The Imposter (9 page)

"Five
step what?" Alex asked.

Donna
explained, "Well, it's really not five steps anymore, not since the length
of stay decreased to three to four days, sometimes even less.   It is a system
of patient responsibility level used as a gauge to grant individual patient
privileges.  As patients improve, they're given more responsibility and
freedom.  On level I, patients are restricted to the floor.  On level V, they
may leave the floor unescorted and take unaccompanied trips off hospital
grounds."

Alex's
legal mind was racing.  Her thoughts scared her.  She interrupted Donna. 
"Are you suggesting that we could have possibly sanctioned an activity
where one of the psychotic patients could have left the hospital last night and
attacked Angie, with CCMC's blessing?" Her eyes were wide with worry.

Dr. 
Desmonde intervened.  "No, we haven't had a patient on level V for several
years, mainly because insurance won't pay.  They figure if the patient can be
off hospital grounds, he can be out of the hospital.  Most of our patients
reach level III, meaning that they can leave the unit in a group, escorted by a
staff member.  They go to the coffee shop for meals, the gift shop, and so on. 
Right, Donna?"

Donna
looked pleased.   "Good, Monique.  Very good.  You are the first attending
shrink that ever understood the system! I'm proud of you." Donna grinned
at Dr.  Desmonde.

Alex
smiled as the nurse and physician high-fived each other.

"I
don't know if admissions will ever return to the pre-HMO days when a psychiatric
admission actually changed behavior.   According to news reports, mental health
services are supposed to get better under the new health care system. 
Supposedly, 32 million additional mentally ill people will receive psych
benefits and the benefits of the 30 million Americans who already have them
will improve.  I just don't see how that is going to happen, but it surely
sounds good," Monique added.  "Of course, I am totally clueless on
how we are going to care for them.   We have no space for more admissions now
and I am pretty sure we have more than our fair share in Louisiana," she
added.

"Yes,"
Alex agreed.  "It sounds good in theory, but it's all determined on how
states interpret the "rules" set forth by the President.   Some
states could make as many as 500 drugs available for the mentally ill, while
other states may only allow access to 250 drugs.   Benefits will occur on a
state by state basis.  The same will be true for inpatient care for the acutely
mentally ill and for substance abuse treatment.   Some states may allow longer
acute care stays or better rehab programs than others.   It remains to be seen
how all of that will settle out, particularly in Louisiana."

Monique
looked at Alex and repeated, "Yes, particularly in Louisiana.   I think we
already know and shouldn't look for much to improve.   There will be no silver
linings for us," she added regretfully.   "We'll just have many, many
more patients with no place to put them.   I am not looking for any great fixes
to occur in the next few years."

"Anyway,"
Donna continued, "getting back to your question about patients leaving the
unit, each staff member is allowed to take five patients off the unit at one
time.  And, believe me, the patients raise hell if they've earned level III and
they don't get to go.  It goes back to basic trust in the building of the
therapeutic environment.  If our psych techs are out with patients, it's hard
for the few who are left caring for the others to monitor everything else. 
There are just not enough of us.  We usually do monitor the seclusion, suicide,
and quiet rooms, though.  We’re pretty good at that, unless there's an patient
or staff emergency on the floor!" Donna looked a little sheepish.

"I'm
happy to hear that," Alex said wryly to Donna.  "I'll do my best to
get you some more help."

Donna
smiled, looked grateful, and said, "Alex, I don't mean to kick a gift
horse in the mouth or anything, but Sarah Chassion, the nurse manager who heads
the prison unit, is in worse shape than I am.  Her patient population is much
worse and more violent.  Many of them have medical needs also.  Lots are
HIV-positive and/ or recovering dopers.  That's not even mentioning the serial
killers, rapists, and murderers they care for over there.   As a matter of
fact, Sarah swears there is a dope line coming into the prison unit.  She has
the same staffing ratios I do, and although my job is hard, hers is even
worse."  Donna looked at her watch.  "I gotta go.  It's almost 5
o'clock and the daycare gets ugly when you're late picking up your kids. 
Thanks for your time."  Donna waved at them on her way out.

Monique
turned to Alex.  "I've got to go also.  Rose is waiting for me in my
office.  Do you have time to catch a bite to eat with me in the cafeteria
around 6 o'clock? I'd like to talk about things."

