by Barbara Ebel
Bob began to feel some relief from his guilty thoughts. “But I don’t understand. In the hospital, how on earth can a patient commit suicide under staff surveillance?”
“Again, where there’s a will, there’s a way. Most frequently they hang themselves.”
Annabel gasped. “How?”
“Almost any piece of clothing or bed linen can be utilized for self-asphyxiation.”
“What can they possibly use to hang themselves from in a hospital room?” Bob asked.
“The bedroom, the closet, or the bathroom. Staff must give a patient a little privacy for a short period of time and some have a private bathroom with a lockable door. It only takes four or five minutes of adequate carotid artery pressure to die by oxygen deprivation to the brain. They hang themselves while in a sitting or kneeling position from a shower or bathtub support bar. You know, one of those ‘grab’ bars.”
The students’ eyes widened but Selina didn’t stop.
“Then there are the low methods. They can attach their dreamed-up ligature to a sink drain, bed frame or hard doorstop and stand up.”
“You can’t make this up,” Annabel said softly. “Non-depressed people would never dream of such tactics.”
“There are also patients like your schizophrenic patient, Mr. Blake. They can be serious suicide risks. Imagine the scenarios their vivid minds can conjure up. And if they are hospitalized, their inpatient suicide risk declines more slowly than a patient with only depression.”
Annabel shook her head.
“Dr. Keeton,” Bob asked, “don’t families and loved ones get angry? Do you think Mr. Wells’ wife is going to sue?”
“She’s coming in to talk to me today. You are correct to think that. Almost fifty percent of inpatient suicides result in a claim and juries are sympathetic to the fact that there should be better preventive control. However, we did perform an adequate assessment of him and were taking necessary steps. I will speak with her, give her the team’s condolences, and give her all the facts. We’ll see what happens.”
Annabel sipped her coffee but put it back down when she discovered it had cooled off too much. She looked at Bob. “Are you going to ask Dr. Keeton about your report topic?”
“I’m so absorbed, I forgot,” he said. “Do you think I could write about depression for my report?” he asked Selina. “I could use Mr. Wells as my example. Unfortunately.”
“Yes. I am glad you or both of you came to that conclusion. I expect the best papers from this rotation to come from the two of you.”
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Selina listened to Dr. Washington’s report on their patients for the next fifteen minutes before she heard more from Annabel and Bob. A knock sounded at the door and a female staff member poked her head in. “There’s a delivery here for you, Dr. Keeton.”
“Send him in,” Selina said, “but don’t go away.” A spry teenager walked in with three stacked boxes of doughnuts. “Put them on the kitchen counter,” she instructed him, “but give the young lady a box to take back out to the desk.” She dug into her pocket and handed him a bill. “No change,” she said.
The young man tipped his head and handed one box to the woman.
“Thanks, Dr. Keeton,” the woman from the nurse’s desk said. She went out the door with the teenager.
“Let’s take a little break,” Dr. Keeton said. “Who wants to put on a fresh pot?”
“I’ll do it,” Joshua said.
Bob gathered everyone’s mugs and went over to rinse them.
“Dr. Keeton,” Annabel said, “yesterday morning when the two police officers came in with Noah Goodman and before the afternoon incident, the younger one asked me a question as a spokesperson for the both of them. They would like to ask you and me out.”
Selina raised her eyebrows. “Interesting. What do they have in mind?”
“The one around my age, Dustin Lowe, suggested a twenty-four hour diner. One of their favorite spots, I guess, with a hearty breakfast menu. He gave me their numbers so I could text our response. Sounded like any evening would be fine with them.”
Selina frowned. “Hmm. Refresh my memory. What’s the name of the older one?”
“Edgar Banks.”
“What an unusual surprise,” she said and smiled. “It’s nice to be considered by someone other than a patient for a change.”
Joshua came over with two steaming cups of coffee and headed back to the coffeepot. Bob reached for plates.
