The Bleeding Edge

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There are many ways to hurt yourself.

You can make mistakes, says things you shouldn’t, get into relationships you have no business being in, or accept responsibilities you have no training for. Some of these are indirect and take days or months or even years to manifest themselves to you, even though others may have seen the problems long before you did. 

Some hurts are long, slow, and painful. They fester, ooze and seep into all parts of your life as surely as a blood-borne infection travels to the far reaches of your body before it kills you if left unchecked. These hurts can be self imposed, as when one stays in a career entered because of family tradition and not passion. They can be foisted upon you by others, as we see in sexual abuse or neglect that steals away the innocence of childhood and pulls a dark veil down over adulthood like a musty bedroom window shade. 

Some hurts are self inflicted, surgical, quick. They serve different purposes. 

I see a lot of people who are cutters. Their term, not mine. 

They use pocket knives, straight razors, kitchen knives, box cutters to inflict wounds on themselves. Often, these are on the inside of the wrist or arm, neat row after neat row of older-to-newer red lines in various states of healing that read like an archaeological dig of psychological pain and suffering. Sometimes they are on the back of the arms, hiding in plain sight. Sometimes they are on the abdomen, always there but hidden behind this season’s tank top and that one’s bulky sweater. Other times they live on the inside of the thighs, a quiet altar of introspective pain that is shared with no one, visible to no one.

Staff at emergency departments, like other professionals, get very antsy and go into action when they see four inch longitudinal cuts on wrists requiring sutures. The cleaning, anesthetizing, and re-approximation of cleanly sliced skin can be done by any competent health profession with eyes closed and mind on the next trauma coming through the door. 

Problem is, every cutter is then summarily stamped suicidal in big red virtual block letters on their chart. Cutting equals bleeding equals exsanguination equals death equals very bad undesired outcome equals emergency psychiatry consult.

All that glitters is not gold, and all that cuts is not seeking death.

Cutters tell me differently, and I believe them.

“It helps me feel something other than the pain in my life.”

“It takes my mind off my mom’s death.”

“It grounds me. It helps me focus better.”

“I like watching the blood trickle down my arm and drip onto the table. It makes me feel real.”

“It makes me feel like I’m in control, even if it’s just for a little while.”

Cutting of the sort I’m describing to you rarely portends death.

On the other hand, it is a sure sign that someone is in pain and wants to live. 

It should be viewed as a sign that someone is reaching out.

As surely as clean lacerated edges come together and heal, albeit leaving visible scars, emotional slashes can be healed too. 

The scars will be there, unseen, most likely forever.

The difference will be that the person will put down the cutting tools and learn how to stitch themselves up emotionally when life rips something open again.

As it inevitably, inexorably is wont to do.

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3 thoughts on “The Bleeding Edge

  1. My son has several diagnosis. He cut and burned-tried to hide it. One day I smelled meat cooking. I saw him in the kitchen and asked him what he was doing-nothing just burned himself.
    A few days later he told me it wasn’t an accident. He was on a med that made his skin creep and crawl. His mind told him that it was ants crawling on him, so he was burning the ants off. I got him to talk to his doctors, and they did something with his meds.
    He also cuts himself to see if he can feel physical pain-make sure that he’s alive-that’s he’s not dreaming. I get worried when he talks. He was taciturn before he was injured. He’s taciturn now. When he opens up and starts talking, I know that he’s in deep trouble. One day I went up to the ward, and a very happy nurse told me that he finally ‘opened up’. I said, “oh, no.” She began explaining psychiatry to me. I told her that he crashes really bad when he talks a lot-it was his way of calling for help, reaching out, please watch him. The next day, the nurse was still smiling. The next day, he crashed and was in the ‘quiet room’-the nurse said-We have it on his chart that ‘opening up’ is a warning sign.

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  2. I just recently learned how cutting is used in high school as a means to fit in, to be part of the crowd. After reading this and Mary’s comment, what does it say about the mental health of our children in general?

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  3. Hey Greg (or Dr. Smith?). Thanks again for continuing to eloquently discuss these topics in ways that can be startlingly true to a (long-time) psych patient who has never felt understood.

    It would be very nice if healthcare professionals could be better educated on the topic of cutting. It is very hard to convince cutters to get medical attention, even when they know they need it, because of the response from healthcare professionals.

    Urgent care will refuse to treat & call a (non-emergency) ambulance for transport to hospital ER. At the hospital (regardless of mode of transportation) the ER triage nurse will mark the patient as suicidal, which spurs all the problems you’ve noted previously, notably: stripped of belongings including phone/ipod/kindle/books, etc., have to change into paper scrubs, locked in exam room or put in an exam “bay” with security. Even after sutures (and let’s hope anaesthetic is actually used), the patient is held for a psych consult – even when the MD doing the sutures agrees the patient is not a danger to her/himself. As you know, it is possible to wait hours for a psych consult.

    Beyond all of that, of course, is the demeanor of paramedics, nursing staff and doctors (among others). Repeatedly (ie by same person) drilling the patient with “why would you do that?!” or even just the tone of voice and facial expressions used increase the shame associated with cutting – but the patient will attribute a lot of that to asking for help.

    I’m not saying staff shouldn’t treat cutters carefully – and certainly should be spending some time to figure out true suicidality, however, current treatment modalities just teach patients that it’s not worth seeking medical attention for cleaning/sutures. I, for one, will never again go to a UC or ER. My GP’s office is compassionate – I will see them if possible, or handle things on my own.

    Also, on inpatient units, the nurses who do intake exams should be allowed to order neosporin for healing cuts, rather than requiring an additional consult by a hospitalist (which also means another charge for the patient, on what will already be an expensive bill).

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