As the first and second year passed, I recognized a pattern in my own behavior. Around March, I wold become curt, unsettled, and business-like. I was angry. Despite knowing my function and that time management on a given floor depended on a good working relationship with nurses, come March and April, I would question, argue, piss, and moan through every phone call from a nurse, lab technician, or Emergency Doctor asking for my opinion. I had slammed the phone down one evening after a terse exchange, and a “Mr. Man” was called. I broke routine; I wanted to be there. I walked briskly up the flight of stairs and pushed the buzzer to be let in. The action was in the, “not so padded” room. The other patients were mostly sequestered in their rooms or the TV room and a few nurses were outside the door. I went in and saw that two of the attendants, each weighing in at two hundred and fifty pounds this evening were with back to the walls, opposite each other. In the middle of the room, standing on an iron bed and bedspring, totally naked, was a wild eyed man, weighing perhaps 160 pounds, swinging a broad leather belt with a large silver buckle on the end around his head, lasso style. He had long fly-away hair and bulging eyes staring with a Cheshire Cat smile on his face. I took charge. “On three,” I said, perhaps a little fast, “Onetwothree,” and went for it. I was tackling the quarterback in the fourth quarter, the one who had decimated our defense. I timed the tackle to avoid the belt buckle and before I knew it, I had brought him down—directly on top of me. The attendants were dumbstruck but picked up the slack. No one was hurt. They gave me funny looks. This was NOT in my job description but I had clearly welcomed the challenge.
Just as you fight nausea, in my case, desperately, when you do finally vomit, you are usually, much better for having done it. So it was here. I felt a release in that tackle that is embarrassing. Why did it make me feel better? To this day that experience finds me with some sympathy for those who act out in frustration and do foolish things.
Not always. Not usually. And the more foolish, the less forgiving I am, but to be sure, I have been there and was better for it.
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