Alex
nodded.   "Sure.   By the way, Don refused to meet with us today.  Big
surprise, huh! He says he has little authority on psych because of the contract
management."

"Yeah,
gee, what a surprise," Monique agreed sarcastically.

"Sure,
I'll meet you.  Is it okay with you if I review some of the charts up here? I'd
like to know a little about the patients."

Monique
smiled at her and laughed,  "Alex, you know darn well you don't need my
authority to review charts.  Help yourself.  But, thanks for asking! See you at
6 o'clock!" Monique flashed her a smile as she dashed off.

"Pick
me up in the nurse's station," Alex said, watching the elegant Monique
Desmonde rush off.  She again found herself admiring the psychiatrist and her
commitment to the deranged and mentally ill
.  It's a heck of a job,
Alex
thought to herself.
  I'd never do it.

There
was no one that Alex recognized on the evening shift.  She introduced herself
to the RN in charge who was supervising level II patients in the day room.  The
nurse identified herself as Joanne Waters, an agency nurse, who was helping
out.   Joanne laughingly asked Alex to fill her in on the patients after her
review of the patient charts.  She admitted she hadn't had a chance to look at
any of them.  Joanne also reported that one psych tech had taken five patients
to dinner in the hospital cafeteria and that the other tech was making rounds. 
Further questioning by Alex confirmed that Joanne had never worked psych at
CCMC.  Joanne also admitted she knew little about psychiatric nursing and was
pretty scared to be up there after what had happened "last night."

Alex
shook her head as she entered the nurse's station, taking several records with
her into the staff lounge.  She hated temporary agency help.   Why not pay
their own nurses more and not spend $150 an hour for temporary nurses.  
This
type of care is unsafe,
she thought to herself. 
This place is a
catastrophe waiting to happen. 
At least Favre could hire agency nurses
with a background in psychiatric nursing! Of course, as Alex remembered, Favre
was a believer in the warm body theory.   As Favre saw it, if you had a warm
body and a nursing license, you could practice anywhere in the hospital.  Alex
continued to reflect on the unsafe, risky environment in the Pavilion,
imagining how catastrophic things could become.  Her imagination in no way
prepared her for the reality that was to set in a few short hours later. 
Psychiatric services at Crescent City were explosive, to say the very least.

Alex
had reviewed about three charts and was looking at Jim McMurdie's chart when a
voice behind her asked coldly, "Who, may I ask, are you?"

Alex
turned around in her seat and saw a tall, cold-faced man, who was obviously
furious.  His face had the appearance of cold granite, his dark eyes looked
like chipped, black ice.  She stood up to meet his stare.   She felt a bit
unnerved, but her voice was strong.

"My
name is Alexandra Destephano.  I'm the lawyer for the hospital.  Who are
you?" Alex's voice was equally cold and formal.

The
man had soft features.  His black hair was thick and curly, with abundant grey
at the temples.  His nose was sharp, and his lips were thick and pouty.  He had
a high forehead.  All in all, his appearance was effeminate and Alex didn't
like him.   She didn't like him at all.

The
man surveyed Alex carefully.  His cold black eyes canvassed her tall, graceful
body.  Alex suppressed a shudder as his eyes stopped and surveyed her breasts,
then continued down to stare at her hips and her long legs.  The man was
positively undressing her before her very eyes.   She was totally humiliated
and furious at the same time.

The
man extended his hand." Oh, I should have known.   I've heard about the
beautiful, auburn-haired CCMC lawyer ever since I arrived.   I am Lester
Whitset, the onsite contract manager over the psych, oops, I mean behavioral
health department here at CCMC.  I'm surprised we haven't met before."

Alex
accepted his hand.  It was cold, so cold Alex likened it to a corpse.  It had a
clammy feeling and gave her the creeps.  Lester Whitset was so white he looked
positively dead.   Ugh, she thought to herself, as she shivered slightly in
disgust.   There was something malevolent about the man.  He totally grossed
her out.  

"I
believe I was out of town when your group took over the operation of the CCMC
psychiatric services.  That was in March, wasn't it?" Alex knew she was
right.  That was when she, Jack, and Robert Bonnet had spent three weeks in
Virginia, resting up from Mardi Gras in New Orleans.

