The Beauty in Breaking

by Michele Harper

  “Mr. Williams, are you with me?” I asked in a manner that sounded far calmer than I actually felt. I took deep breaths to still my palpitations, to cool the warmth rising in my chest. I looked through the open door to see Lorraine staring at me wide-eyed over her computer.

  Mr. Williams looked back toward me. His body was still tense, and each limb was rigid on the bed, as if secured by suction cups. But his face softened, and his eyes were pleading. “Yes, yes, Doctor.”

  “Mr. Williams, do you still want to proceed?”

  “Yes. Okay. Yes, yes.”

  “You just have to stay really still—perfectly still. If you move, I can’t put in the sutures.”

  There are times when we take an uncompromising stance with patients, when we tell them to either cooperate or leave. But sometimes a softer approach is necessary. This patient seemed too fragile: I knew I would have to nurture him through the process like a doting aunt.

  A third of the way through the procedure, he suddenly drew up his legs and before I could ask him to stop, he said, “It’s okay, it’s okay. You’re okay. She’s okay. We are safe here. It’s okay.”

  I held my instruments in the air as the suture dangled between us. I waited for the outburst to pass. I waited to complete the world’s fastest sutures. I thought about just stopping, even contemplated zipping through a simple continuous running suture (a type of stitch where the sutures aren’t separated. You simply place throw after throw, then tie the suture material off at the end so that the tissue is connected by one long piece of suture material. The benefit of this stitch is that it prioritizes speed. The downfall is that if it breaks anywhere along the material, the entire closure comes apart), but finally reminded myself that this was his hand and I should do the sutures for the most effective wound healing, so that he would have the best chance of retaining its function. But the key was still to finish fast.

  He shifted his gaze to the needle driver and forceps and then to the black nylon thread pulled taut. He then looked over to the scissors and other sharp instruments to my right. His eyes parked there, and I lowered my hands to rest my instruments on the tray. I laid the suture down so it wouldn’t injure him and left the untied suture in place of the most recent stitch. I felt myself drawing my tray of sharps closer to me. He exhaled and appeared to settle again, reminding himself aloud that he was okay, I was okay, and he was safe. Within moments, I completed the fastest sutures I had ever thrown.

  “All done!” I announced as I collected the instruments. I undraped his hand and asked him to wait where he was, so the nurse could clean and dress the stitched-up wound.

  He lay on the stretcher, clasping and unclasping his hands, exclaiming “No!” and then slapping himself on the thighs and forehead. I reminded him not to do anything to hurt his already injured hand.

  This was not going to be a quick treat-and-street. Sure, now that I’d stitched him up, I could have given him his papers and sent him on his way. This sort of thing happens all the time: We ignore the inconvenient problem because it doesn’t have a rapidly accessible answer. As a physician, I cannot fix intimate partner violence, homelessness, addiction, or their brethren in one ER encounter. I can help, but I can’t fix them, so it can feel easier to focus instead on what I can fix, the laceration I can suture shut. Asking the other questions opens a Pandora’s box. Heaven forbid a patient said, “Yes, my boyfriend stabbed me; and he hits me all the time.” Then I’d have to offer comforting words, followed by a call to social services—and we all know that social work involvement can prolong a patient’s ER visit by several hours. But what’s even worse is when I ask the question, and the patient declines assistance. Their doing so shouldn’t feel like a personal affront, but for an instant, it can. Of course, if a patient declines help, that has nothing to do with me personally. Clearly, I’ll go home to my life and not be beaten just the same. Perhaps what bothers me most is the raw realization that I care more deeply for the welfare of another human being than he cares for himself, and that that human being will leave my care to suffer more needless violence.

  Even though I had no idea what had happened to Mr. Williams, I could see that this man was seriously ill. There was the problem of his injury, yes, but there was also a more penetrating problem of his psyche.

  “Mr. Williams, you seem very upset, very anxious.”

  “Yes, yes.”

  “I think it could be a good idea for you to speak with the psychiatrist. He could help you feel less anxious. What do you think?”

