It’s a common scenario in emergency room telepsychiatry. 

Sixteen year old female comes in after an argument with her boyfriend or her parents (usually fathers, sorry guys). She decides that she is going to get back at the person she fought with, and show them a thing or two. She rifles through the medicine cabinet. The thing that immediately jumps out at her is a big bottle of acetaminophen, the 500 count. It’s cheaper that way you know. She thinks what the hey, it’s Tylenol. How bad could it be if I take a handful or two of it? It’s headache medicine. She proceeds to do just that. Someone finds her, calls 911, gets her to the local ER. Her acetaminophen levels are through the roof, and rising rapidly. Houston, we have a problem. A big problem. Acetaminophen taken in even larger therapeutic doses over a long time can cause liver damage. Overdoses of it can cause liver failure. These ODs kill livers. And sixteen year olds who didn’t really mean to die. 

He’s a stud, a late twenty something with nice tattoos and even nicer pecs who thinks the world is his oyster and the girls will always fall for him. He works hard in construction during the week, but the weekends he considers his to blow out and party like it’s 1999. (RIP, Prince) He starts with marijuana at nine, alcohol at fifteen, cocaine at seventeen, and now and again a little crystal if he can score it. This time, on this Saturday, he goes a little too far. The cocaine, most likely cut and adulterated with God only knows what, treats his heart like crap. He has an arrhythmia that won’t go away. Hearts need to beat regularly. If they don’t, dirt nap. 

He is one of the most genteel and dignified men I’ve ever seen. His silver hair is still thick and full, his skin is ruddy and healthy looking, and he is dressed in nice khakis and a polo shirt. He smells of alcohol, his other vice (expensive cigars). He saw his family doctor the morning before he was admitted to the ER. He is on a small dose of antidepressant and something for sleep. His alcohol use is escalating, he has isolated himself, and he rarely sees his friends any more. He has stopped reading, and he doesn’t care at all this year about another love of his, presidential politics. Oh, and as for love? His partner, his true love, his wife of sixty five years, finally said goodbye to him when she passed away peacefully in her sleep six months ago. He has felt lost, alone, and abandoned ever since. He can’t shake it, and now he’s not even sure he wants to. “Let me die, Doc. Please just let me die.” 

The sixteen year old wakes up, feels a bit better, eats a little. 

“It was just Tylenol, for God’s sake. I was pissed at my dad. I didn’t mean to kill myself. Can I just go home, please?” (Insert grand eye roll and turn away from Doctor, arms crossed)

Her insight is nil. She damn near died. There are real problems at home, not to mention the fact that she has zero coping skills when normal day to day problems arise. She see none of this-yet. 

“It’s a fluttering, Doc. My heart is all a flutter, I guess, you know. The way I affect the ladies. They see me, and boom! They fall for me. It’s a curse.” 

He winks at me, unshaven, hair mussed, but still brash and arrogant and full of the misdirected passion of youth. He has little insight into the fact that he is a heartbeat away from nonresidency. 

“Oh, c’mon, Doc, give a guy a break. I still got some weekend left before seven AM work time on Monday. There’s beer in the fridge at home, buddies are blowing up my phone. I’m good. I’m really good. Let me out of this prison. Please!”

A single tear runs down his handsome tanned face. He looks up at me, telegraphing quite clearly that if he does not get some help, if he is sent home, that he will die. Oh, did I mention that he is an avid hunter and has a safe full of guns at home?

“May I please be discharged now? I’d like to get home to feed my dogs, and take a nap…” He trails off, head hanging down to his chest, hands clasped limply in his lap. He begins to sob, quietly. 

The common threads here are obvious. 

Some patients are at extremely high risk of self harm, even death. Some are young and naive, some are full of the vigor of young adulthood, and some are old and tired and sad. 

The other common thing about all these types of consults is that each patient, without fail, asks to go home. They have almost succeeded in poisoning themselves to death, they are playing Russian roulette with needles instead of guns, and they have given up on any further happiness in life. Somehow, they get to the ER and seek help. Yet, they can’t see the gravity of the situation, the extreme risks, the pain they would cause the ones left behind. They only want what they want, which is not to be in the emergency room. 

What to do?


You push me…

I pull you…

…with any luck, back into your own life. 

Don’t remember what a pushmi-pullyu was? Watch the video below and it’ll come back to you. 


3 thoughts on “Pushmi-pullyu

  1. and thank goodness you are there to do just that, and they’ve been given a chance to be pushed and pulled. I know it doesn’t always work (I’ve seen teenagers need liver transplants after they emerge from their hepatic coma, I’ve seen the atrial fibrillation from cocaine and meth result in devastating strokes, I’ve seen the obituary notices of the depressed and lonely elderly men who can’t take on another day) but at least you are trying to open the door back to life.


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