Suffer the Little Children

We are all happy that with the arrival of three vaccines against COVID-19, the end of this long, stressful pandemic might finally be in sight. However, I read two articles recently that gave me pause. I wanted to share them with you .

The first, entitled Kids’ Mental Health is Still Pediatricians’ Greatest Concern, was in the Sunday, March 7, 2021 edition of the Augusta Chronicle. In it, Steven Shapiro, Chair, Department of Pediatrics, Abington Hospital, Philadelphia, PA, stated that “20% of calls are now to put kids on more medications for panic attacks and anxiety.” He was quite concerned that the uncertainty and anxiety spurred by the pandemic, coupled with a lack of social contact, may be having lasting effects on the mental health of children and teens. As we have all seen, children seem to be less likely to have serious physical illness from COVID-19, but the emotional toll of this ongoing pandemic may be affecting them more than we know. Vaccines are super and many of us have already had at least one dose, but they are not yet available for children. Moderna began testing its vaccine for young children just recently, so there is hope that this age group may soon be part of the more fully protected when a vaccine is deemed safe for them to take.

What kind of emotional affects does the pandemic have on kids? For one, they worry about somehow getting infected, then making their parents, grandparents, and teachers sick, according to Stephanie Ewing, Assistant Professor in Counseling and Family Treatment at Drexel University College of Nursing and Health Professions. Routine health appointments and follow up visits for well checks and vaccinations, among other things, fell drastically in the first few months after the pandemic was discovered and stay at home orders became more common. According to a November 2020 Blue Cross/Blue Shield report, vaccinations for measles and whooping cough fell 26% compared to the same time in 2019. On the positive side, there has been a decrease in the number of cases of strep throat, flu, and ear infections due to social distancing, says Jonathan Miller, a pediatrician at Nemours/Alfred duPont Hospital for Children. Dr. Miller also notes that children have been much more inactive, they have had an increase in screen time, and they have been home for a much longer period of time than pre-pandemic times. He wonders about the impact of these on overall wellbeing. There has been an increase in depression and anxiety symptoms in his practice as well, and he has shifted to a more proactive stance and an emphasis on preventative care when dealing with behavioral and mental health issues.

The second article, MUSC Doctor Says Pediatric Suicide , Suicide Attempts “unprecedented” Amid Pandemic, appeared in the Post and Courier on 2-19-21. It continued to look at the issues we’ve already outlined but went a step further to drill down on the issues of suicidal ideation, suicide attempts and completed suicides. It also made this issue much more real for me, as these doctors live and work on the South Carolina coast in the Charleston area.

Dr. Elizabeth Mack, Chief of Pediatric Critical Care at MUSC, says that the number of these suicidal kids has reached a crisis in Charleston during the pandemic. What they are seeing inside the pediatric intensive care unit is much higher than normal and unprecedented. “We’re seeing a twin pandemic in many different ways. The isolation is really amplifying the inequities that have been laid bare for us.”

What are some of the factors that are contributing to the rise in pediatric suicide attempts and suicides? Isolation, grief secondary to the loss of loved ones, and financial insecurity are just three. Delayed return to school, which of course may be rectified in the coming months for many students, has lead to increased anxiety and depression. Schools are also safety nets for kids who don’t have enough food, who get most of their social needs met there, who have better access to physical and mental health care in school, and who sometimes are rescued from various kinds of abuse when a teacher or counselor sees warning signs and investigates further. Even when they are in school, some children worry about getting infected with COVID-19 themselves. Plexiglass barriers, mask wearing and social distancing also lead to odd emotional reactions in some children.

What can we all do to help?

Parents, teachers and counselors can be as open as possible with kids, including sharing some of their own healthy emotional responses to the pandemic and how they dealt with them. Focusing on the future can be very helpful. All of us can be vigilant, and if a child acts or sounds or interacts differently than usual, taking them to their pediatrician is a good first step. One more potentially lifesaving thing we can all pay attention to? Gun safety.

