I picked her up and put her over my knee with my foot on the couch. I hit her back hard, angling her head down. Whap! Whap! Whap!
Nothing.
Oh my God, oh my God. She’s choking to death. She’s not moving any air. The squeal was dying out. Her face was getting more dusky. Is she going to die? I can’t get the pretzel out!
What do I do? You’re not supposed to Heimlich a little baby. What else can I do? I have to do something.
I spun her around and put my fist in her stomach, lifting her up against it. I not only Heimliched her, I did it with all her weight against my fist.
Pop.
The pretzel sailed across the couch.
She began to wail.
I started to breathe again.
I held her tight, squeezing her to me, trying to calm myself down so I could calm her down. No more pretzels.
Before Molly was born, as my wedding date neared, Mary had asked me how I would feel if Jeremy died. I don’t remember what brought this up, but I do remember answering that of course I would be heartbroken, but that eventually I would pick up the pieces and get on with my life, and down the road I would probably even fall in love again. She may have been surprised by the coldness of my answer, but I was getting used to my usual defense against any kind of loss or pain.
But now, when I think about how I would handle Molly’s death, I’m not so sure I could go on. It feels more accurate to think that if she died, I would have to die as well. I couldn’t tolerate the pain.
How will Pablo handle his pain? And what can I possibly say or do for him that would offer him any real comfort? To murmur the same lines as everyone else—”My heart goes out to you. I am so sorry for your loss.”—what does that accomplish?
As my years go by at Bellevue, and I clock in more time, the stakes keep getting higher. The threat of loss looms larger now that I have people depending on me. It’s not just my survival, which never was that big a priority. I notice with my second pregnancy that I am thinking more in terms of my family, and how to keep it intact. I must stay healthy and safe so I can take care of them. I begin to feel more at risk, the way I did after I was punched. It’s the little things now, not just intimidating patients: for instance, the shampoo we use to kill lice. It’s toxic to a fetus, and pregnant women can’t be exposed to it. With new regard, I look at the bottles lying around the nurses’ station and shudder as I put on a pair of gloves and move them to the locked area where we store medications.
Once again, as I start to show with my second pregnancy, the nurses won’t let me go out into the patient area unless it is absolutely necessary. They treat me like a delicate, though bloated, hothouse flower, and I enjoy the pampering that comes with my gestation. I start spending more time in the nurses’ area doing paperwork, and less time going out to meet the patients in the triage area. I especially don’t go onto the unit if a patient is escalating and will likely require restraints, the way I would’ve in the past.
It gets boring, having less patient contact, but it also makes me feel cared for, knowing that the nurses are watching out for me, protecting me and my family as if I were a part of their family. And they’re right; a pregnant doctor does need extra protection.
A few years ago, when I was pregnant with Molly, a new television show called Wonderland came on the air. The creator and writers had befriended the Bellevue staff, and had observed how CPEP and the wards were run. In one episode, the female CPEP attending, who also happened to be pregnant, got stabbed in the belly with a hypodermic needle, injuring her fetus. She was doing a consult on a patient in the medical ER. The morning after that show aired, Daniel made a joke about it at rounds, saying how I, the pregnant psychiatrist, could go to the AES to do consults if any got called in. We all laughed, myself included, though I remember thinking he was such an asshole to say that. But I also remember feeling nervous. What if some nut job saw the show and it gave him an idea?
Then there was the nagging memory of the pregnant pathologist who was strangled at Bellevue before I began working there. Six months along and choked to death. I thought of her often while I walked the empty corridors late at night during both my pregnancies.
Besides stabbings and stranglings, there are also infections to worry about. When Molly was about a year old, there were two weekends when CPEP was under quarantine. Some patients had come down with Norovirus, a virulent GI virus that had recently wreaked havoc on a cruise ship. The good news was that CPEP was shut down. We couldn’t admit any more patients into the area, so EMS diversion was a hard-and-fast rule, not a courtesy; I could actually turn ambulances away. After two weekends, the census got down to zero. Someone took pictures of the empty hallways and stretchers, labeling the Polaroids stuck to the wall “The Perfect CPEP.” I had spent the bulk of my shifts watching DVDs and eating microwave popcorn.
Coming in for work that first night, it was exciting to see the doctors and nurses wearing yellow paper gowns and masks. But then, I realized there was a chance I could carry home the virus, spreading it to my husband and daughter. Norovirus causes so much vomiting and diarrhea that children can die from dehydration. When I got home the next morning, I stood at the doorway, afraid to walk into our apartment, afraid to hug them hello. When Jeremy asked me what was the matter, I wanted him to hold me and comfort me, but I felt contaminated and contagious.
How am I going to keep working at a job that’s potentially life-threatening not just to myself, but to my children? I can’t keep placing us all in harm’s way.
But the next Saturday night, and the ones after that, I drive down to Bellevue, gearing up for another round.
Leaving the Note
I have a manila folder full of suicide notes.