"Yes,
it was.  I've heard a lot about you, Ms.  Destephano.  The grapevine has it
that you're a pretty good sleuth.  Are you looking through the patient records
so you can find our rapist?"  Whitset eyed her carefully, a thin smile on
his lips, his eyes cold and unwavering.

Alex
was stunned by his question.  "Actually, no.  I witnessed a potential
disaster here today, a fight between the patients, Mr. Whitset.  I'm glad we've
met each other.  We have some work to do up here."

"Please,
call me Lester.   We're colleagues, are we not?  I'd be pleased to call you
Alex."

Alex
was uncomfortable at the thought of Whitset being a colleague.  "Yes, I
guess we are.   In a sense." She stammered her reply, caught off guard for
a moment.  The man repulsed her and she wasn't sure why.  He gave her the
chills.  She began again.  "Mr.  Whitset, I'm concerned about the staffing
levels here on the behavioral health units.  I understand you cut staff 20%
when you took over?”

Whitset
glared at her and said nothing.

 "I'm
convinced that staff numbers aren't appropriate to provide safe care to
patients or protect the staff.  As a matter of fact, I'm not sure we're meeting
a minimum standard of care." Alex continued to belabor her point,
uncomfortable under his stare.

Whitset's
look froze Alex in her tracks.  His voice was equally as cold.  "I assure
you, Alex, that safety and standards are being met here in psychiatry.  My
company was hired to reorganize the psych department and to make it fiscally
sound.  I've been successful in doing just that.   We are experts in Behavioral
Health and behavioral health care.   Behavior Health at CCMC was a money loser
before we took over.  I've managed to put it back in the black in six short
months -- an accomplishment greatly appreciated by your CEO, Donald
Montgomery."

Alex
was not to be bested.  She gave Whitset a hard look.  "Perhaps you have,
but at what cost?  I'm not so sure.  I plan to assess the conditions here, do a
risk assessment, and determine just what the care is like, from a risk
management perspective, of course.   I may hire a team of risk appraisers from
outside of Louisiana to review our practices." Alex watched his face
darken, suffused with anger, and then continued, "Furthermore, I'd like a
copy of your management policies and documents to review as part of the
investigation."

"Anything
you want, Alex." Whitset's voice was controlled, and only the pulsing of
his right carotid artery gave any indication of his rage.  He continued,
"My office is your office, any time," he said as his eyes wandered
over her body.  "Anything else you need?" The man was positively
leering at her and his intent was clear.  His voice remained cold.  He gave her
a sly smile as he touched her hand.

Alex
was startled by his touch and pulled her hand away.   The man was positively
vile.  There was something about him that was malignant.  "No, nothing.  
Please send your internal documents to my office ASAP." Alex turned away
from him to continue her chart review.

Whitset
persisted, "Alex, "I'll be happy to.  Can I interest you in a cup of
coffee in my office? It's a gourmet blend, one of Louisiana's finest."

"No,
thank you.  I'm leaving shortly."  Alex didn't look at him.   Her reply
was short, to the point.

"Don't
work your pretty little head too hard now.  All work and no play makes Alex a
very dull girl." Whitset's voice was hushed and Alex could feel the chill
of his body behind her.   Finally, he left the room, his heels clicking in a
military-like fashion.

What
a weird dude,
Alex thought to herself.   It took her
several moments to relax after he left.  Her heart was hammering so hard her
chest wall was hurting.   There was something about him that was repulsive, but
she couldn't articulate it.  She continued to think about him for a few
minutes, then returned to Jim McMurdie's chart.  

She
was surprised to learn that Jim was a former New Orleans police detective.  He
was presently on disability from the department due to mental illness.  The
chart indicated that he had snapped when his wife of 12 years left him several
months ago, taking along their six-year-old daughter.  His wife had been
pregnant with their second child at the time she left.  An interview with Mrs. 
McMurdie revealed that Jim had become more and more aggressive in his behavior
towards her.  In fact, he had suddenly begun accusing her of having
extramarital affairs when she was three months pregnant.  It was documented
that Mrs. McMurdie had become increasingly frightened of Jim and had gotten a
restraining order against him.   Jim had become so angry at this that he had
tried to beat her, which is what had precipitated her filing for divorce.  
Jim's medical record indicated the treatment team was hopeful that he could
control his rage, anger, and jealousy through psychotherapy and with
psychotropic drugs.  Alex was about to read the physician progress notes in the
chart when Monique Desmonde tapped her on the shoulder.