Dr. Annie Andrews, Director of Advocacy in the Department of Pediatrics at MUSC, noted that pre-COVID-19, thirteen million children lived in homes with firearms present, and four million of these in homes where the firearms were not secured. Children in homes with guns are three times more likely to die from suicide. Eighty per cent of children who attempt suicide with a gun will die. Only 2% of those who attempt to kill themselves by ingestion/overdose will die. Gun safety means unloading, locking up, and separating ammunition from firearms. As many as five children a week have been brought to MUSC with self-inflicted gunshot wounds, either accidental or intentional, and many of these kids die.

As Dr. Andrews and others in these articles said, these data are still anecdotal, but more data will be forthcoming as we go forward. As I started this column by saying, we are very happy that one pandemic seems to be heading towards its latter stages. Unfortunately for our children and teens, another pandemic may just be beginning, and we will be wise to watch for it and confront it wherever it arises.

More Than Words

Do you remember the old E. F. Hutton commercials?

The premise was of course that “when E. F. Hutton talks, people listen”.

We have known for centuries that words can influence, motivate, demean, inspire and otherwise cause communications between people to take on all kinds of meanings. Words can elevate issues to the highest levels, and words can shut down meaningful intercourse between countries, leading to war.

We have known many famous people who use words to get their messages across.

Winston Churchill, in Great Britain’s darkest hour, was to have famously said, “Never, never, never give in.”

Dwight Eisenhower said, “I have only one yardstick by which I test every major problem — and that yardstick is: Is it good for America?”

Pope John Paul II said, “The ultimate test of your greatness is the way you treat every human being.”

That last quote leads me to write about one of the issues and stories of our time.

Yesterday, Michelle Carter of was found guilty in a Massachusetts courtroom of involuntary manslaughter in the death of her friend Conrad Roy III. She is to be sentenced on August 3rd, and she faces up to twenty years in prison. She is twenty years old.

At issue in this case was whether or not words, simple words, can cause the death of another person.

You by now know the story. Roy was a shy, anxious boy, a troubled teenager who had a mostly technological relationship with Carter from 2012 to 2014. Carter had her own baggage and demons, and these seemingly clouded her good judgment when it came to how she responded to her friend’s anxiety, depression and suicidal ideation. At first, Carter encouraged Roy to get help for his troubles, but in the two weeks before he killed himself on July 12, 2014, she seemed to abruptly shift gears, telling him repeatedly that he should simply go ahead and commit suicide.

The guilty verdict did not seem to hinge on the many text messages between the two, no matter how inappropriate or negative they were. In the end, the judge focused on the phone call that took place between the two as Roy was sitting in his truck, which was rapidly filling with carbon monoxide. He seems to have changed his mind about killing himself at the last minute, as those who struggle with these thoughts often do, and got out of the truck. He told his friend that he was scared.

Instead of telling him that he did not have to complete the act, or that he should call someone for help, or instead of calling someone herself, she simply told him to get back in.

She knew, after two years of communication with him, about his ambivalence, his fears, his worries, but she disregarded all of that.

She told him to get back in.

She knew that he would most likely die, that he had said that he wanted to die, and she encouraged him, by phone, to stay in the environment that eventually killed him.

This was a landmark case, in that most of the time, someone who is contemplating suicide or carries out the act has thought about it, maybe even planned it out as Mr. Roy had. It is considered to be an act of free will, a person deciding that they no longer want to live and taking steps to insure that their plans to kill themselves come to fruition. In this case, Carter knew that by telling her friend to get back in the truck that he would likely die, but she did nothing to stop that eventuality. She did not tell him to get out, she did not call his family, she did not call the police and she, by her direct words to this unfortunate young man, directly contributed to his death.

The prosecution, and the presiding judge in the case, evidently felt quite strongly that her physical absence from the scene of Mr. Roy’s death was immaterial.

