Weekends at Bellevue (36 page)

It’s tough to decide who’s really serious about suicide, whom to detain. Anyone who’s recently made an attempt is an automatic keeper; that’s easy. Talking about it is one thing—threatening, writing notes, those are things that will make me consider an admission—but if they went through with any sort of dangerous activity, they’re in, end of story.

It is standard practice when evaluating a recent suicide attempt to do a “walk-through.” I ask the patient to take me through that whole day, step by step, to get a sense of how much thought and planning went into the attempt, if any. What were the thoughts and hopes while carrying it out? Many attempts are impulsive and barely thought out. Other times, people will admit that they were hoping to be thwarted, that a loved one would finally understand just how desperate things had become.

Another situation that comes up every once in a while is “suicide by cop.” Patients, usually psychotic or high on cocaine or both, will try to get the police to kill them with their guns. Sometimes they will do this by trying to provoke aggression. Other times, they’ll reach for the cop’s gun, trying to get it out of the holster, which is trickier than it looks—I’ve tried it (with permission, of course).

Obviously, patients who successfully commit suicide don’t cross my
path. They go to the medical ER to be resuscitated, or they go to the morgue. The patients that I do see are the failed suicide attempts. The note has been found in time, or the patient is discovered in the bathroom with a noose around his neck, or in the tub with his wrists cut and bleeding.

These are the most pathetic things that I deal with, bar none—the botched suicides. It’s not that easy to successfully kill yourself. Sometimes the plan is too elaborate, and then there is bound to be a gaffe. When I was a medical student, I had a patient who ate ground glass. He ended up with a lot of severe problems with his stomach and esophagus, but he survived. Then there was the patient who set up an intricate pulley system, hauling a heavy metal engineer’s desk up onto the ceiling and sitting underneath it. It didn’t kill him, but it did leave him with a lifetime of chronic pain due to the crush injuries. Then there are those brain-injured patients who survive shooting themselves in the head.

It’s tougher than you think to end it all, take my word. And after a failed attempt? You thought your life sucked before, just wait.

What is always infinitely hard to predict is the future, when there hasn’t yet been an attempt, but there are hints. I can’t always tell just how desperate a person is, or how far he’ll go to escape his painful life.

Most of us have had friends, family members, or colleagues die at their own hands. How many of us knew it was going to happen? How many of us missed the warning signs, so easy to see in hindsight?

It’s easy to blame yourself endlessly when someone you know ends his life. I should’ve known he was in pain. I should’ve offered more of my time and my heart. And when it’s someone who is assigned to be under your care, it’s even easier to beat yourself up.

My first suicide happened when I was a fourth-year resident at the Bronx VA—my last year of training. I was thirty. A thirty-four-year-old guy with a heart of gold—nice guy, but a very sick man with intense mood swings and intermittent psychosis—was assigned to me. This illness is called schizoaffective disorder, and it carries a prognosis more dire than bipolar disorder due to its deteriorating course. When I inherited this patient from the outgoing resident in July, she let me know he was in trouble. I had a talk with him, man to man, my desk in between us. He never took off his dark sunglasses during our discussion. (One of the things I fixated on later, in my own interminable postmortem.)

“You’re my most dangerous patient,” I began. I assumed he’d like to think of himself in those terms. I could tell by the sunglasses, or so I thought. “You just got out of the hospital after attempting suicide. Statistically, you’re at risk to try it again.”

He nodded wordlessly. I was hoping he’d start to open up and tell me why, so we could begin to make a connection, but no, just the nodding.

“What can you and I do to keep you alive, I wonder?” I asked. Let him know he’s part of the treatment team. We’re in this together.

“Search me,” he said, shrugging his shoulders.

“Can you please promise me you’ll contact me to talk about it if you’re feeling suicidal? Can we at least agree on that much?”

“Sure thing, Doc,” he promised. He sounded genuine.

Patient contracts for safety
, I wrote in his chart.

He seemed to do okay for most of my outpatient year, which goes from July to June, but at some point in the winter, he missed two appointments with me, one for a group session and another for an individual session. After the second missed appointment, I called his wife to see what was up. She told me bluntly that he had checked himself into a hotel, drunk a bottle of vodka, and taken a few months’ worth of hoarded prescriptions that I had written for him.

At first I blamed myself, and was nervous that others would blame me as well. If he had hoarded my prescriptions, this meant he was off his meds while I was still seeing him. I was specifically worried about the peer-review process, the morbidity and mortality conference where I would have to present his case to the other doctors and defend my choice of his medications. But then I felt guilty that I was focusing on me, how this reflected badly on my skills as a psychiatrist. I needed to do something to shoulder more of the responsibility, even if the other doctors didn’t bear down on me.

I called his widow again, to commiserate. It was a very emotional phone call; I allowed myself to really open up to her loss and grief, and also, most important, to her anger. I needed to feel guilty because I had let both of us down, and she helped me with that, as she had a right to.