For a while at Bellevue, if I came across one at my job, I would Xerox it and add it to my file. Eventually, I stopped doing this. It became overstuffed and sadly redundant and meaningless. There are few things as demoralizing as a stack of suicide notes—all that hopelessness, so much sorrow and regret concentrated in one place. It’s unnatural. Some of the notes are apologetic: “Tell Ilana I’m sorry.”
“I know I’m hurting you by what I’m about to do, but I see no other way out of this.”
“I am so sad and so sorry. Please forgive me.”
But there are plenty of notes full of anger, not apologies.
One note, addressed to an ex-boyfriend, says succinctly, “This is all your fault.”
At least the notes make it easy for me to make a decision about how to handle the case. They are tangible proof that a patient wants to die, which allows me to fill out the paperwork for the admission. The problem is, not everyone leaves a note, and even if they’ve written one, it doesn’t always signify seriousness or intention. Plenty of completed suicides leave no note. And plenty of staged suicidal gestures are accompanied by long letters.
Sometimes a patient will make a veiled or outright threat of suicide on the phone. The person on the other end of the call, not knowing what else to do, dials 911. Then I get a new angry patient showing up in CPEP, dragged out of his home by EMS, forced against his will to undergo a psychiatric evaluation.
One of the rules of thumb that I’ve developed over the years is to base my treatment plan not on what someone says, but on what he does. People threaten suicide for all sorts of dramatic reasons. I try not to take away their civil liberties and force them into a Bellevue stay unless I have proof of actual harmful intent. Dramatic phone calls don’t count. I’ve had countless situations where the ex-boyfriend calls 911 after the girl he dumped threatens to kill herself. She was hoping he’d come rescue her, but what she gets instead are a couple of ambulance drivers escorting her to a night with me. Now she has to convince me that she has things to live for. Lucky for her, I’m not hard to convince. I let most people leave the CPEP as soon as we’ve had a quick chat, once I get the feeling that they have “future thinking.” I write up a T & R, documenting that a patient has no suicidal intent, is not hopeless, and
has future plans and future thinking. These are key components in the decision to release a patient.
It’s tough to decide who’s really serious about suicide, whom to detain. Anyone who’s recently made an attempt is an automatic keeper; that’s easy. Talking about it is one thing—threatening, writing notes, those are things that will make me consider an admission—but if they went through with any sort of dangerous activity, they’re in, end of story.
It is standard practice when evaluating a recent suicide attempt to do a “walk-through.” I ask the patient to take me through that whole day, step by step, to get a sense of how much thought and planning went into the attempt, if any. What were the thoughts and hopes while carrying it out? Many attempts are impulsive and barely thought out. Other times, people will admit that they were hoping to be thwarted, that a loved one would finally understand just how desperate things had become.
Another situation that comes up every once in a while is “suicide by cop.” Patients, usually psychotic or high on cocaine or both, will try to get the police to kill them with their guns. Sometimes they will do this by trying to provoke aggression. Other times, they’ll reach for the cop’s gun, trying to get it out of the holster, which is trickier than it looks—I’ve tried it (with permission, of course).
Obviously, patients who successfully commit suicide don’t cross my path. They go to the medical ER to be resuscitated, or they go to the morgue. The patients that I do see are the failed suicide attempts. The note has been found in time, or the patient is discovered in the bathroom with a noose around his neck, or in the tub with his wrists cut and bleeding.
These are the most pathetic things that I deal with, bar none—the botched suicides. It’s not that easy to successfully kill yourself. Sometimes the plan is too elaborate, and then there is bound to be a gaffe. When I was a medical student, I had a patient who ate ground glass. He ended up with a lot of severe problems with his stomach and esophagus, but he survived. Then there was the patient who set up an intricate pulley system, hauling a heavy metal engineer’s desk up onto the ceiling and sitting underneath it. It didn’t kill him, but it did leave him with a lifetime of chronic pain due to the crush injuries. Then there are those brain-injured patients who survive shooting themselves in the head.
It’s tougher than you think to end it all, take my word. And after a failed attempt? You thought your life sucked before, just wait.
What is always infinitely hard to predict is the future, when there hasn’t yet been an attempt, but there are hints. I can’t always tell just how desperate a person is, or how far he’ll go to escape his painful life.
Most of us have had friends, family members, or colleagues die at their own hands. How many of us knew it was going to happen? How many of us missed the warning signs, so easy to see in hindsight?
It’s easy to blame yourself endlessly when someone you know ends his life. I should’ve known he was in pain. I should’ve offered more of my time and my heart. And when it’s someone who is assigned to be under your care, it’s even easier to beat yourself up.
My first suicide happened when I was a fourth-year resident at the Bronx VA—my last year of training. I was thirty. A thirty-four-year-old guy with a heart of gold—nice guy, but a very sick man with intense mood swings and intermittent psychosis—was assigned to me. This illness is called schizoaffective disorder, and it carries a prognosis more dire than bipolar disorder due to its deteriorating course. When I inherited this patient from the outgoing resident in July, she let me know he was in trouble. I had a talk with him, man to man, my desk in between us. He never took off his dark sunglasses during our discussion. (One of the things I fixated on later, in my own interminable postmortem.)
