Baby Come Back

Death is final. The end.  El fin.  It's the existential dread of Homo sapiens, the only species we know of that contemplates it's own mortality.  So it's surprising to me how many people come to the ER and say they want to die.  Their numbers keep rising, and it's a fair argument to try to figure out why and to assign the requisite blame.  (I've even heard the suicide rates of middle-class white men being tied to the rise of Donald Trump.). But while there are truly desperate people out there who need genuine help, it may be surprising to learn that they're usually not the ones who I see in Sinatra's wee small hours.

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.

Ah, but then there's the rest, the ones who make up bulk of our "suicidal" clientele.  These are the folks who respond to life's stressors by chasing down some vodka and few Tylenol, perhaps guzzling down a handful of their psych medications for good measure, and then call everyone they know (and especially the ex) to let them know they're killing themselves.  There is wailing, thrashing, and tears.  There is also a lot of texting and cellular calls.  This is not a cry for help.  This is attention-seeking behavior, or (to use a technical term) a "dramarama."  It's the ER equivalent to the Security Theater performance of the Transportation Security Administration.   

While experience gives you a gut feeling abut who's really suicidal and who's not, there are some objective clues to guide the neophyte.  First, there's no lethal mechanism involved.  This might not have been a clue in the pre-Internet era, but today anyone with a cellphone can figure out how much of what medicine to take to kill themselves.  Similarly, if you want to kill yourself by jumping, or with a gun, you don't sit on the railing of a bridge and think about it until someone pays attention, or wave your gun around to make sure it gets noticed.  And speaking of cellphones, if you've texted and called people (especially the ex...that wasn't a joke) to let them know what you're doing, you're not in it for real.  And they don't put it on a "to do" list, as did one patient whose list, on a thin notepad festooned with flowers and tiny kittens, included things like "buy groceries" and "kill myself."  (I'm not making this up.) People who truly want to commit suicide just get on with it.

A second clue is that the patient, when confronted with the fact that their "attempt" is going to result in consequences, is suddenly no longer suicidal.  Patients with psychiatric disorders can certainly have labile moods, but you can't turn depression on and off like a light switch ("It's a clever little Mormon trick."). You don't go from wanting to quit life to laughing and smiling when friends and family (and especially the ex) arrive, ideally to fawn over your poor lost soul.  One of the questions I always ask patients is, "If I gave you a clean and painless way to kill yourself right now, would you do it?"  It's the ones who immediately answer "yes" in a firm voice, no tears, looking me straight in the eye that I worry about. If you're investing your energy in weeping and wailing and calling and texting (there's that cellphone again) and wondering where your beloveds (mother, father, boyfriend, girlfriend, or ex) is, you've got no intestinal fortitude for what you claim to have done.

A corollary to this is that patients who are not truly suicidal refuse to cooperate with care when informed that labs may need to be drawn and they may be held in the ER for psychiatric screening, claiming they have "rights' and we can't "make them do anything."  We do inform them early n that since they made a suicidal gesture, the law obliges us to hold them for their own safety until they are cleared; and that we hope that they'll cooperate with us in what we need to do.  The truly suicidal accept this with resignation.  They're beyond caring what happens to them or why.  The dramatists rebel, and sometimes it gets ugly.  They're also the ones who specify what hospital admissions and discharge plans are acceptable to them, and threaten to call their lawyer.  (Standard response:  "Go ahead.")  But no matter what they ask for a meal tray and a Sprite within 45 minutes of arrival.  You can time it.

It also shouldn't be forgotten that there are other kinds of secondary gain from claiming suicidal thoughts or tossing down a few pills.  There are a number of "regulars" who are quite skilled at playing the "suicide card."  If you have no place to stay, you now get food and lodging for at least a night at a local psychiatric clearinghouse.  If you were going to jail, perhaps now you don't.  If you're lucky, maybe you even get admitted to the hospital and Case Management invests time in finding you a place to live or getting you signed up for benefits and services.  And if nothing else, at least you have time to sober up in a warm, clean place.  The psychiatric clearance process often takes time, and at night that usually means you're with us 'til sunup.

So for many patients who come is with a suicide attempt, especially involving an overdose, they know it's all about attention just as we do.  But our medicolegal system, as well as our cultural belief that no one is responsible for their own actions, means that we have to maintain some kind of fiction that something needs to be done rather than just simply calling someone out on their script.  That fiction is called the psychiatric screen, and the resultant "Contract for Safety," where the patient agrees in writing to call for help as needed and to follow-up with counseling., because every truly suicidal person is going to be help up by a signature on copy paper.   

But here's the paradox of clinical practice.  I really don't mind taking care of these folks.  It's fun to watch the show.  It's admittedly kind of a power trip to tell people what they can and can't do know that they're on your turf, and watch their faces as they realize they've set events in motion far beyond their control.  They're easy patients as well; with very few exceptions, modern overdose management is simply watchful waiting.  And from a workload standpoint, it's great. They often need several hours of observation based on the peak blood levels of the drug they took, and then several hours after that to arrange a psychiatric disposition.  Which means they clog your rooms up for quite some time, decreasing your patient turnover and ultimately your overall workload.   The bean-counters who have never touched a patient but still grade you on throughput time as a measure of "quality" hate it, but from the standpoint of the working doc they prolonged ER stay in entirely justifiable and quite welcome, thank you very much.  

(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.)

Most of the one-act plays we see are attempts to curry favor in a relationship.  I've never been able to figure that out.  It seems to me that if I'm dating (or have just broken up with) someone who takes a bunch of pills in an effort to make me feel bad, the long-term prospects of that relationship are pretty poor.  Whenever I think about this, I'm always reminded of the college student I saw while working in Daytona Beach.  He was down there for Spring Break, and found his girlfriend walking the beach with another guy.  By the time I saw him, he had already taken a few swings at a paramedic, which meant now he was spread eagled on a cot in four-point restraints, and not in a fun, Stevie Nicks, leather-and-lace filled way.  

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!)

Sadly, there's also the other category of people with terrible illness who want to die and you absolutely understand why.  There are people with terminal cancer in perpetual pain, those in end-stage heart failure or emphysema where every breath is agony, and patients with degenerative neurologic disease who can't move, eat, or speak. If they say they want to die, it's because it's the last moment of control they have over their own lives when disease has stripped them of everything else.  We don't do physician-assisted suicide in the ER.  But I will ask these patients and their families if they really want to be fully evaluated and admitted, or can we just do something kinder and gentler, like give you some pain medicine for home and perhaps a bit of steroids to improve your appetite? You'll be surprised how many of these kinds of patients just want to go home and be in peace, and they seem grateful that someone's willing to join them on the plank.  And I'll confess that, when I sense that's what going on in a patient who can't speak for themselves, when I see that look of resignation in their eyes, I'll choose a tone of voice for the family that suggests the right answer. Sometimes you need to go gently into that good night.)