  “Yes, yes. He can help?”

  “Absolutely. Would you also like some medicine to calm down?” He bobbed his head in compliance. “All right. Why don’t we have you change into a gown and we’ll check some labs just to make sure everything is okay.”

  “Okay, Doctor.”

  He was fragile but compliant. I walked over to Lorraine, relieved to be safely out of his room.

  Lorraine looked up at me. “Good to go, Doc?”

  I pulled my chair over to her and looked back to the room to make sure Mr. Williams was out of earshot. He was pacing again, resuming the argument with himself, one that, sadly, he appeared to be losing.

  I leaned in close to Lorraine. “I cannot discharge this man. He is truly not stable. I don’t have much information on him, so I can’t know how close this psychosis is to his baseline. I’m very sorry, but I have to keep him on one-to-one observation because he certainly can’t leave unless Psychiatry clears him. We’ll need to get some labs for medical clearance, too. Let’s have him get changed, the way we do with all psychiatric patients. Amazingly, he has agreed to everything. He’s very redirectable and cooperative.”

  As I passed the triage area on my way to the psychiatric department, the triage nurse, Steve, called out to me. “Dr. Harper, can you come here a minute?”

  “Yup. Are there more people out there to be seen?”

  “Not exactly,” he replied.

  With coffee in hand, I leaned on the desk next to him, waiting for his update, but mostly I was stealing a lovely opportunity to quietly sip coffee in a department still filled with Sunday morning calm.

  “There are some detectives out here waiting to talk with you.”

  “City police? About what?”

  “Something about a murder. Apparently, that last patient—”

  “You mean the only patient in the department?”

  “Yeah, the patient is a suspect in a murder that happened in Old City this morning.”

  “Whhaaaat?!” I set my coffee down and took a seat next to Steve. “Okay, wait a second. What happened?”

  “I don’t know all the details, but the cops were saying an old woman was stabbed in Old City outside her church and they got a tip that led them to Mr. Williams, so they followed him here.”

  “How long have the cops been here?”

  I looked out and saw three middle-aged men in suits sitting in a semicircle. One was leaning forward with a notepad in hand, joking with the other two, who were seated casually as if in reclining chairs.

  “I dunno, maybe thirty minutes or so. But they’ve been on the case since the tip.”

  I thought back to how I had been in the room with Mr. Williams alone. I recalled him mumbling to himself and staring at the sharp instruments as I repaired his hand. I remembered the exact moment my gut told me that he and I were both unsafe there, and then the moment my instinct told me I could and must deliver us from that danger quickly. At that same moment, unbeknownst to either of us, the police were just outside, waiting for us both.

  “So, you mean we were all back there with this guy who had probably just murdered someone while the cops sat outside in the waiting room joking? I was actually in the room alone suturing him, and none of those cops thought it a good idea to alert the staff or maybe even come back to the department to make sure we were safe?”

  Steve frowned. “
Yeah, that’s a good point, Doc,” he said. “Guess not.”

  I picked up my mug and headed toward the waiting room. As I approached the officers, all three stood up, each one of them at least six feet tall.

  “Doc, you’re taking care of Mr. Paul Williams?” one of the detectives asked. I nodded. Apparently, as they explained, my patient had been witnessed attacking an elderly woman, and the police were in the process of obtaining a warrant for his arrest.

  “Is he good for us to take to the station?”

  “Well, he’s okay medically. I just had to stitch him up, and in that respect he’s fine. But he is banana nuts. I mean nuts and berries not okay.”

  “Is that a medical term, Doc?” one of the white detectives asked, throwing his head back in laughter.

  “Yes, it’s one of our new terms. But in all seriousness, I’ve just ordered him some medication to help calm him down. In my opinion, he is truly psychotic. I’m having the psychiatrist see him.”

  “C’mon, Doc. Don’t you think he’s just faking? Pretty convenient to be mentally ill all of a sudden,” the black detective said with a smirk.

