This is nuts: A bizarre tale of the insanity that is SF's mental health system
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Shortly before midnight on April 21, 2001, Jason Grant Garza walked into the psychiatric wing of San Francisco General's emergency room and said he was having a mental health crisis. A staffer there refused to admit him. When Garza insisted on seeing a doctor, he wound up strip-searched and thrown into jail. Now, after six years of legal wrangling and bureaucratic buck-passing, SF General has officially conceded that Garza was denied proper service. But Garza says he is still waiting for the help he needs and the justice he demands.
As I sat across from Garza on a recent afternoon, it wasn't hard to imagine a busy hospital worker or government official blowing him off rather than dealing with his frenetic energy. Diagnosed with a so-called "adjustment disorder," Garza was intense, to say the least. Running his hands through his wiry, gray-streaked hair and leaning over the table as he spoke, the 47-year-old Panhandle-area resident railed against "the system" for well over an hour. At one point, he likened his suffering to that of "a starving kid in Africa ... [except] the starving kid in Africa still has hope. I have none of that."
Garza's ire and his penchant for hyperbole might be exasperating at times, but his behavior also seems to bolster his main contention that he needs help with his mental health, help that he claims a flawed public health care apparatus has failed to provide. He says his attempts to receive care and support have only exacerbated his condition, increasing his isolation and his sense of persecution. "I'm dead right," he said repeatedly. "And yet I've gotten nothing for it."
Garza declined to recount specific details of his story or be photographed. Instead, he referred the Guardian to a 2003 deposition he gave to deputy city attorney Scott Burrell. According to the deposition, his ordeal began shortly after his lover and "soulmate" killed himself in January 2001. That April, Garza became despondent over his loss and called a suicide hotline. The phone counselor directed him to visit SF General's Psychiatric Emergency Services.
Garza took a cab to SF General and told PES charge nurse Paul Lewis that he was "wigging out" and badly needed to see a doctor. According to Garza's deposition and other court documents obtained by the Guardian, Lewis asked him if he was suicidal. Garza is quoted in his deposition as responding, "If I was crossing the street and fell, I don't know if I'd get up." Lewis determined that this answer meant Garza was not suicidal and thus not in need of emergency care. He asked Garza to leave. When Garza refused, the hospital's institutional police escorted him out.
Garza did eventually get into the hospital that night, but not in the way he was hoping. After he was ejected from the premises, he stole back into the main lobby and called city police to help him receive treatment. But hospital cops returned instead and stuck him in a holding room. Sheriff's deputies arrived four hours later, early in the morning of April 22. They arrested Garza for trespassing and possession of marijuana, even though he had a prescription for medical cannabis in his wallet.
At the city jail, Garza finally got someone to acknowledge that he was experiencing a psychiatric emergency. He says he told jail staffers that he "didn't care if he lived or if he died," and as a result, he was stripped of his clothes and placed naked in a cell for his own safety. "That nurse [at the jail] classified me as an emergency," Garza told us. "So one says I'm in an emergency, and the other [at SF General] says I'm not.... At what point am I going to get any help?"
To recap: When Garza voluntarily tried to find care, he was told he was not sufficiently distressed. Only when he was arrested and thrown into jail for demanding help was he declared a danger to himself. His "treatment" consisted of a strip search and a jail cell.
But that's only the beginning of the insanity.
The Emergency Medical Treatment and Active Labor Act was passed in 1986 to prevent hospitals from triaging out, or dumping, difficult or impoverished emergency room patients like Garza, a former business owner, cabdriver, and bookkeeper who has been on Social Security disability since 1995. EMTALA mandates that any patient who goes to an ER must be given an "appropriate medical screening examination." After he got out of jail, Garza sued the city, SF General, Lewis, and other city employees, contending they violated his rights under the act. He could not afford a lawyer, so he represented himself.
In one of the strangest twists of this twisted tale, Garza finally made it into the inner sanctum of SF General's PES as a result of his suit against the city. But as with his night in jail, the circumstances of his psychiatric care were not what he was expecting.
While Garza was giving a deposition at the City Attorney's Office in March 2003, his behavior prompted staffers to call in the authorities. According to an official report of the incident, Garza made suicidal remarks like "I have no desire to live." He also allegedly said that he "needed/wanted bullets and a gun." These statements are not present in the 168-page deposition. Garza did acknowledge to the Guardian that he became upset that day, especially when questioned about his experiences at SF General and the suicide of his lover, but he claimed that deputy city attorney Burrell "set him up" and that the calls to the mobile crisis unit and police were part of "an attempt at witness intimidation." Whatever the reason for the calls, Garza was detained for a 5150, a procedure under which subjects are involuntarily committed for up to 72 hours. The City Attorney's Office had no comment on the issue.
