Bruce Goldfarb


When people complain about quarantines, masks and social distancing, I think about Ralph Burke, a man locked up because he was a menace to public health.

The summer after Elvis died, I was a 21-year-old paramedic student working in a psychiatric unit at John Gaston Hospital in Memphis, the city’s public hospital. John Gaston — locals either used the full proper name or just City Hospital — was a six-story Depression-era gothic revival building on Madison Avenue. It was an aging hospital, with office doors topped by working transoms, dark brass ornamental trim in the lobby, and pale sea-green glazed block hallways that looked like faded photographs.

By the late 1970s John Gaston was nearing obsolescence. The hospital still had open wards, with several patient beds together in one large room, allowing little privacy or space for visitors. Generations of indigent Memphis women were introduced to motherhood in John Gaston’s maternity ward, with ten or more beds jammed side by side.

Along with five other students, I was hired for a new clinical program — a psychiatric emergency room. The idea was to create a place to evaluate and triage patients urgently needing psychiatric consultation, who might be dangerous to themselves or others, or were in some sort of crisis. Many patients were people who made a scene and tore up someplace or behaved bizarrely in public, and held for 72 hours on an emergency commitment. People charged with murder and other heinous crimes were brought in to evaluate their competency for court appearances.

Our job as techs was to assist the nurses, mainly by helping them give medications and, when necessary, to contain and restrain those who were acting out violently. Before the psych ER formally opened, we were trained to restrain patients without anybody getting hurt. We were familiarized with straitjackets, restraining vests and Posey restraints; padded leather cuffs to strap ankles and wrists to a bed frame. The Posey cuff was a small leather belt with a steel loop that went through one of several slits, depending on the size of the wrist or ankle. A leather strap through the steel loop kept it secured to the wrist and attached to the bed frame.

We learned to coordinate a plan when it became obvious that a violent and uncooperative patient required restraint. A group of four techs divvied up limbs, each assigned one arm or leg. Instead of counting down, which tipped off the patient that something was about to happen, the cue was an innocuous non sequitur such as, “Would you like some Jell-O?” As the patient processed that tangential thought, we immediately pounced, holding on to a limb flailing like a bucking bronco. Even a strong person had difficulty overpowering a full-grown man with one arm, much less four at once. We held them long enough for the nurse to step in with a syringe of Thorazine. Within minutes, it was all over.

Psychiatry occupied the entire top floor of John Gaston. The elevator to the 6th floor opened to a Plexiglas box not much larger than a phone booth, enough room for two or three people. An intercom let visitors speak to the nurse’s station on the other side of a reinforced glass window, where an employee at the desk pressed a button to unlock the box and admit the visitor into a larger lobby. Devoid of furniture or any other objects that could be used as weapons, the lobby was separated from the psychiatric unit by a heavy steel door with a small rectangular porthole.

Only one person, the charge nurse for the shift, had the key to the elevator lobby door. Two people were required to get in and out of the unit; the charge nurse and somebody to press the button to open the Plexiglas elevator cage. Every window on the floor was secured with thick steel wire mesh.

About half of the 6th floor was an inpatient unit no longer needed, since a nearby state hospital assumed all long-term care for indigent patients. This area was designated as the psych ER. Furniture had been removed from the former inpatient day room, leaving a large space empty except for a security guard’s desk. Patient rooms with steel doors and portholes lined one side of the dayroom. The nurse’s station had large windows on three sides, overlooking the day room, patient rooms, and elevator lobby.

At the other end of the 6th floor was John Gaston’s prison ward, one hallway of patient rooms with doors heavier and more secure than the psychiatric unit, more like jail cells. The larger rooms at the ends of the corridor were four-bed wards. The other half-dozen rooms could hold one or two beds each. The prison ward looked and felt like a small jail, a corridor of patient rooms behind steel bars and a deputy sheriff on duty 24 hours a day. Another heavy door separated the prison ward from the rest of the 6th floor, making an area for the deputy’s desk and a couple of chairs, a bathroom, and a wall of handcuffs and leg irons hanging on hooks.

John Gaston had the only hospital lock-up facility in the state of Tennessee. Prisoners and others in custody from throughout the state were brought to John Gaston if they needed medical care. Inmates assaulted in prison were brought to have their injuries treated. People, who tangled with police and ended up shot or beaten while being taken into custody, were hospitalized, shackled to the bed frames.

