No. 15: My patient tried to kill himself

7 minute read
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Intern year:

“NO! Please don’t! PLEASEEEEE!” came the blood curdling scream of a 16-year-old girl. She was shaking and crying in anticipation of pain, and I couldn’t blame her: the resident taking care of her was about to pull off her fingernail in order to drain a collection of pus in the tip of her finger. Yes, you read that right, he was about to pull off her entire fingernail. She had gone to a new nail salon a few days ago, and unfortunately ended up with a terrible infection (be careful at these salons, ladies and gents!).

To complement her screams, disgruntled patients were shouting, machines were beeping, a baby was crying, and an orchestra of odd smells filled the air. Such was the typical state of an emergency room (ER) in a busy hospital: just overall chaos. Until that point in my first year of residency, I was only in the ER for short spans of time, usually visiting patients that were going to be admitted to my team. I would ask them questions for about 10 minutes, and then jet out of there as fast as I could. For this particular two week stretch, however, I was assigned as one of the primary residents on the ER rotation, meaning that my job included working full shifts in the ER day after day. I was STRESSED. While some physicians enjoyed the fast pace, on-the-fly decision making, and lack of continuity that came along with working in the ER, I did NOT. I felt overwhelmed and anxious all the time, and more exhausted than I had felt in a while.

A man stood impatiently in the doorway of the room next to the girl with the fingertip infection. “Can SOMEONEEEE COMEEE DISCHARGEEEE MEEEE,” he shouted with slurred words, teetering a bit on his feet. “I’m going to drive HOMEEEE.” He was a 27-year-old male who had driven himself to the emergency room for a headache. As it turned out, he was drunk off his rocker. After giving him IV fluids, I had been spending the last few hours going into his room at different intervals to convince him to stay in the ER until he sobered up.

Just as I was about to go speak to him again, someone ran into the emergency room and screamed, “THERE’S A MAN DOWN OUTSIDE THE EMERGENCY ROOM, I’M GONNA NEED SOME HELP! MAN DOWN!” Instinctively, I ripped off my jacket, grabbed a box of gloves in preparation to get on the ground and do chest compressions if needed, and ran outside into the chilly night. When I got outside the ER doors, I couldn’t help but gasp at the sight: a frail old man lay unconscious on the ground just outside the door, blood gushing from his wrist and trailing down the sidewalk for a yard or two down the road. A stack of papers was tied around his neck, and a blood-covered razor was laying a few feet away.

The chaos increased 10-fold. As I knelt down, grabbing a few gloves out of the box to use as a pad to hold pressure on his wrist, someone ran to get gauze. Another person looked at the papers around his neck to see if there was any helpful information. “His name is John, and this note says he tried to kill himself!” someone yelled out. “Quick, someone get a stretcher!” “Someone get the code cart!” “Did you guys clear a room? Let’s get him inside!” “Watch his neck!” “Let’s move, people!” “Should someone call psychiatry?” “No, wait until he’s stable!”

Two minutes later, he was inside a room and connected to monitors. I continued to hold pressure on his wrist, with gauze now (which was much more effective than the ball of gloves I had been using before). Everyone was running around: A nurse gave the patient narcan (a medication that reverses the effects of opiates, in-case he had overdosed on a narcotic drug), someone started two IV lines to give him fluids, a tetanus shot was ordered for him because of the huge wound in his wrist, blood was drawn to send to the lab for all the necessary blood tests, and blood products were placed on hold in-case he needed a blood transfusion. 

“This is crazy,” another one of the residents whispered, holding the stack of papers that had previously been around the patient’s neck. “It’s a 15-page suicide letter. Typed. He details everything people have done wrong to him over his whole life. He attempted to kill himself right outside the ER because he is a former employee here, and got fired after a co-worker lied about something he did. Whoever did it apparently still works here, and this guy was hoping that his dead body outside the ER would finally convince his old co-worker to apologize!” The patient was starting to wake up as I was still holding pressure on his wrist.

“Hey John,” I said loudly, using my free hand to shake his shoulder. “Wake up sir, you’re in the emergency room.”

“I know,” he mumbled. “Just let go. Let me die.”

