January 18, 2013

wish them well

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.
Spirits turned bitter by the poison of envy
Always angry and dissatisfied
Even the lost ones, the frightened and mean ones
Even the ones with a devil inside

Thank your stars you're not that way
Turn your back and walk away
Don't even pause and ask them why
Turn around and say goodbye

People who judge without a measure of mercy
All the victims who will never learn
Even the lost ones, you can only give up on
Even the ones who make you burn

Even though you're going through hell
Just keep on going
Let the demons dwell
Just wish them well
"wish them well" by n. peart

     Admitted on a Monday night while I was on call, she was gone by the end of the week.  She left AMA (against medical advice).  She was fed up with her bipolar nature, with the staff, with the hospital, with her life.  She had tried every medication and every street drug and nothing helped.  Her previous suicide attempt had been halted only by a rather miraculous medical intervention. We spoke with the mother over the phone. Unable to listen, the patient stormed out in a fit of rage after only a few minutes. The mother continued her story for a good half an hour.  She corroborated everything the daughter said, even adding details the daughter didn’t get to. This one was not faking, not exagerating, not just a drug seeker. The mother told us:
Look, I appreciate everything you’ve tried, I really do, but you have to realize that she’s been worked up countless times.  She had an extensive psych and neuro workup – everything – at multiple institutions and they couldn’t do anything to help her.  She’s been to so many doctors and nothing. Everything we've tried....nothing. We’ve given her places to live and she’s destroyed them. I’m still paying off the damages at her last place. She's my daughter and I lover her dearly and I know this sounds cold and heartless, but I’m surprised she’s still alive.

     Many of the staff hated the patient.  Her raging temper was set off by saying the wrong thing, even by a wrong look.  And she herself hated it.  She hated herself for not being able to stop it.  You could see her speech begin to speed up fasterfasterfaster as her lips struggled to keep up with her racing thoughts.  She wanted it to stop.  She said so but then two minutes later she was cussing someone out.  There's a fine line sometimes between distinguishing an asshole from someone with mental illness. There was no doubt in my mind she belonged to the latter.  Nor the doc who sadly but realistically doubted this patient would survive the year. 

    And yet the patient had never raised her voice at me.  She never got angry with me.  She never threatened me. The attending, exasperated, finally relegated the patient to me since she seemed not to be able to talk to anyone else without becoming frankly violent. To be honest, I’m not sure why I was able to talk to her. When it comes down to it, I think I saw my son there. My wife’s family has mental illness running in its past and I thought to myself, “if my son had been born into that situation, this could be him.” It scared me tremendously to know that the genetic possibility was there. So I talked to the patient as if she were my own son. But that wasn't enough.

​      Before the patient left, I went to say goodbye to her. I told her, “I wish you well." It's all that I had left to give.

     And that’s the part that bothers me the most. The patient was cognizant enough to know that she needed help.  She knew that she was headed for a bad ending. Her entire being was unraveling. But she was powerless to stop it. And so were we. We had nothing in our bag of tricks to help. Was she too broken for us to fix? Was there ever even a point in her life that interventions could have changed her path? Had the medical system failed her by not being able to permanently institutionalize him? Was she just a bad person who continued to choose drugs over treatment? Was she just trying to manipulate me?

     She’s the one that got away. The patient that I couldn’t treat. But more than that, she was a broken human being that could not be helped. We are taught never to give up. To never quit on a patient. But that doesn’t work in real life. Tragedies do happen. Horrible things do occur. I learned that first hand from my brother. And we as doctors, as human beings, are all too often unable to do anything about. In that regards, serious mental illness is no different than cancer, than heart disease, than HIV. They all tragically take human life.  Her life was indeed tragic and his story will stick with me always.

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