  I smiled because I knew that the acute onset of an assortment of medical symptoms when a person is arrested or doesn’t want to report to work on a nice day are all epidemics that present to the ER. “Yeah, I have to tell you, I’ve seen a lot of people malingering or, as you say, faking. I’ve seen a lot of mentally ill people, too. Either he’s ill or he’s an Academy Award–winning actor, and an actor he is not. Sorry.”

  The detectives shuffled around. They seemed disappointed. I told them that I was still waiting for lab results, and more critically, the psychiatrist would need to see the patient before any decision could be made.

  “We think it’s best if some of our guys stay in the department,” one of the detectives said. “We spoke to the VA police, but they don’t have the staff to leave a couple of their guys here the whole time. Okay if we set up here for a while?”

  “Of course. I think it’s safer, too. Right now he’s fine. He was redirectable all along and should be medicated now. He’s honestly more cooperative than many, perhaps even more than the majority, of the sane patients I’ve treated,” I said, smiling.

  “Okay, Doc. We got you.” It was nice to hear. It was the type of collegial collaboration I was used to with the police in the ER back in my South Bronx days.

  I turned to Steve and called through the triage window. “Please show the detectives back. They’re gonna hang out for a while. Introduce them. Make them comfortable,” I said.

  The psychiatrist on call was not in the psychiatric ER but undoubtedly sleeping in the on-call room. I asked the psych nurse to page him to the main ER and then walked back to the department to update the staff.

  I turned to Lorraine. “I know he’s calm right now, but given everything that’s occurred,” I said, recalling Mr. Williams’s behavior during suturing, “I think it’s safer to do restraints until he’s medicated. That will give us time to see that he’s really psychiatrically stable and not a danger to himself or staff.” I glanced over into Mr. Williams’s room; he was still agitated but compliant. I saw that Mr. Carey was just being wheeled back to the room next to his.

  Mr. Carey was a frequent flyer at the ER, someone who was once known to drive himself there weekly. When he arrived, he’d saunter through the waiting room and then stroll up to triage. The moment he thought he was within view, his pain would mysteriously intensify, to the point where he’d be doubled over, instantly unable to walk. He would begin shaking violently and scream in pain. Patients with gunshot wounds or kidney stones and women in labor didn’t even scream like that—they were the howls of someone who was insisting on full submission to his demands. Predictably, he would begin acting out convulsions, pausing only to explain that his symptoms had been evaluated for over a year with exhaustive tests, including labs, CTs, MRIs, ultrasounds, urine tests, endoscopies, and colonoscopies, that had all, sadly—audible sniff—yielded only normal results. He would then go on to explain that, thankfully, his incapacitating pain was singularly responsive to a couple of rounds of intravenous Dilaudid.

  I made sure to stand in the hallway as he rolled by, so that he could see me. He knew that I was one of the physicians who would not give him narcotic medication, so it was likely he would walk out at any minute. I had seen him do it before.

  “Lorraine, maybe we can just do restraints on his feet,” I said, referring again to Mr. Williams. “Or perhaps feet and one arm so that he can still eat and use the urinal. Whatever you think. Just let me know.”

  “Okay, Doc.”

  I wrapped my arms tighter around myself, shivering in my fleece, trying to keep the dry, chill air of the department at bay. Mr. Carey was on my left, Mr. Williams on my right. To my left, a medically well man with no diagnoses in his medical record except for nonspecific abdominal pain and mild reflux. His room was a theater of unparalleled noise. To my right, a psychotic man in mental distress. Nurses Lorraine and Bill were both with a calm Mr. Williams to administer medications and place restraints. I saw Lorraine speaking to him, presumably explaining what was about to happen. He slowly extended his left leg for her to affix it to the stretcher. Then the right leg he granted to Bill, who tied it to the bed. Next, he extended his left arm so it could be secured. Lorraine placed a urinal within reach on his right side. Mr. Williams kept his arm perfectly still as Bill started an IV to administer the sedative Ativan and draw blood. Lorraine removed two pills from a cup and raised them to Mr. Williams’s mouth. Mr. Williams lifted his chin and parted his lips to receive the meds.