Between the psychiatric ER and the prison ward was an intermediate inpatient unit with a capacity of 15-20 patients in rooms that surrounded a central nurse’s station. This was an area for people who needed short-term hospitalization, usually 30 or fewer days. Many of these patients were floridly psychotic, dangerous to themselves and others, in the hospital for evaluation or to adjust medications. The intermediate unit was sealed with locked steel doors at either end, one leading to the prison ward and the other to the psych ER.

The head nurse of the intermediate unit was Dorothy McCoy (everyone’s name has been changed), an older woman barely five feet tall with a severely curved spine. She stood with her hips and shoulders arched backward, elbows angled out from the sides, like a question mark enclosed in brackets. Scars ran down her upper arms, lingering traces of some long-ago corrective surgery. McCoy walked with a stiff gait, a marionette marching down the hallways. I never mustered the courage to ask about her condition, but it was obvious that she had spent a great deal of her life inside hospitals. McCoy knew nursing inside and out, and proudly wore a starched white cap as an emblem of her profession. She was a pint-sized spitfire of a punctuation mark, loud and intolerant of foolishness, wielding an authority that far outsized her physical stature.

My first day on the job, there were no patients in the psych ER. After sitting in the nurse’s station for a while, I was told to go help out on the intermediate unit next door. I unlocked the door and let myself in, and stood there for a moment to get oriented. Dan Bellino, a psych aide wearing a white lab coat like mine, sat at a table in front of the nurse’s station with two other men.

“You’re one of the new guys?” Bellino asked.

“Yeah,” I said. “I don’t know what I’m supposed to be doing.”

“Do you know how to play spades?” he asked.


“Have a seat,” Bellino said.

“We’re supposed to play cards?” I asked, sliding into a chair.

“We’ve already done medication rounds. That was at 4,” he said. “There’s nothing to do until meals come around in a couple of hours. So, until then we hang out, play cards, smoke cigarettes, and keep an eye out for trouble.”

Bellino and I became good friends.

One of the patients playing spades that first day was a young man with bipolar disorder in a manic phase. He had been admitted to John Gaston in order to have his lithium titrated to control his mood swings. I learned that people in mania could be a lot of fun — talkative, creative, and often very funny. Not a bad way to spend a few hours on the job.

The other man at the card table was Burke, the only patient in the psych unit without mental illness. Burke had tuberculosis. He was also an alcoholic and lived as a drifter. Burke was a binge drinker. Once alcohol touched his lips, there was no end to it. Burke would go off on an extended drinking jag for weeks until he woke up in a soybean field or jail cell with no reckoning of how he got there.

At the time, TB was treated with an antibiotic regimen that took two or more years to complete. Burke would get drunk and forget to take his medicine. He didn’t mean any harm. He was a nice guy, reasonably intelligent and kindly, when sober. But he kept screwing up over and over until public health officials charged Burke under a law that hadn’t been used in 100 years, since yellow fever coursed up the Mississippi River in the late 1870s. It was the sort of law used to lock up Typhoid Mary. The state confined Burke for treatment until he was no longer contagious and posed no threat to public health. Maybe two to three years of therapy. No trial, no appeal, no definite release date.

Burke had no family who ever visited or inquired about him. Nobody seemed to care about him. Alcohol was an effective fuel for burning bridges. The few scraps of clothing he owned were threadbare and ill-fitting, hanging on his scrawny frame, so he spent most days wearing a hospital gown backward like a bathrobe over a stained t-shirt, and hospital-issued slippers.

Burke was surrounded by frequent outbursts of bedlam. Patients became agitated and acted out, sometimes holding loud conversations with imaginary voices. There were fights among patients. Prisoners got violent, smashing the hospital beds and furniture in their rooms. At any moment the techs could be called to get a patient back into their room, on a bed, and in restraints. Each nurse’s station had a panic button that summoned help from city police stationed in the emergency room. The cops quickly joined the affray with enthusiasm, applying their skills at forcing submission with fists, gouging eyeballs with their thumbs, and twisting limbs into unnatural positions.