Alex
jumped at the touch.

"Good
Lord, Alex.  I did not mean to scare you! Are the charts making you nervous?"
Monique was laughing at her.

"No,
Monique.  I guess I was just so engrossed in Jim McMurdie's chart that you
startled me.  Let's go.  I'm famished."

As
Alex and Monique left the attending chart room, Alex was surprised to see
Lester Whitset sitting in the day room talking with the patients.  He was
joking with Jim and Anthony, who were both still pretty doped up, but out of
seclusion.   Both patients were laughing uproariously with the administrator.  
Alex moved a little closer to the entrance of the day room and saw that the
three were playing cards.  Rose was looking at them disdainfully, in obvious
disapproval.  Mrs.  Smithson was knitting a sweater and smiling benevolently at
them.

Alex
nudged Monique’s shoulder.  "Is it usual for Whitset to converse with the
patients?  I think that's inappropriate."

Monique's
eyes traveled to the day room.  She shrugged her shoulders and shook her head
in disapproval.  "Yep, he comes in most every evening.  The nurses hate
it.  They say he usually stays until after bedtime.   Sometimes he's here all
night.   He's available in the late afternoons and evenings mostly.   Angie
told me several weeks ago that he seemed to upset the patients from time to
time.  I've asked him not to be so friendly, but he maintains it's part of his
system of quality assurance."

"That's
total BS.   Can't you keep him out? It seems unprofessional to me that he
should visit with them."

Monique
shook her head.   "I couldn't agree more, but the answer is no.  I can't
keep him out.   I've asked him not to be so familiar with the patients, but he
just smiles at me.   He knows it makes me mad, so now I don't say much about
it.   Actually, most of the male psychiatrists disagree with me.  They've heard
positive things about him from their male patients.   The female patients don't
seem to like him.    I can't garner enough support from my male colleagues to
even complain to Don.   The whole thing actually disgusts me.   Some of the
male psych attendings are such pissers." Monique said, obviously piqued by
her male colleagues’ behavior.

Out
of the blue, Alex retorted, "I don't like the man.  He gives me the
creeps.   I just get an uneasy feeling from him.   He's so cold.   Yuck."

Monique
looked at her curiously.  "What do you mean cold?  Why does he give you
the creeps?"

Alex
shrugged her shoulders.   "I don't know for sure.   I guess it's the way
he looked at me.  He pretty much undressed me with his eyes."

"Yeah,
I know that feeling," Monica intoned.   "You, me, and all the female
staff.   I agree.  He is inappropriate as hell, but how can you reprimand
someone for looking at you, not that he comes under my review?   All he ever
does is look.  He never says anything lewd or vulgar.  I wish he would because
I'd love to get him out of here on a sexual harassment charge," Monique
replied.   "That would make my day."

"I'd
love to help you, but the guy is way too smart for that.  My guess is that he
plays it to the hilt without ever doing anything wrong.  I just don't like
him.   And he is so cold." Alex shivered when she remembered her
conversation with him.  

"What
do you mean 'cold'?  You've said that twice now." Monique asked.

"Well,"
Alex thought a moment, "When he extended his hand in greeting and I
accepted it, his hand felt cold, dead, like there was no blood running through
it.   You know, like somebody who's had a stroke or something.   It was just
gross, like touching a dead person." Alex shivered at the memory.

Monique
nodded.  "Not sure I noticed that.   I try my best not to touch him. 
Thank goodness I don't see him much.   He's mostly around when I'm not.   By
the way, Jack's going to eat with us.  I didn't think you'd mind."

"Of
course not.  How did that happen?  Does he have any info about Angie or the
rapist?"

Much
to her surprise, Alex saw a faint blush crawl over Monique's pale face.  Her
friend looked a bit guilty, as if she had been found out.

"Well,"
she said with some hesitation, "Jack and I are pretty good friends."

"Yes,
well Jack and I are pretty good friends, too, but I don't blush when I talk
about him," Alex retorted, confused by Monique's response.

"Well,
we sort of decided ... well, we're special ...," Monique rambled,
stumbling for the best way to describe the change in her feelings for Jack.