  I stood outside Mr. Carey’s door. “Mr. Carey, abdominal pain again?”

  He shrieked something with a discernible “yes” in the middle.

  “Well, in that case we’ll do the same workup,” I responded, before returning to my desk.

  “Wait, Doc! I’ll need pain medicine first, before I can let you do anything!”

  “Sure. I think it’s safest to give you a really strong antacid medication for your gastric reflux. That should help your pain while we get your blood work and X-ray completed.”

  “No, I don’t want that! I need pain medicine. I won’t do anything without pain medicine!” he screamed, and then resumed his kicking and flailing.

  I turned away from him. “You certainly have the right to refuse evaluation and any offered treatment. If you don’t want those things, you will need to leave.”

  He continued to thrash about on the stretcher. “I am not leaving!” he shrieked. “I am not doing any useless tests, and I am not leaving!”

  As I made my way back to my desk, I called out to the clerk, “Please call the hospital police to help Mr. Carey out of the department.”

  Lorraine called out, “Dr. Harper. Psychiatry.”

  I picked up the call and introduced myself.

  “I’m one of the moonlighters, Ken. What’s up?”

  “Well, we have a murder case.” I updated him about Mr. Williams and the detectives waiting for his psychiatric evaluation.

  “I’ll come right down. This is a little complicated legally. Let me see the patient, then make a couple of phone calls. I’ll get back to you.” Ken was always very formal in his presentation. He wore white standard-fit cotton button-down shirts and plain dress shoes, and his language always matched his attire. He was also quite thorough and, despite his mechanical tone, clearly cared about doing right by his patients.

  As Mr. Carey’s yelling intensified with the arrival of the VA police, I felt my father’s letter burning a hole in my bag—both, I knew, were best ignored so I could wrap up my work and be ready for the psychiatric input on Mr. Williams when Ken called back.

  Lorraine again called out to me. “Doc, I’m sending a call in to you. It’s Psych again.”

  “I saw Mr. Williams,” Ken said. “I agree with you. He’s psychotic and
needs psychiatric inpatient stabilization. He can be hospitalized in a mental institution and be under arrest. It happens all the time. Unfortunately, it would be against hospital policy here to admit a person under arrest,” he said, sighing heavily. “So, I’ll have to write up my assessment, and then he’ll be released to the police. He’ll have to get his care through the prison system. It’s also true that psychiatric care in the prison system is inferior. It’s a shame, but it’s out of our control. We’ll keep him here until the police have their warrant. I spoke to the police already. Everyone’s on the same page.”

  “Yeah, it’s a shame the way our systems fail patients.”

  “It’s all we can do.”

  “Thank you, Ken.”

  I checked the clock: fifteen minutes until the day doc was to arrive. I looked back toward Room 17 to see Mr. Williams lying still on the stretcher, his eyelids soft. His hand had been sewn, his clothing changed to psychiatric scrubs, his shoes replaced by hospital socks, his agitation soothed by Ativan and Geodon. Now he could finally rest.

  The VA police I’d called for a belligerent Mr. Carey were still with him. Negotiations had resulted in the police putting on their gloves and surrounding his stretcher. Apparently, Mr. Carey was still refusing to get up and walk back to the car he had used to drive himself here. Nursing slid open the glass doors of his room as the police wheeled Mr. Carey’s bed out the back entrance of the ER.

  The clerk looked at the video feed of the scene outside and dissolved into laughter. “Wow, Mr. Carey just got up and gave the police the finger, and now he’s walking away. What an ass!” he chuckled. “You know, he’s walking just fine. Guess his pain got better!”

  I packed up my things, wondering how Mr. Williams’s story would be told days later in the news, weeks later in court. Would the prosecutor conjure a story of a savage, cold-blooded killer? The “If it bleeds, it leads” mentality gives a distorted sense of reality. Mr. Williams was no more ferocious than the kids who pretend to look tough on Instagram, or the commercial artist from the burbs who raps about the hard life in the hood that he never had. But this sensationalism sells images that, while disconnected from the truth, can have very real consequences.