(no subject)
Find A Way
Suicide is one of those topics spoken about almost casually: hanging from the end of a rope, bloated and facedown at the bottom of a pool, in the master bedroom with an open bottle of seroquel - and did you watch the Italians get their heads handed to them this morning in the World Cup? Still, after every time-of-death pronounciation there's more than a few solemn moments before everyone starts to shuffle out of the room, time enough for everyone to contemplate their mortality. I have a ritual for these chasms: a methodical exhalation followed by the mantra of I'm glad that wasn't me - neither an invocation of hate nor of pity, but existing at a liminal space between hope and relief.
From a medical standpoint suicides are a relatively straightforward affair. Contact the appropriate authorities, inform the family, be wholly reverent and professional but otherwise wash our hands of the affair. Our business is with the infirm. And it is when suicides obligingly shift - a change of heart prompts the gun barrel to change by a few degrees or a knife is paused midway down the forearm - that we are given the most work. Often the emotional weight of a suicide doesn't prompt consideration of an intention gone awry. And this is the problem - our bodies, unlike our fragile emotions, are designed to withstand some of the worst insults of a suicidal intent. They survive bullets through the skull, slashed arteries, prolonged deprivation from oxygen - enduring massive traumas and emerging wrecked but alive. The iron resolve of biological survival combined with
Some of the things I have seen are almost supernatural to watch, even if they are scientifically sound and chillingly repeatable. A patient tried to end her life with a shotgun and tried to stop at the last second - blowing through her jaw, sending bone fragments and lead shot into her sinuses and hard palate. Medical staff replaced three-quarters of the blood in her body1 while surgeons carefully cauterized the bleeding vessels, wired her jaw back together and packed what remained of her face with gauze. Heroin overdoses have been put on ketamine drips by anasthesia to wake up forty eight hours later, groggy but free from a potentially lethal opiate withdrawal.
***
An elderly suicide was brought in once for trying to end his life by putting a gun to his chest and trying to destroy his pacemaker. He succeeded - shattering his clavicle with the first shot, bullseying the pacemaker with the second - but EMS brought him in before anything else happened (apparently one can survive with a broken pacemaker - a body's resilience is astounding). We later learned that this was the second pacemaker he'd been through - for reasons unknown to us he'd destroyed the last one as well, had it replaced and lived with it for quite some time before attempting a repeat performance. And this is the thing that gets me about medicine - the cilice constantly abrading away at my sense of duty. It is this: in many situations health care pits a system's overtly finite resources against the surplus of human will. With noncompliance2, obesity, suicide - it frustrates me that while we can change human physiology we cannot ethically change behavior.
Medical care is not cheap. The cost of a pacemaker - installation, inpatient care, a thousand other billable expenses - can exceed $50,000. Go through three of them and you've more than taxed a system that is supposed to provide services for both the indigent and the affluent.
My current philosophy is this: You are (will be) my patient. It is not my place to worry about the cost of your care, or the strain that might be placed on society if I order more expensive tests to confirm my diagnosis. I readily concede that this is an indefensible, childish, myopic stance: in a system where resources are finite a set of rules will evolve to determine how those resources are shared. So at some point perhaps I will have to become both a physician and an economist - and piss off a lot of patients who will hold me up as a symbol of a dysfunctional system. And part of my resistance to rationing care comes from this aversion to dislike: I don't ever want to be told that I'm not doing enough to fully treat a patient. Somewhere along the line, however, this will break down.
At what point do I let a suicide go unchallenged?
1. The average human body contains 5.6 liters of blood. This is not an insignificant amount.
2. Noncompliance = medical jargon for a patient that does not take their meds. Often this can be perjorative, but the true causes vary wildly - sometimes patients have 25+ (!!!) medications to take in a day and trying to get through all of them seriously taxes their willpower. Other times, patients believe that their own judgement supplants that of their physicians - and days later they wind up in our emergency room. Again.