“You’re my most dangerous patient,” I began. I assumed he’d like to think of himself in those terms. I could tell by the sunglasses, or so I thought. “You just got out of the hospital after attempting suicide. Statistically, you’re at risk to try it again.”
He nodded wordlessly. I was hoping he’d start to open up and tell me why, so we could begin to make a connection, but no, just the nodding.
“What can you and I do to keep you alive, I wonder?” I asked. Let him know he’s part of the treatment team. We’re in this together.
“Search me,” he said, shrugging his shoulders.
“Can you please promise me you’ll contact me to talk about it if you’re feeling suicidal? Can we at least agree on that much?”
“Sure thing, Doc,” he promised. He sounded genuine.
Patient contracts for safety, I wrote in his chart.
He seemed to do okay for most of my outpatient year, which goes from July to June, but at some point in the winter, he missed two appointments with me, one for a group session and another for an individual session. After the second missed appointment, I called his wife to see what was up. She told me bluntly that he had checked himself into a hotel, drunk a bottle of vodka, and taken a few months’ worth of hoarded prescriptions that I had written for him.
At first I blamed myself, and was nervous that others would blame me as well. If he had hoarded my prescriptions, this meant he was off his meds while I was still seeing him. I was specifically worried about the peer-review process, the morbidity and mortality conference where I would have to present his case to the other doctors and defend my choice of his medications. But then I felt guilty that I was focusing on me, how this reflected badly on my skills as a psychiatrist. I needed to do something to shoulder more of the responsibility, even if the other doctors didn’t bear down on me.
I called his widow again, to commiserate. It was a very emotional phone call; I allowed myself to really open up to her loss and grief, and also, most important, to her anger. I needed to feel guilty because I had let both of us down, and she helped me with that, as she had a right to.
She told me how she had known him for eighteen years, and how they’d finally gotten married six months ago. She described how their eight-year-old son kept leaving his seat and going up to the coffin to kiss him good-bye during the open-casket funeral. She shared with me how she felt like his soul had entered her body, and how she spent all day with his ashes, feeling like her heart had been ripped out of her chest and torn apart.
She was full of questions. Why did he leave her so soon after they were finally married? How could he abandon his son? And how could I, his doctor, let this happen?
It was tempting for both of us to blame each other. She asked why I had prescribed certain medications instead of others, and why I couldn’t see him more frequently. Wasn’t there more I could have done?
I wanted to know why no one thought to call me for help when he stopped talking for a week at home. He began sitting alone in dark rooms, sleeping more and more. Why didn’t she let me know what was going on with him? Why didn’t he call me?
I didn’t realize anything different was happening with him. I fixated on the signs I should’ve picked up on. He wore his dark sunglasses one day in group therapy. Maybe that meant something. He seemed irritable with the other patients, which was unusual for him. Maybe that should’ve tipped me off. And why the hell didn’t I call him immediately when he missed his first appointment for group therapy?
My patient did not want to be found. He didn’t try to hang himself down the hallway while his family ate dinner. He didn’t call an ambulance five minutes after he swallowed some pills because he changed his mind. (These are common occurrences in a staged suicidal gesture.) This man checked himself into a hotel room, telling no one where he was going. He left no note, and he took multiple full bottles of multiple medications, chasing the pills down with nearly a quart of vodka. Clearly, he wanted to die and took precautions so that he would not be stopped.
But couldn’t I have stopped him anyway?
Mostly, what I heard from other doctors at the VA was how some patients are absolutely intent upon ending their life and we can’t always prevent them. That this is a rite of passage. It’s a fundamental part
of residency training in psychiatry; every doctor loses patients. You learn and grow from it, and you go on to the next patient, trying not to let it happen again.
When I’m at the CPEP deciding whether someone should be kept in the hospital or released, I need to choose the path of least mortality: Will this person go out and kill himself or someone else? Dance in the middle of the FDR and cause an accident? Jump from the Brooklyn Bridge?
My answer, more often than not, is, Who the hell knows? Does anyone see a freakin’ crystal ball on my desk? I don’t have all the answers. I’m doing the best I can with what I have, which sometimes is not much information at all. I’m always pressured to send the patients out, because we only have so much room at the hospital. The busier we are, the higher my threshold for what gets caught in the safety net, and thus pulled into the safe harbor of the psych ward, such as it is.
There is an element of uncertainty with every T & R. I have to be okay with that ambiguity if I’m going to work weekend after weekend. I trust my gut and try not to gamble too much on any given case, and usually the house wins.
Before I became a psychiatrist, I rationalized that people had a right to commit suicide. If you’re at a lousy party, you should be allowed to leave if you’re not having a good time. But after talking to that man’s widow, I got to experience a fraction of the pain that a suicide causes, and my first time sharing that grief made me see things differently, made me understand more fully my own obligation as a physician.
Suicide is not just about wanting to leave the party. Depression changes the experience, coloring the perception, which makes it impossible to enjoy the party. As a physician, I must combat the illnesses that cause suicidal thoughts and behaviors. I have an obligation to eradicate the depression that poisons the mind, just as surgeons need to defend their patients from the cancers that hijack the body.
Weekends at Bellevue Page 28