Of course I wasn’t going to tell him this, but even if I were to let go at that point, he most likely wouldn’t die. Although he had lost blood, besides having a slightly fast heart rate, his vital signs were normal. He hadn’t lost nearly enough blood to threaten his life. Given that he started waking up soon after getting the narcan medication, we suspected that he had also taken some narcotics before trying to kill himself.

“I was trying to kill myself, and I had an important point to make,” He said, interrupting my thoughts. “I wanted everyone to see, and you f*cked it up, toots. Now there’s no justice.”

I looked at him for a moment, expecting him to go on. He didn’t. With the most sympathetic face I could muster, I told him I would need to irrigate his wound with saline (clean it out), and then put stitches in his wrist. He didn’t respond, so I just continued to do my work. A person walked into the room and introduced himself as the “sitter” (aka babysitter who we had called earlier to sit with and watch the patient at all times to make sure he didn’t try to kill himself again). Another resident called the psychiatry team, who agreed to come evaluate him, and planned to admit him to their hospital service once it was clear that there was nothing wrong with him medically.

I asked him if he had any family members or friends he wanted us to call. He glared at me in silence. And then… continued to glare at me in silence. Eventually I attempted to fill the quiet with an awkward “So, how are you feeling?”. Ugh I’m so weird! Of course he isn’t feeling well, I thought while kicking myself mentally.

“You’re wasting your time, toots.” He said. “I don’t need you asking questions, pretending you give a sh*t about me.”

“Please stop calling me toots, I’m your doctor. And I do care.” I started placing stitches on his wound.

“What are you gonna do about it? You can’t really threaten a guy that was about to end it all, I have nothing to lose. Plus, maybe if I piss you off, you’ll just let me bleed out.”

“Not a chance,” I replied, annoyed.

“Why not? If I want to kill myself, why won’t you just let me die?”

“Because I care,” I said, placing another stitch.

“No you f*cking don’t. C’mon toots, you’re just doing your job.”

The truth was, in that moment I wanted to be anywhere but in the emergency room arguing with this patient. Instead I said, “Just cause it’s my job doesn’t mean I don’t care… I got into this business because I care. That’s why I’m here. I don’t know all that you’re going through, but it must be bad. I can’t imagine. If you want to talk about anything, I’m here, and I’m not going anywhere until you’re stable.”

“You want to talk about my sh*tty life? You want me to tell you everything?” His eyes were wide.

“If you want to tell me, I want to listen.” I gave him a small smile and squeezed his hand while I finished stitching him up.

The patient looked at me for a moment, and then exploded: “Stop being so f*cking nice to me!” He started to cry. “It’s pissing me off! No one was being nice when I got fired and falsely accused! No one was being nice when I lost my house because I couldn’t get another job. No one is ever nice!”

He launched into the story of his life, all the people that hurt him, all the people that lied to him, the love of his life that left him… At times my heart hurt for him. At times I wondered how much of the story was true. To be honest, at times I found myself thinking, He really just wants attention, huh. Once or twice, I left him with the sitter to see other patients, promising to come back each time. I listened to him, occasionally interjecting with a “Mhmmm” or “I can’t imagine” or “That must have been hard.” Once I found myself saying, “I really think that with the right help, things can get a lot better for you.”

A few hours later, he was stabilized and ready for transfer. As the patient transporters prepared to take him to the psychiatry wing, he smiled and waved at me with a cheery “Thanks for the pep talk, Toots, but you ARE aware that I’m still going to kill myself, right? Probably with a gun next time.”

I sighed as they rolled him away.

The rest of the night was relatively uneventful. An older man came in with chest pain. A younger man came in because he fell and wanted imaging of his head. Yet another patient came in for medication refills. The whole time, I thought of the suicidal patient. The optimist in me wanted to believe that I could make a difference, that something I said to him that night might make him think differently in the future. The realist in me knew that was unlikely to be the case. Such had been the emotional balancing act I had been trying to perform all through residency: Optimistic enough to give a patient my best, realistic enough so that I wouldn’t become depressed, cynical, or apathetic when nothing changed.

Even now, I wonder if he’s still alive, or if he carried out his master plan – stick it out through the psychiatry ward, get discharged, kill himself in a more definite way than cutting.

Even now, I still hope for the best.

Until next time,

Dr. Oye