Katie Rayburn, an assistant district attorney, said, “She was in his ear, she was in his mind, she was on the phone, and she was telling him to get back in the car even though she knew he was going to die.”

Such a sad case involving two very troubled teenagers whose very investment in each other turned sour and caused the death of one and the possible incarceration of the other.

When people speak, especially those who we admire, respect, love or try to emulate, we listen. We may listen superficially, we may dwell for a time on what they say, or we may obsess about it.

We may act on what we hear.

Our actions may have consequences.

Whether coming from a pope, a statesman, a president of the United States, or a friend who is as troubled as we are,

words matter.

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:







SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.




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.

Death, Where Is Thy Sting?

In 2014, the suicide rate in the United States was 13 per 100,000 people, the highest recorded rate in 28 years. Over that year, 43,000 Americans killed themselves. The U.S. suicide rate also rose 24% over the 15 previous years (1999-2014), with the rise correlated to the period’s severe economic slump.


I am getting ready to enter a five day stretch of work, during which time I will spend fifteen hours in mental health clinics, up to seven hours in probate court related evaluations, and thirty seven hours doing telepsychiatry consults in emergency rooms around South Carolina. If past history is any predictor of future trends, which it always is, then many of those hours in clinic and ED will be spent assessing suicide risk. 

Threatening to commit suicide can be a cry for help, a manipulation to control an estranged spouse, a last ditch effort to control debilitating anxiety, the only perceived way out of a drug addiction, or a gamble that one might be admitted to a secure hospital when one has no where else to go. It may also be, unfortunately, the successful ending of one’s life by one’s own hand. 

We see various forms of threats. Let’s me say right off the bat that ALL threats should be taken seriously. ALL. 

There are teens who cut themselves. Although some folks do indeed cut themselves seriously enough to to die, most of these self-identified cutters do so to control anger, stem impulsive and destructive urges, or to “just feel something”. 

There are others who have suicidal ideation, real thoughts about dying, without any specific plan or intent or mean to carry out the threat. 

Other groups have suicidal ideation, specific plans, and means to carry out those plans. These are often considered gestures if they involve non-lethal methods such as swallowing a small amount of household cleaner, burning oneself, or trying to drown oneself in the bathtub. Again, some of these gestures can be inadvertently lethal, such as when a preteen decides to take a whole bottle of a “safe” household drug like Tylenol, shuts down her liver and dies. 

Then there are the more serious attempts, such as overdose with a lethal amount of an antidepressant (one week’s worth of some such pills is enough to cause death), hanging (still one of the most common methods used in jails), and self inflicted gunshot wounds. I have seen patients who tried to hang themselves and succeeded only in causing anoxia severe enough to cause permanent brain damage. I have also seen a police officer, well trained in the use of guns, attempt to kill himself by pulling the trigger of a shotgun with his toe, only to have miscalculated the kick of the weapon, blowing his face off but leaving him very much alive. 

The most serious of suicide attempts, the ones who succeed, often give you clues to the act before they carry it out, but manage to succeed anyway. They are often middle aged to elderly men, divorced or widowed, with medical problems, a history of depression, substance abuse, taking antidepressants and who have made some contact with a healthcare provider within days of killing themselves. These men are disconcerting, because they are often resigned to the fact that they are going to die, are relieved and even happy about it, are firm in their convictions and plans, and are very likely to be successful. I have seen some of them leave all the bills paid, the financial and other documents neatly organized on desk or disk drive, and have a letter, will, and other documents laid out for easy discovery by their grieving families. 

Who kills themselves the most? 


For every one completed suicide, there are about twenty five attempts. Often, these are women using overdoses, cutting or other attempts. Men tend to use guns, although women are catching up to them in that department. Firearms account for almost fifty per cent of all suicides. White males accounted for seven of ten completed suicides in 2014, and middle aged to elderly men are still the most at risk group of them all. 