“Are you interested?” Selina asked.
“Meeting them would be all right. Perhaps even fun.”
“What about timing?”
“If I work around my studying and report, I’m good any night except tomorrow.”
“Okay, I’ll leave it to you. Let me know what night next week you all decide on.”
Bob and Joshua both came back with their hands full. Bob placed a delivery box and plates on the table.
“These smell so good,” he said, opening the box and selecting one. “Some of them are filled with creamed custard.”
Annabel selected the same. “These are mouth-wateringly fresh,” she said after taking her first bite.
“Wateringly?” Bob asked. “Is that another made-up word form you’re using?”
“Mm-hmm,” she managed with another mouthful.
“Before I forget to mention it,” Dr. Keeton said, “I made sure administration gave the emergency psychiatry receptionist and security guard off for a few days. I also scheduled them for an appointment with me, pro bono, to dispel any fear or anxiety they may be experiencing after witnessing Mr. Wells’ suicide yesterday. Two other individuals will be filling in their positions. And Dr. Palmer, if you suffer the slightest PTSD symptoms, I want you to come visit me as well.”
“Thank you. Your talk about suicide and guilt has helped me already.”
Selina chose a chocolate-glazed donut and scooted her chair in further. “Good. Understand that I am here for all of you as well as my patients.”
When they finished their share of sweet-fried dough, Dr. Keeton asked Annabel, “Now it’s your turn to tell me, in a presentation style, about your new patient’s status, behavior, and ongoing workup.”
Annabel’s head went up and down; she didn’t feel any pressure at all as she responded thoughtfully.
“Our first-year med student, Noah Goodman, continues to undergo hyperactive verbal and physical activity since his admission yesterday although he’s not as loud. His thought processes continue to be tangential, he slept little overnight, and he has marked inflated self-esteem this morning. Since he came in after a big manifestation of mania – overspending – he obviously cannot do that in here. So this morning he changed his tactics and expressed a heightened interest in sexual goal-directed activity.
“Regarding diagnostic criteria,” she continued, “several lab values came back negative for alcohol and drug abuse.”
“Pointing to our diagnosis of bipolar disorder,” Dr. Keeton said.
“The plan is to treat Mr. Goodman with lithium carbonate and therapy. Dr. Washington started him on lithium this morning and he received a benzodiazepine yesterday as a first-line mood stabilizer.”
“Dr. Washington,” Selina said, turning to him. “Why don’t you give the students a thorough pharmacologic discussion on lithium? It’s a commonly used drug recognized by the public. The name gets tossed around a lot, so let’s approach the remedy from the appropriate physician’s viewpoint.”
“I would be happy to,” he said. “Dr. Keeton knows I’m partial to the wonderment of this amazing drug. It’s been used for over fifty years in treating bipolar disorder and yet it’s still not understood. We know it inhibits an enzyme, but its mechanism of action is still not known.”
“How crazy,” Annabel said. “And that’s a long time. How did someone ever figure out the way to use it anyway?”
“That’s what I’m talking about,” he said. “Oh, and another piece of trivia … it’s the only FDA-approved drug for ma
nia in kids over twelve years of age.”
Dr. Keeton skirted her chair back again and crossed her legs while listening.
“You may not know the reason why I ordered as many tests on our patient’s admission as I did,” Joshua said. “Many of them were preliminary screening tests for safely starting him on lithium. For instance, obtaining a baseline EKG because it can cause cardiac dysrhythmias. Or thyroid function tests because of the potential to cause hypothyroidism.”
Joshua looked down at his almost-finished second doughnut.
“I did read up on it last night,” Annabel said. “Using the drug requires constant monitoring.”
“Yes,” he said. “After he’s stabilized on it, levels need to be checked with blood work at least every three months.”
“Why?” Selina asked.
“To prevent toxic levels,” Annabel said, “which could cause seizures or a coma or even result in death.”
“Very nice. You will be sure to see questions about lithium on your final exam,” she said, and winked.
