That is not to diminish the very real pain of those who are truly hopeless. The ones we're talking about those for whom an attempt at suicide is just an event. People who actually want to commit suicide see it as a resolution. They are they ones who often present in advance, recognizing their suicidal thoughts but not wanting to surrender to them. These are the true "cries for help," and with a bit of experience you can identify them almost immediately. Their despair is palpable, the air between you thick with emptiness, and as you talk you begin to feel that suicidal thoughts are probably not a sign of illness, and that suicide is a conscious, rationale, and even reasonable option. And there are truly suicidal patients who are found by friends or family unconscious and unresponsive, keeping everyone in the dark about their plans, and who are genuinely disappointed that it didn't work and often puzzled by their failure because they've done their research in advance. These are the people in true crisis for whom we should bend every rule and twist every arm to get them the help they need.
(This is where I take moment to lament the loss of a what we might call "educational" therapy. It is often true in medicine there are both easy and hard ways to achieve the same result. For instance, I can resolve a case of gonnorhea with with a shot in the butt of an antibiotic called Rocephin or with a large oral dose of a different antibiotic. Which one you get depends on how you've treated the ER staff, and if I think you're the victim or the perpetrator. If I think you need a strong disincentive to your continued risky behaviors, or you've been a jerk yo the nurses or to me, you get the shot. It's educational, in that you learn the difference between acceptable and unacceptable behaviors. Twenty years ago, we had a lot of "educational therapy" in overdose management. We'd take these huge half-inch plastic tubes called Ewalds and shove them down the patient's throat into their stomach, under the premise that we were going to wash out their stomach with a tube big enough to get out all the pill fragments. Or maybe we'd just give them a nice big slug of ipecac so they could vomit and puke and upchuck for hours on end. These actions would not only be therapeutic, but serve as disincentives to engage n the same behavior in the future. Alas,science has deprived us of some of it's fun, as it turns out that with rare exception there really re no pill fragments to go after, and by the time the patient gets to the ER there's really nothing left in the stomach to barf up. About all we get to do is make you drink some grainy powdered charcoal...just like in your grill but without the impregnated lighter fluid...if you show up within an hour of your overdose. Maybe if you refuse the urine test we restrain you and pass a catheter into your bladder, but that's about it anymore. Sigh.)
As I recall, our conversation went something like this:
Me: "Hey, I'm Dr. Rodenberg. What's going on?"
Him: "Fuck you, man."
That's as far as I got in Round 1. The paramedics filled me in on the rest. His girl had gone off with another guy, and he decided to get back at her by taking four...count 'em, four...Tylenol. For the record, I take four Tylenol for a headache. (Yes, I know that's technically an overdose, but I can calculate my weight-based toxic dose so I'm good. The lethal amount can be found online by anyone who's serious about suicide. See above.). He took the Tylenol, then called the girl, who called the police but, in what I can only assume is a flash of insight and maturity, did not return to their hotel room to offer comfort or solace.
There are other educational interventions besides tubes and purgatives. Reality testing, for one.
Me: "So I hear you took some pills to piss off your girlfriend. Where is she? is she here now?"
Him: "She's fucking Bobby."
Me: "So how's that working out for you?"
Him: "Fuck you."
The truth is a harsh mistress. Maybe even worse than an Ewald tube.
(While this particular entry into the blogosphere addresses those who say they want to die but really don't, let's not forget that there are two related groups in this discussion as well. The first are those people who don't want to die but have done everything in their power to do so. These are the morbidly obese, the ones who can't be bothered taking their medications or seeing the doctor. It's those whose eating habits and lack of exercise are practically invitations to death. It's the smokers, the alcoholics, the drug abusers. You can make a case...weakly, in my opinion, but at least more than for fibromyalgia...that these people have different physiology, that they react differently to stressors and stimuli, and that they are subject to unique and oppressive psychosocial and economic factors resulting in health issues that are not really their "fault." There may perhaps be some truth to that, but there's also truth to the fact that we can choose a healthy lifestyle and that we can take advantage of community resources to help us with our issues. Because we're no longer willing to build personal responsibility into our health care policies, we keep wasting time and effort giving first class medical care to those who don't care enough to do their part. I have no problem caring for someone who's done damage to themselves but is now doing their part...quit smoking or drinking, losing weight, following-up with their own physician. For those who accept no responsibility for their own well-being, at some point our expenditures have to stop. The devil, or course, is in the details. The solution lacks the clarity of what we might call the Jean-Luc Picard Limit. (The line must be drawn here! This far, no further! And I will make them PAY for what they have done!)