It’s Friday morning. I buzz my temporary ID badge to enter the locked inpatient unit, and once again to enter the nursing station.
Tom, one of the nurses, is in the middle of a story about his toddler pooping all over the living room. There are chortles of laughter. (Six months later, as I stick my gloved finger into a steady brown ooze coming out of the rectum of a patient on the operating table for a large bowel obstruction I will suddenly remember this story.) I find my patient charts to review the medication administration records and care notes. I talk to Alex, the nurse taking care of the patient I’m about to go assess.
“Neel was up at 5AM asking for his razor to shave. He seemed anxious, kept asking when the doctor was going to come.”
The morning I met Neel, I had called from the ward doors to say, “Yes, this is Emily, I am the medical student starting here today.” Day ones on clerkship are like a pop song chorus, mildly nauseating and recurring at dependable intervals. That morning, I sat across from Neel and experienced an impulse of terror. How was I to begin a conversation with someone about their attempt to end their life?
Neel is a 58 year-old man, born in Hyderabad. Two weeks ago, he transferred money onto his wife’s account and wrote a will. Then, he waited for a time when his wife and daughter were out of the country on a trip before ingesting 20 tablets of phenobarbital, which he had obtained from an overseas relative for sleep aid. He showed up to work until the day he planned to die. His daughter, who had begun to notice changes in her father’s behaviour, had called home from Chicago. On receiving no answer, she called 911. He was found unconscious on the floor of his apartment and rushed to the Emergency Department. On arrival, his Glasgow Coma Scale was 3. For reference, a dead person’s GCS is also 3. He spent several days in the intensive care unit before being transferred in stable condition to inpatient psychiatry.
(Five months later, I will see a trauma patient with a self-inflicted knife wound. On arrival, only the hilt of the steak knife will be visible in the midline of her neck. In the OR, we will find that the knife has missed her trachea and all major blood vessels, but a later MRI will show she has transected her spinal cord at C8. Her suicide attempt will result in incontinence and partial body paralysis.)
I unlock the door to the interview room and Neel follows me inside. He is a tall, skinny man. This morning he is well-shaven and wearing a crisp, ironed shirt. Neel tells me he slept well. His family had visited him the night before and brought clean clothes and some of his favourite foods. I ask about Diwali and he says, yes, they brought along some sweets to celebrate which he didn’t eat too many of since he has diabetes. He shows me a piece he did in group art class where he spelled out his daughter’s name in foam letters and glitter glue.
“I feel great. I was wondering if Dr. Moreau can give me a weekend pass. It will be convenient because my wife can pick me up after she gets off work today.”
This is the question I echo to Dr. Moreau when I present my oral report.
“Do you think he will do well on a weekend pass?”
I hesitate, “I don’t know. I’m not a psychiatrist.”
“Well,” he chuckles. “How do psychiatrists decide? We can’t predict the future. Committing someone to hospital isn’t something we do lightly. Neel had a serious suicide attempt: He waited for an opportunity where the possibility of being found was slim. It was not impulsive. In the days leading up to the attempt, there were few clinical signs of depression. This puts him at high risk of another attempt in the future. A weekend pass is part of recovery. If it goes well, he’s one step closer to discharge. Now, did you ask him about current thoughts of suicide?”
I shake my head in embarrassment. In trying to keep the conversation lighthearted, I had forgotten to ask the one question that was most necessary to determine if Neel would be safe going home for the weekend.
“When we sign off on a patient pass, it isn’t merely medical-legal. We can’t run a blood test to see if he can go home. What we can do is construct a clinical decision. Part of that is how he’s done with the half hour passes off-ward earlier this week. Another part is the mental status exam—mood and affect, speech, thought form and content, insight and judgement”
We go in to see Neel together. I watch Dr. Moreau conduct the interview. Neel denies any suicidal thoughts, promises to come back to hospital if he feels unsafe. The weekend pass order is signed. Back in the nursing station. Dr. Moreau presents his assessment to me. It’s as if Dr. Moreau has heard everything, things said and unsaid.
Lying in bed that night, I think about how Neel is doing.
How would he interact with his family members?
How would he feel going back to the place where he tried to die?
Is the phenobarbital still lying around?
I am very relieved when I see Neel walking the hallways on Monday morning.
In a spasm of indecision, I thought about publishing this series a) after I graduated or b) anonymously. There is something imperative about telling the story now, and that I take responsibility for its telling. Thank you to the colleagues who read and critiqued my drafts. To protect confidentiality I have altered identifying details. All names have been changed, but people are more than their story and any error or misrepresentation is my own.