“Now, let’s go back to your presentation a few minutes ago,” Selina said. “You mentioned Mr. Goodman’s previous overspending and sexual innuendos this morning. That was a good pickup … how he changed his attention because he’s not in a mall right now. Did he direct his indiscreet flirtation to someone in particular?”
Annabel grimaced. “Unfortunately, me. Since I’m only a third-year, it’s a bit early for underclassmen to take a shine towards me.”
They all laughed.
“Shows you’re still pretty to look at,” Bob said.
“Shows you’re keeping your figure while eating doughnuts,” Joshua said.
“Shows you rate high in his manic mind,” Selina said.
Annabel smiled. “You guys …,” she said, and waved her hand at them.
“I must refer you all back to my three rules,” Dr. Keeton said, “especially important when dealing with psychotic patents. Don’t shake hands, dress appropriately, and sit with an exit strategy. We had a devastating incident and result yesterday but, thank God, none of us got hurt.
“Let’s get up from this table and poke in on our patients. Afterwards, Dr. Washington will be in charge for much of the day. I have the responsibility of talking to our deceased patient’s wife, Susan Wells, and then the medical school about Noah Goodman’s hospitalization and diagnosis.”
Annabel stretched when she stood and closed the empty box. Her admiration for her attending was growing by the day. Now she looked forward to setting up that double date.
“By the way, Dr. Keeton,” she said, “thanks so much for surprising us with the delicious doughnuts this morning.”
“My pleasure. And nice work. All of you.”
Chapter 11
Dr. Keeton smoothed a wrinkle from her lab coat, took a deep breath, and entered the private family room where Susan Wells waited patiently for her arrival. Selina preferred her patient psychiatry sessions a lot more than seeing family members. Family often wanted her to ‘do more’ with their loved ones; people’s expectations of fixing a person’s mental illness were too high. Psychiatry wasn’t like surgery where a body part could be fixed and an observer sees physical results. No, this specialty didn’t work like that; mindful changes in a patient could take years.
“Mrs. Wells,” Selina said, “I am glad you came to see me right away.” She put out her hand. The physical contact between them was like a comforting clasp of hands rather than a handshake.
The lack of a good night’s sleep and puffiness under her eyes from crying took a toll on Mrs. Wells. She blinked several times trying to add natural moisture to her eyes; they were so dried out she couldn’t produce another tear if she tried. Yesterday when Selina met her in the emergency unit, she was a neatly dressed and an attractive woman. Today one snap on her blouse and the smart twist to her hair was undone or gone.
“Right now is not soon enough,” Mrs. Wells said. “I’m not sure if I’m better off for not being present yesterday to witness what Eugene did. It was bad enough getting called and going straight to see his dead body and identifying him. That was the most gruesome sight I ever saw and it was my husband!”
“Events since yesterday must be tragic for you. If there is anything my department can do for you, we are here to help.”
“I don’t want to presume I know exactly what happened yesterday. I need to hear details from you because, otherwise, I may have doubts later on about him being adequately supervised or wonder if I could have prevented this tragedy if I hadn’t left.”
Susan backed up against the couch and sat down, twisting her hands. Selina handed her a tissue from a box. They often worked well for patients to wad up in their nervous hands if they didn’t use them for crying.
“You deserve a thorough explanation of what happened,” Selina said and told her about her husband’s remaining time after she had left the building.
Susan remained attentive and thought it all over. “I suppose it comes down to the same two questions in my mind,” she said. “Would he have died if I had stayed? And if my husband, Eugene, made it over to the hospital ward, would he still have found a way to commit suicide or would he still be here?”
“Chances are your husband would have succeeded with any rash action or thought-out plan until maybe he was therapeutic on an anti-depressant. We can never know and second-guessing our actions is always futile. When you leave here today, if you walk down Aisle A to your parked car or decide to walk down Aisle B, you could encounter drastically different outcomes.”