Turmoil and violence were daily occurrences. One time, I was blindsided with a punch to the side of my head from a patient, knocking my glasses off and momentarily dazing me. The patient was a large bald-headed man with a diagnosis of hebephrenia, a type of chronic schizophrenia. One look at him and you could tell something wasn’t right. People with hebephrenia often acted childish and engaged in bizarre behavior. The oversized, crazy-eyed toddler thought he heard me say something nasty about him. But I hadn’t. It was an auditory hallucination. That punch was my penalty for not being aware he was standing behind me.

(On another evening, when the hospital served slabs of gray meat creatively described as roast beef au jus, the same patient stood holding his dinner tray, repeating “Au jus, au jus, au jus…” Finally, I walked up to him and said, “Not bad, how about jus?” He giggled and went into his room to eat his meal. So, I guess there were no hard feelings between us.)

No matter how volatile the situation, McCoy stepped up fearlessly, hands on her hips, sternly telling patients who were acting out to stop the nonsense, or easing into a comforting and cajoling tone when necessary. In her uniform pocket was a capped syringe loaded with Thorazine or Haldol at the ready.

Often, it was possible to avoid physical confrontation by reasoning with patients, convincing them to calm down and go into their room for a period of time out, let the nurse give them a tranquilizer shot, or even to get onto a bed and in four-point restraint.

Look, we both know how this plays out. You’re going to end up on that bed in restraints until you cool down. That’s going to happen. We will make it happen by force if necessary. There’s no way out of here. You can cooperate, or we will make you do it. It’s your choice.

Sometimes that worked. Sometimes patients chose force. They still ended up in restraints. 

During the outbursts, Burke sat at the card table with his legs crossed, amusedly watching the action unfold. On occasion, he withdrew into his room for safety.

The intermediate unit had a patient with gestational psychosis, a rare mental illness that developed during pregnancy. Denise Reynolds was in her 20s with her second child. She had been through it before. While pregnant, she was overcome with delusions and was so disorganized that she presented a danger to herself and the baby she was carrying. After she delivered the baby, McCoy told me, she’d be right as rain.

Reynolds sometimes believed that she was receiving instructions from god, or that the government was monitoring her. She often tried to eat things — paper clips, sheets of paper, books of matches, anything she could get her hands on. One day, she lit a cigarette and dashed into her room, jumped on her bed and pulled the sheet over her head, nearly setting herself on fire.

When Reynolds was uncontrollable, the nurses would have her secured to the bed in four-point restraints, both wrists and both ankles. Despite her psychosis, Reynolds was easily able to get out of the restraints, free and walking around within minutes.

“How the fuck does she do that?” I said to nobody in particular.

“Ask her,” Burke said, tapping a twisted cigarette between his stained fingers.

“That’s funny,” I said. “She’s out of it, Ralph. She’s not even sure we’re real.”

“You’d be surprised what you can learn by paying attention,” he said.

The next time Reynolds was put in restraints during my shift, I propped a chair in the hallway outside of her room and sat. I watched Reynolds struggle against the restraints for a while, then go quiet. Maybe she was thinking, or had a lucid moment. Staring blankly into the distance, Reynolds began to slowly move with purpose. I observed as she raised herself onto an elbow, leaned forward, and craned her neck to grasp the tail end of the Posey cuff with her teeth. She pulled back, stretching the cuff over the steel loop and leather strap, and withdrew her hand. Then she reached over and released her other wrist, and her ankles.

So that was how it was done, using the strength of the cuff to defeat itself.

I disinfected a set of Posey cuffs and had Bellino secure me to a bed in four-point restraint. Once I was able to grasp the cuff with my teeth and get it positioned to tug in the right direction, it wasn’t difficult to loosen it enough to slip my hand out. With one free hand, the rest was easy.

My curiosity piqued; I studied a straitjacket. During night shifts, when the unit was quiet, I’d have a co-worker secure me in a straightjacket to learn how to get out of it. Arms wrapped around in long sleeves buckled around the chest, and a strap from front to back between the legs to keep the elbows from lifting. Struggling with brute force was futile. Taking some tips from Harry Houdini, I figured it out. It could be done, given enough time and if no supervisory nurses were around.