Suicide is one of those topics spoken about almost casually: hanging from the end of a rope, bloated and facedown at the bottom of a pool, in the master bedroom with an open bottle of seroquel - and did you watch the Italians get their heads handed to them this morning in the World Cup? Still, after every time-of-death pronounciation there's more than a few solemn moments before everyone starts to shuffle out of the room, time enough for everyone to contemplate their mortality. I have a ritual for these chasms: a methodical exhalation followed by the mantra of I'm glad that wasn't me - neither an invocation of hate nor of pity, but existing at a liminal space between hope and relief.
From a medical standpoint suicides are a relatively straightforward affair. Contact the appropriate authorities, inform the family, be wholly reverent and professional but otherwise wash our hands of the affair. Our business is with the infirm. And it is when suicides obligingly shift - a change of heart prompts the gun barrel to change by a few degrees or a knife is paused midway down the forearm - that we are given the most work. Often the emotional weight of a suicide doesn't prompt consideration of an intention gone awry. And this is the problem - our bodies, unlike our fragile emotions, are designed to withstand some of the worst insults of a suicidal intent. They survive bullets through the skull, slashed arteries, prolonged deprivation from oxygen - enduring massive traumas and emerging wrecked but alive. The iron resolve of biological survival combined with
Some of the things I have seen are almost supernatural to watch, even if they are scientifically sound and chillingly repeatable. A patient tried to end her life with a shotgun and tried to stop at the last second - blowing through her jaw, sending bone fragments and lead shot into her sinuses and hard palate. Medical staff replaced three-quarters of the blood in her body1 while surgeons carefully cauterized the bleeding vessels, wired her jaw back together and packed what remained of her face with gauze. Heroin overdoses have been put on ketamine drips by anasthesia to wake up forty eight hours later, groggy but free from a potentially lethal opiate withdrawal.
***
An elderly suicide was brought in once for trying to end his life by putting a gun to his chest and trying to destroy his pacemaker. He succeeded - shattering his clavicle with the first shot, bullseying the pacemaker with the second - but EMS brought him in before anything else happened (apparently one can survive with a broken pacemaker - a body's resilience is astounding). We later learned that this was the second pacemaker he'd been through - for reasons unknown to us he'd destroyed the last one as well, had it replaced and lived with it for quite some time before attempting a repeat performance. And this is the thing that gets me about medicine - the cilice constantly abrading away at my sense of duty. It is this: in many situations health care pits a system's overtly finite resources against the surplus of human will. With noncompliance2, obesity, suicide - it frustrates me that while we can change human physiology we cannot ethically change behavior.
Medical care is not cheap. The cost of a pacemaker - installation, inpatient care, a thousand other billable expenses - can exceed $50,000. Go through three of them and you've more than taxed a system that is supposed to provide services for both the indigent and the affluent.
My current philosophy is this: You are (will be) my patient. It is not my place to worry about the cost of your care, or the strain that might be placed on society if I order more expensive tests to confirm my diagnosis. I readily concede that this is an indefensible, childish, myopic stance: in a system where resources are finite a set of rules will evolve to determine how those resources are shared. So at some point perhaps I will have to become both a physician and an economist - and piss off a lot of patients who will hold me up as a symbol of a dysfunctional system. And part of my resistance to rationing care comes from this aversion to dislike: I don't ever want to be told that I'm not doing enough to fully treat a patient. Somewhere along the line, however, this will break down.
At what point do I let a suicide go unchallenged?
1. The average human body contains 5.6 liters of blood. This is not an insignificant amount.
2. Noncompliance = medical jargon for a patient that does not take their meds. Often this can be perjorative, but the true causes vary wildly - sometimes patients have 25+ (!!!) medications to take in a day and trying to get through all of them seriously taxes their willpower. Other times, patients believe that their own judgement supplants that of their physicians - and days later they wind up in our emergency room. Again.