Women attempt suicide three times more often than men.

Men die of suicide 3.5 times more often then women.

Obviously, suicide attempts and completions are still a huge problem in the United States. 

Suicide is the tenth leading cause of death in South Carolina, where I practice psychiatry. On average, one person dies by suicide in this state every 11.5 hours. Our telepsychiatry shifts cover eighteen hours per day. 

The rate of 15.13 suicides per 100,000 people is higher than the national rate of 12.93. 

I will go into this long working stretch knowing that the odds are stacked against us, but that we can make a difference if we listen, intervene, and try to catch those who feel that suicide is the only way out. 

If you or someone you know is suicidal, please seek help through your local emergency room, through your doctor, or by calling the National Suicide Prevention Lifeline at 1-800-273-8255.

Still Waters Run Deep

There was an article in today’s Aiken Standard, my local paper, via the Associated Press wire. The title was “Robin Williams’ autopsy found no illegal drugs”. Aside from my annoyance at the misuse of the possessive, I did think about some things after reading this article.

The autopsy showed that Williams did indeed have evidence of therapeutic levels of his prescribed medications in his bloodstream. It is not a secret to anyone now that he had struggled for years with both mental health and addiction issues, and was in treatment at one time or another for both. He was being prescribed medications to help him with these conditions, and it appears that he was taking them.

He did not have any alcohol or illegal drugs in his system at the time of his death.

His wife, according to this story, was most likely home when he decided to kill himself and completed the act. He killed himself by hanging with a belt.

Even those with money to burn, success, achievements, loving family support, and ongoing treatment and medications can feel terribly isolated, alone, and hopeless. Depression can be devastating. Help can seem light years away.

I see so many hundreds, even thousands of people who struggle with addictions. Life on drugs and alcohol is sometimes overwhelming, fraught with relationship problems, legal problems and financial ruin.

On the other hand, sometimes life without drugs is just as hard to bear, maybe even more so if you have been addicted for years. The raw emotion of it, the demands and stresses and trivial annoyances of daily life seem just too big, too complicated, and too much trouble to deal with. They seem unsolvable.

For Robin Williams, even with treatment, fame, fortune, and family, it was all just too much. He decided that he could not go on.

I cannot and would never judge him or anyone who committed suicide. I have not been inside their heads, and I do not know what final thought they have right before they decide that they must die.

I do know that if someone needs help, if life is just too hard and whatever they are doing is not enough to sustain them, then action is imperative.

Sometimes still waters run deep.

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.”


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.


“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.

Any Given Day

I love football.

There is one thing that I absolutely believe to be true about the sport I love.

Any given team can beat any other team on any given day. 

Sometimes my love of sports and the little metaphors that sprout from it spill over into my workspace as well. 

At the end of each shift I work in telepsychiatry, one of the last things I do is complete an electronic log of the consults I worked on and completed that day. I list the initials of the patients and the demographic information about them for the bean counters who hang out in Columbia making sense of what we clinicians do every day. I add a few diagnostic codes, and then I also look at a little drop down menu that allows me to describe in a few simple words why they needed to see me in the first place. The reason for the consult. 

On any given day, the pattern that jumps out at me is something like this:

Danger to self.

Danger to self.

Danger to self.

Danger to self.

Danger to self…

In other words, the vast majority of folks I see on any given day want to kill themselves. They are suicidal. They have tried to slit their wrists or overdose with pills or drink bleach or hook hoses up to car tailpipes or shoot themselves in the chest. 

Now, most days I am pretty circumspect about my job. I know that it is stressful. I realize that it puts me at risk myself to hear story after sad story about the woes and trials and tribulations that my patients bring and leave at my feet. Anyone who knows me, has had a conversation with me or reads me knows that I am a person who loves stories. I love to hear them. I love to tell them. I love to write them. I will go back to work at the clinic this morning because I know today, through stories, I will learn something that I did not know yesterday, something that I can use to help someone else tomorrow. 