“Maybe fate is responsible,” she said softly. She stared past Selina towards the ceiling. “It’s not smart for a gun to be around someone like that, though.”
“Perhaps not. Although if a mentally-deranged patient threatens visitors or comes in with a weapon, we would be glad protection is on hand or that the guard carries the ultimate deterrent against physical violence.”
Susan Wells took in a short audible breath, tried to fold the crumpled tissue, and shoved it back into her palm. “You must be aware that my husband made the local TV news last night. Two lawyers called me by 9 p.m. Can you imagine? I’m dealing with grief and how to conduct funeral services and they are trying to make a buck. Don’t worry. Despite what happened, I trust doctors more than I trust lawyers.”
The last remark took Selina by surprise. No one had ever told her that one before.
Mrs. Wells nodded at Selina and rose. “If I need any grief counseling in these next few months, I know a good psychiatrist I can see.”
They walked out together with Selina gently resting her hand on Susan Wells’ back.
-----
Dr. Keeton ate a light lunch and arrived at 1 p.m. sharp for the medical school physician’s group meeting. Half of the eight doctors on the panel showed up; with busy schedules, Selina was surprised to see even four of them. The chairman of the teaching institution’s psychiatry department was a Dr. Renner. She knew him well professionally and socially due to the nature of being in the same specialty.
“Dr. Keeton, come on in,” Dr. Renner said as she walked into the small meeting room. He raised his head to look through the bottom half of his bifocals and pointed to a chair.
Selina made herself comfortable by the head of the table. The two other doctors taught freshman and sophomore classes. She had heard about the present gross anatomy professor, Dr. Lawrence, because of the perpetual wide smile he brought into the cadaver lab every day. Word was that he loved working with dead bodies and green medical students.
“Thanks for bringing Noah Goodman’s situation to our attention promptly,” Dr. Renner said.
“I became concerned two days ago,” Dr. Lawrence said, “because he played hooky from lab dissections and I never heard from him. I assumed he was sick but Fred, his roommate, said he was acting bizarre.”
“He may have been on a shopping rampage the day before yesterday, too,” Selina said.
“So tell us what you know,” Dr. R
enner said.
“This is all private patient information but, due to the circumstances, we all are - in a way - responsible for Noah’s medical care and ability to continue or not continue in medical school. My preliminary workup of him rules out other possibilities besides the glaring diagnosis which is staring us in the face … and that is bipolar disorder. Although I started him on lithium and he’s beginning to mellow out, he’s as hyper and manic as they come.”
“This is serious,” Dr. Renner said. “This is the first time in my career that a freshman student has broken out with a major psychosis. If a young person carries the genetic or environmental makeup for it, then there can’t be a better trigger than the stress of med school. We are fortunate we have not seen a major psychiatric problem like this sooner.”
“What do you anticipate,” Dr. Lawrence asked, “as far as his ability to return to class?”
Selina and Dr. Renner looked at each other. Selina shook her head and Dr. Renner winced.
“Statistics are grim enough,” Selina said, “without taking into account his current school situation. The average patient suffers eight to ten of these episodes over their lifetime and each of the flare-ups worsens his or her long-term prognosis. And all of this education he’s getting? Over sixty percent of the highly-educated ones like Noah end up not working.” Selina tapped her finger on the table. “I am only giving you all the stark facts. I do not intend to make a decision for, nor sway, the board.”
“Other brutal facts,” Dr. Renner said, “are what we are discovering about his personal life. Not only is it in shambles, such as the non-payment of his credit cards and other bills. But the police are informing us today that other stores have come forward to press charges for theft. Noah Goodman may be acquiring a ‘record.’”
“Future state medical licensing boards would not be happy with that,” Dr. Lawrence said. “Nor any other credentialing body.”
The chairman took off his glasses and glanced at his colleagues. “I don’t think we have any other choice except to recommend to the entire board that Noah be asked first to voluntarily give up his position in our medical school.”