e pluribus unum

She looked like a whipped puppy that had had a garden hose turned on it and slunk off to a far corner of the yard to dry out in the sun.

She sat there, wizened but hard, thin and wiry, dressed in standard issue blue emergency room scrubs, thin tanned face, long stringy, wet prematurely gray hair falling limply around her shoulders. She looked down at the floor, but when her head came up and she made eye contact with me, her blue-steel eyes cut through me like a sword.

Like many people I see in the ED, she had tried to kill herself and was damned near successful.

“I don’t want to talk about it.”

She said this not in a defiant way, not in a disrespectful way, but matter-of-factly, like she knew I would understand.

I did.

“I know, but I can’t help you unless you talk to me about whatever part of it you think you can share with me.”

The next thirty minutes were a scripted dance. I’ve partnered with thousands of patients in this jerkily choreographed yet smooth and fluid transition from defiance to half-hearted refusal to longing to reservation to willingness to despair to resignation. The new trainee gives up at “I don’t want to…”, citing respect for the patient’s wishes. The young clinician pushes gently into the land of reservation, thinking that he is doing the patient a favor by not making her express her pain in this setting of codes and glaring lights and empty suicide-proof rooms. The tender-hearted provider, overloaded with his own personal grief or depression or closet alcoholism, over identifies with the despair and leaves it there, sitting raw and bloody like a piece of meat, ugly and untrimmed by the butcher, waiting to be wrapped in white paper and neatly labeled and put away in a deep freeze somewhere. The experienced clinician, having seen this story played out thousands of times, simply waits.

I waited.

“I know where the money’s been going now. I work damn hard all week. I clear almost a thousand dollars a week, doc. He said he was paying the bills.”

I wait, because I know she wants to talk about it.

“Pissing his life away. Pissing my life away. My money up his nose.”

We explore the hurt, the betrayal, the fear, the anger, the loss of control. It’s always about the loss of control.

Killing yourself is the final act of defiance, payback, and ultimate control.

“Yes, at the time I really did want to die.”

I believed her, of course. There was no reason not to.

A sudden infusion of energy, anger, fresh anger, now directed at me, at the system.

“I just don’t believe that somebody can haul me in here and make me sit in an empty room and take my rights away and not do a damn thing for me. I promised to defend the constitution of the United States. I made a vow. This is what I get.”

She spat on the floor. If she could have spat through the camera onto my shoes, she would have.

“Why don’t you just leave me alone? Why don’t you just let me make my own decision and let me die? Does it really matter to you? To anybody? Just let me go home. I want to go home.”

Despair.

We discuss the rules of the game in the state of South Carolina. The mandates, the rights and privileges of the citizenry that hold true, always, unless there is a clear and present danger that leads to involuntary commitment and treatment.

Her head hangs, if it’s possible, even lower than before. I do not see her eyes again.

“I’m afraid that you’re not going home today.”

The hose running from the exhaust to the cabin of the truck had decided that even before we talked on camera.

A silent nod.

Resignation.

“Please just let me die.”

The newbie feels a strange mix of pity and fascination and fear.

He responds, “I can’t.”

The old dog knows that the situation, no matter how bleak, will look different once the fog and the darkness have lifted. There is every chance in the world that life will go on, should go on, must go on.

He responds, “I won’t.”

Out of the many he has seen, he will do his very best to help just this one.

Advertisements

8 thoughts on “e pluribus unum

  1. Greg, your contrasts between the newbie and the seasoned clinician are so true. We who have done this work several decades own our clinical decisions rather than blaming the system. We know, we have seen, the light behind the darkness. Wonderful piece.

    Like

  2. Statistically, whats usually the outcome in a case like this? Does their life improve? Do they go back to what their life was before? Or do they sucessfully take their life at a later time?

    Like

  3. Sadly, or maybe not….I have been on one of the sides of your scenario to some degree at least 3 times in my life.  Thankfully, all 3 outcomes were positive. One situation where I might have been involved directly (but was not) ended in a suicide in front of the mother.  It still haunts me that I was not able to keep the suicide from happening even though I had not been involved directly with the 2 people for 6 years when it finally did occur.  I knew in my heart that the chance was so real, but all my efforts were for naught.

    How you can handle the raw emotion on a daily basis is so extraordinary to me!  I refused to complete my Masters in Ed. Psych because I knew I could not be in an office daily listening to teen’s problems without absorbing the pain to the degree that I could not be the “Mom Doc” to my own children.  I do so respect “counselors”…but some of us are not that strong.  Thank God you are, Greg.  Thank you for giving so much of yourself to others…but don’t neglect yourself.  Hold that darlin’ Eloise and your other girls (and boys) and replenish that which is so restorative for you who gives so much to others.  You are appreciated beyond your own understanding. Hugs, Ms B

    Like

  4. Ms. B,

    I’m sorry you have had to deal with this kind of scenario on a personal basis. That is much, much harder than doing it on a professional basis. (I too, have come at this from a personal perspective in the past, and it was much harder)

    Yes, the regrouping and replenishing is something that I am trying to pay more attention to as a grow older. I think it is more important now than ever.

    Thanks as always for reading and commenting.

    Greg

    Like

  5. Stefani,

    That is certainly a multifactorial and complicated question.

    There are roughly 30,000 completed suicides in the US each year, and probably 2-3 times that many attempts, some of which are not listed as suicides at all, but accidents, etc.

    The risk of completed suicide goes up with diagnoses such as alcohol or drug addiction (usually in concert with a mood or anxiety disorder or psychotic disorder such as schizophrenia), personality disorders such as borderline personality and the like. Also, previous attempts often herald a completion later in life, but not always.

    In the case of this person (who of course was not one real patient, but an amalgamation of many people I have seen who present with similar complaints), if proper treatment is started soon and there are no other complicating factors, then the outcome can be quite positive. This might mean a brief hospital stay, counseling or psychotherapy, or medications, or a combination of all of these. Psychosocial issues such as family support, living conditions and vocational situation are also in the mix and play a big role in recovery and stability.

    The risk for completed suicide in someone with many risk factors as above can almost double, so it’s important to address all of these issues.

    G

    Like

  6. Many thought provoking topics here. I think this would be the saddest state to ever be in, to be so hopeless and broken that you wouldn’t want to go on. Life is so hard and sometimes it just takes one more thing to put someone over the edge. I’m so thankful for the work that you and others do. It must be very hard to deal with this every day so do take care of yourself too.

    Like

Comments are closed.