On any given day, however, the stories can be so bad, so terrible, so hopeless and so horrible that they try their very best to not only beat me up, but to beat me. Finish me. Pummel me. Make me quit. Send me packing. Some days I feel defeated by them. Some days I am flat out of answers, suggestions and positive statements. Some days I slink out the back door, swiping my little electronic card to get out, half hoping that when I come back the next day it will malfunction and not let me back in. 

But you know, if this list of woe, this chronicle of misery can beat me yesterday, then today is a new day. It can be my time to come back, march down the field, score a last minute touchdown and win the game. On any given day, I can be the one who comes out on top, not the misery that the world would throw at me by way of my chosen profession. 

I saw a lady yesterday who is very, very ill. She is sick physically as well as emotionally. She knows this, and it torments her. She cannot do what she used to do, no, she will never be able to do those things again. She is depressed, sad, sometimes hopeless, sometimes suicidal. She has been in counseling. She has taken medications. She is only marginally better. She is worried that nothing is going to work, that she will never feel good again. 

I could sit there with her and commiserate, feeling sorry for us both, the defeated patient and her defeated doctor, helpless in the face of one of the illnesses that lead to more than thirty thousand suicides a year in this country. I could write her off as just another very, very difficult case that I don’t know how to solve, how to fix. 

That’s not why I went into medicine.

On any given day, my job is to be there for her, this lady who came shuffling in with braces and cane and aches and pains and depression to see me when she’d rather have stayed at home hidden away from the world. 

On any given day, my job is to be there with her, to listen to her story, find something in it that will guide me and teach me how to best help her. 

On any given day, my job is to try, and try, and try again, until there is no more time on the clock.

That is the only way to win, in football, medicine and life. 



Judgement Day

“If they’d rather die then perhaps they had better do so and decrease the surplus population”

Ebenezer Scrooge


Convicted Cleveland kidnaper and torturer Ariel Castro was found dead in his prison cell recently. He hanged himself until dead, a punishment that he had undoubtedly decided to inflict on himself with no prodding from any court or judge. He was serving a sentence of life plus one thousand years for his crimes. 

Fellow mental health doc ClinkShrink published a piece about this the other day (read it here) and I feel compelled to at least add my two cents in a general way to this discussion. 

We hold these truths to be self-evident:

1) Those who commit heinous crimes, and are convicted of those crimes, should be punished according to the system of laws and punishments that we have established in out country to deal with such issues.

2) Inmates in prison are entitled to humane treatment. We are not, as a rule, a nation of torturers and sadists.

3) Incarcerated individuals should be kept safe, not only from others in the general population, but from themselves if they are considered potentially self destructive. 

4) No matter how good the provision of mental health services, no matter the precautions, no matter the safety procedures put in place, a person who is committed to ending his own life will find a way to do it and will be successful. 

There will be much discussion of this event, as there was of the death of Jeffrey Dahmer and other notorious prison inmates that had their time in the bright glare of the national spotlight after committing their crimes in the dank, dark recesses of their sordid worlds. Dahmer was bludgeoned to death with a broomstick and was found with massive head injuries in a pool of blood in a toilet area by the prison gym. My hunch is that, given time, Castro may have suffered the same fate, or something very similar. Even criminals have their code of ethics. Abusers and killers of women and children are not the most revered of prison occupants. 

My personal opinion? 

This man was a human being, just like me. He did some unspeakable things, and he was to spend the rest of life without the freedoms that all of us enjoy. Did he deserve that? Yes. Did he deserve to die, especially by his own hand? No. 

A very close friend and I have had several conversations about heaven, hell, limbo and purgatory. My friend believes that anyone, even my oft-used example Adolph Hitler, is allowed, even deserves the chance to work earthly things out in the afterlife, to be given the chance to repent for even the most grievous sins. 

I am not a theologian.