Amazingly, police took Garza to the same PES department at SF General where the saga began. This time, though, he made it past the lobby and received a medical screening exam, marked by a report and other SF General paperwork. The mere fact of this report's existence, Garza claims, proves that he did not receive proper care when he went to the hospital voluntarily in 2001. Deputy city attorney Burrell informed Garza by letter that the only record the hospital could produce from his 2001 visit was a triage report filled out by Lewis, the nurse. EMTALA does not permit triage of a patient without a subsequent medical screening examination.
However, in pretrial motions, the city argued that Lewis treated Garza like any other would-be patient and thus complied with the law: "EMTALA requires hospitals to provide a screening examination that is comparable to that offered to other patients with similar symptoms." In other words, Garza's treatment may have been poor, but so was everyone else's, so he had no case, the city contended. Judge Phyllis J. Hamilton agreed and tossed out the suit.
Perhaps the strongest proof of Garza's "adjustment disorder" and need for psychiatric care, ironically, is the fact that he continued to press his case even after his lawsuit was tossed out, taking on a health care system that could make anyone feel unhinged. For the past six years, he says, he has badgered "10 to 15" local, state, and federal agencies, as well as government officials like Sup. Bevan Dufty and aides to House Speaker Nancy Pelosi (DSan Francisco). In the process, he has compiled an encyclopedic collection of letters, petitions, records, and even audiotapes of phone conversations.
"There isn't a single agency that's in charge of anything," Garza said of his dealings with the health care bureaucracy. "You're parsed. You're sliced and diced and parsed as a medical patient ... and it's designed to fail."
Not surprisingly, Garza's efforts to find accountability have irked some officials and members of the bureaucratic corps. When he requested a copy of his arrest report from the Sheriff's Department, he received a mocking denial letter signed "R.N. Ratched," a reference to the asylum nurse in Ken Kesey's novel One Flew over the Cuckoo's Nest. As the Guardian reported in 2002, Sheriff's Department legal counsel Jim Harrigan eventually confessed to penning the letter, but only after Garza raised a fuss before the Sunshine Ordinance Task Force.
At Garza's urging, the Centers for Medicare and Medicaid Services (CMS) asked the California Department of Health Services to investigate his treatment at SF General. In a letter dated Nov. 13, 2006, CMS official Steven Chickering informed Garza that the DHS "found no violation of statue [sic] or regulations." Chickering concluded his letter to Garza by warning him to back off. "Your frequent communications have become disruptive, distracting, and nonproductive. Therefore I have instructed CMS Regional Office staff not to accept telephone calls from you in this matter."
Despite his setbacks with the CMS and other agencies, Garza pressed on. He contacted the Office of Inspector General at the federal Department of Health and Human Services and asked it for help. OIG spokesperson Donald White declined to discuss specific details of Garza's case, but he did tell the Guardian that "Mr. Garza came to [the OIG] directly, and we contacted CMS, and they conducted another investigation."
That second investigation found an EMTALA violation after all.
On April 19, Garza's relentless some might say quixotic or even crazy pursuit of what he calls the truth finally produced some results. Nearly six years to the day after his 2001 visit to SF General's PES, hospital officials inked a settlement agreement with the OIG in which SF General conceded that Garza had not been examined properly, a violation of section 1867(e)(1) of EMTALA. Section 6 of the settlement states plainly that the hospital "did not provide [Garza] with an appropriate medical screening examination on April 22, 2001."
The hospital agreed to pay a fine of $5,000. But Garza, as White told us, "is not a party to the settlement." In other words, he got nothing.
"That's the way EMTALA works," White said, meaning that hospitals found in violation of the law pay restitution to the government, not to the victim. "We took the steps required under the law."
Reached by phone, Iman Nazeeri-Simmons, SF General's director of administrative operations, acknowledged that hospital officials signed the settlement agreement but noted that in the course of the investigation leading up to it, "the state did give us a very thorough EMTALA survey and came out with no problems."
"It has been made clear to Mr. Garza that he is more than welcome to come back and access services here," she added.
Garza denied that he had received any follow-up calls from SF General offering services, and he balked at the idea of returning there: "That's like sending someone back to the priest that molested them." He told us he would like to pursue further legal action against the hospital and the city but still has not found a lawyer. After the settlement was signed, he claimed, he asked officials at the OIG "where I could go now for legal and medical help, and they told me, 'That's not our jurisdiction.' "
"So even though I'm dead right, I'm still without help because everybody's pointing fingers ... as opposed to getting me the help I need, because they don't care, they're unaccountable," Garza said. "Ten different agencies told me I was wrong, and now [with the settlement] I'm right?"
He threw up his hands. "Does that make sense to you?" *