The next challenge was the most difficult; handcuffs. When time permitted on the night shift, I hung out with the deputies in the prison unit, where they watched late-night shows on a small black-and-white television set. One deputy was particularly friendly, letting me examine handcuffs and the key to see if I could learn to pick the lock. Over the course of several weeks, I spent hours at night working with handcuffs, figuring out how to bend one end of a straightened paper clip just enough to push the release mechanism in the handcuff lock. I got good enough to do it without looking, with my hands behind my back.

Learning how to escape from restraints was an unexpected benefit of working in psychiatry, though a skill I have never applied outside of the clinical setting.

Bellino and I spent evenings playing spades with Burke and other patients. Burke told great stories about hopping trains and other feats of dereliction while hand-rolling cigarettes of Bugler tobacco, the economical choice of destitute smokers. One night, Burke claimed that he could leave the unit whenever he wanted.

“I am here voluntarily,” he said. “I choose to be here of my own free will.”

“What are you talking about,” Bellino said. “A judge locked you up here.”

“I could walk out of here anytime,” Burke insisted. “I could leave tomorrow if I wanted to.”

“The guys in the prison ward say this place is tighter than any jail in Tennessee,” Bellino said. “Nobody has ever escaped.”

“Walls are an illusion,” Burke said. “They exist only in the mind. An open mind is an open door.”

“That’s crazy talk,” Bellino said. “You’re full of it.”

“I tell ya’ boys, there never was nothin’ I couldn’t walk away from,” Burke said. “Girlfriends. Jobs. Family. You think this hospital can keep me? I am here of my own volition.”

“If you can leave whenever you want,” I asked Burke, “why are you still here?”

The tip of Burke’s cigarette glowed a deep red as he inhaled and formulated his thoughts. “Three squares,” he said. “I got new glasses, and for that I am grateful to the good, taxpaying citizens of Tennessee. And I like you boys. I enjoy the company.”

Burke set down a card to take a trick. “Honestly, if I wasn’t here, I’d likely be dead by now,” he said. “This place is keeping me from drinking myself to death.”

By the time I met him, Burke had been confined for almost a year. He hadn’t been outdoors, hadn’t even an open window for fresh air. I looked into getting Burke a day pass, which turned into a prolonged negotiation with McCoy. Her first answer was a flat-out no. She eventually allowed a half-day pass, four hours of liberty, under very strict conditions. She would permit it if Bellino and I escorted him together, two on one, and never let Burke beyond our reach. He had to wear a mask at all times. No public transportation or sit-down restaurants.

Bellino and I had to sign documents accepting personal responsibility for Burke. He isn’t an ordinary patient, McCoy warned us. He’s locked up here by an order of the court. If anything happens, if he runs off, your asses will be in slings. You’ll have to answer to a judge.

As we left her office, McCoy pressed a five-dollar bill into the palm of my hand.

Burke wanted to go to a drugstore, so we walked to Walgreens. He bought himself a transistor radio, a tin of Bugler cigarette tobacco, and a new deck of cards. We bought ice cream cones with McCoy’s money. For the rest of the time, Burke just wanted to sit in the park. We sat on a bench, basking in the afternoon sunshine. He was happy and grateful. Then we went back to the hospital. The outing was uneventful.

Several weeks later, I arrived at work and was informed that Burke was gone. Overnight, he had somehow eloped from the 6th floor. Nobody saw a thing. All keys to the unit were accounted for. It was as though Burke had just vanished into thin air. McCoy wanted to speak with me and Bellino in her office immediately.

“You two have some explaining to do,” she said. “He couldn’t have done it himself. He’d have to walk past two nurse’s stations, pass through three locked doors, stand practically bare-ass nekkid out in the open until an elevator comes up to the sixth floor, and go by security in the lobby downstairs, all without being seen. It ain’t possible. Which one of you lunkheads helped him get out?”

Neither of us had anything to do with it. As it happened, I was at a cookout with Bellino and his family the previous night. We had alibis. I liked Burke, but wouldn’t have risked my job for him. McCoy reluctantly believed us.

How did he do it? No idea. Burke had all the time in the world to observe the staff and the routines on the psych unit. No doubt he was paying attention the whole time. He probably noticed something that nobody else ever did. How he escaped remained a mystery, since John Gaston was torn down to make room for a modern hospital. 

And Burke surely drank himself to death long ago.

© Bruce Goldfarb

Bruce Goldfarb is the author of 18 Tiny Deaths (Sourcebooks, 2020). He lives in Baltimore.

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