Whether or not Ariel Castro will get to do this and be forgiven for his decade of brutal torture and assault of three innocent women is beyond my ability to fathom. I will leave that dilemma to God, and I am very glad that I am not Him. 

I do know two things.

Our surplus population, that group of individuals who are incarcerated and maintained for years behind bars for committing crimes most of us will never understand, has been decreased by one. 

Our collective societal sense of wholesomeness and wellbeing has also been diminished, and can never be improved upon by the senseless death of one of our own, no matter how marginalized he was. 


They Were Soldiers Once…


Yesterday was the sixty-ninth anniversary of D-Day, to the day, to be exact.

Today is the eighteenth anniversary of my father’s sudden death of a brain aneurysm at age sixty-two. I can remember the exact date that my father died, because it was one year and one day after the fiftieth anniversary of D-Day. Yeah, I’m a history nerd. I’m weird like that.

I watched Saving Private Ryan last night for the umpteenth time. Helluva movie.

That movie always gets me thinking about a lot of things.

War. Death. Country. Patriotism. Sacrifice. Loss. Courage. Family. Teamwork.

Lots of good themes that Mr. Spielberg and Mr. Hanks really made us consider as we watched the utter horror of the beach landing, the carnage wrought by bullets and shells, and the intense, painful, agonizing up-close look at death that is hand-to-hand combat.

Sixty-nine years ago. Wow. Ancient history, right? Yes…and no.

We still fight each other. Some say we have dumber people but smarter bombs. We send in drones where no rational human would dare to fly. We kill from thousands of feet in the air or hundreds of miles away, instead of making one last, glorious stand before blowing the bridge. That “whites of their eyes” thing is so eighteenth century.

One thing that hasn’t changed?

Human casualties of war.

Not just the dead. We don’t have the daily Vietnam body counts any more or even a wall or monument yet built to those who have served in the choking deserts or the arid plains. School children and many adults still struggle to find the places on a globe where all our modern-day soldiers serve.

I see them in the emergency department sometime. They come in quietly, suffering in silence as they were trained to do. They drink too much. They smoke pot and do coke and they cope. They get depressed. They have panic attacks. They want to kill themselves. 

They were soldiers once.

When I was a very young intern, and later a slightly less young resident, a wallet biopsy was always the first procedure performed on a vet as he (it was always a he back then, but not so much now, of course) hit the door of the Life Support Unit, as the downtown emergency room was called in those days. A purple 100% service connected card was golden. A blue card, not so much. Services were rendered by staff as services had been given by the vets. Orders followed, no questions asked, no cost too high, no river too deep or mountain too high. Semper fi. No man left behind. That was then.

This is  now.

Where did we go wrong?

Vets are struggling to get the services they need. They are dying in droves by their own hand. Sometimes they take a loved one with them. Oh, I exaggerate, I hear you say. Read this.

They call the veterans hot line and talk to a nice person who directs them to the closest local emergency department. Outsourcing, I guess you could call it. Something like that. Admission? Maybe, at a veterans’ hospital in this state or one over. Groups, drugs, counseling, the usual bill of fare. Suicide prevention classes and education. More hot line numbers just in case.

I always try to thank them for their service. Sometimes I forget, or they are too out of it or psychotic or hopped up on drugs to hear me or understand. But I try. It’s the right thing to do.

Can you imagine what it must have been like, sixty-nine years ago, being propelled out of that Higgins boat, feet not touching ground but water, sinking, not hearing but seeing, seeing bullets whiz past your head underwater? Coming up for air and struggling to make the beach just to struggle again for shelter from the hailstorm of lead and fire and spattered blood and brains? Trying to survive?

Can you imagine what it must be like now, coming back from the desert heat and the sand and the glaring sun and the mountain posts and thinking that death is the best option to get you out of the hailstorm of routine life-after-living-death? Not knowing where to turn or who to call? Trying to survive?

They were soldiers once.

They didn’t fail us then.

Will we fail them now?