She told me how she had known him for eighteen years, and how they’d finally gotten married six months ago. She described how their eight-year-old son kept leaving his seat and going up to the coffin to kiss him good-bye during the open-casket funeral. She shared with me how she felt like his soul had entered her body, and how she spent all
day with his ashes, feeling like her heart had been ripped out of her chest and torn apart.

She was full of questions. Why did he leave her so soon after they were finally married? How could he abandon his son? And how could I, his doctor, let this happen?

It was tempting for both of us to blame each other. She asked why I had prescribed certain medications instead of others, and why I couldn’t see him more frequently. Wasn’t there more I could have done?

I wanted to know why no one thought to call me for help when he stopped talking for a week at home. He began sitting alone in dark rooms, sleeping more and more. Why didn’t she let me know what was going on with him? Why didn’t he call me?

I didn’t realize anything different was happening with him. I fixated on the signs I should’ve picked up on. He wore his dark sunglasses one day in group therapy. Maybe that meant something. He seemed irritable with the other patients, which was unusual for him. Maybe that should’ve tipped me off. And why the hell didn’t I call him immediately when he missed his first appointment for group therapy?

My patient did not want to be found. He didn’t try to hang himself down the hallway while his family ate dinner. He didn’t call an ambulance five minutes after he swallowed some pills because he changed his mind. (These are common occurrences in a staged suicidal gesture.) This man checked himself into a hotel room, telling no one where he was going. He left no note, and he took multiple full bottles of multiple medications, chasing the pills down with nearly a quart of vodka. Clearly, he wanted to die and took precautions so that he would not be stopped.

But couldn’t I have stopped him anyway?

Mostly, what I heard from other doctors at the VA was how some patients are absolutely intent upon ending their life and we can’t always prevent them. That this is a rite of passage. It’s a fundamental part of residency training in psychiatry; every doctor loses patients. You learn and grow from it, and you go on to the next patient, trying not to let it happen again.

When I’m at the CPEP deciding whether someone should be kept in the hospital or released, I need to choose the path of least mortality: Will this person go out and kill himself or someone else? Dance in the middle of the FDR and cause an accident? Jump from the Brooklyn Bridge?

My answer, more often than not, is, Who the hell knows? Does anyone see a freakin’ crystal ball on my desk? I don’t have all the answers. I’m doing the best I can with what I have, which sometimes is not much information at all. I’m always pressured to send the patients out, because we only have so much room at the hospital. The busier we are, the higher my threshold for what gets caught in the safety net, and thus pulled into the safe harbor of the psych ward, such as it is.

There is an element of uncertainty with every T & R. I have to be okay with that ambiguity if I’m going to work weekend after weekend. I trust my gut and try not to gamble too much on any given case, and usually the house wins.

Before I became a psychiatrist, I rationalized that people had a right to commit suicide. If you’re at a lousy party, you should be allowed to leave if you’re not having a good time. But after talking to that man’s widow, I got to experience a fraction of the pain that a suicide causes, and my first time sharing that grief made me see things differently, made me understand more fully my own obligation as a physician.

Suicide is not just about wanting to leave the party. Depression changes the experience, coloring the perception, which makes it impossible to enjoy the party. As a physician, I must combat the illnesses that cause suicidal thoughts and behaviors. I have an obligation to eradicate the depression that poisons the mind, just as surgeons need to defend their patients from the cancers that hijack the body.

Doctors are supposed to alleviate pain. Psychiatrists are meant not only to soothe the despair and hopelessness that a depressed person experiences, but also, I have come to realize, to prevent the pain of the ones who would be left behind. This means I must do all I can to prevent the leaving.

J
anuary 2004. Kathie Russo calls me in the morning on my cell phone, just before I’m leaving the hospital. She should sound frantic, yet her voice is somehow friendly, as always.

“Spalding’s missing again.”

“Oh, no …” I say.

“Can you find out if he’s in the ER there, or …” she trails off.

The morgue
, I think. “Sure. I can ask them if they have any John Does. You want me to call the medical examiner, too?” I ask as casually as I can.

“Yeah. I guess so. I think he’s really done it this time. He left on Saturday night, saying he was meeting a friend for dinner, but when he didn’t come home I called his friend. He didn’t have any plans with him. And Spalding called Theo to say good night around ten o’clock, but he never came back. He left his wallet here.”

“Boy, that doesn’t sound so good, Kathie, leaving his wallet.” I don’t say the word: suicide. Spalding has been talking about it for years, and he’s made several attempts since I’ve known him. There was that time on the bridge in Sag Harbor in September of 2002. He didn’t jump. That’s what EMS calls a “bridge up,” as opposed to “bridge down.” (There’s also a “hang up” and a “cut up,” more ways to trivialize the event, surgically removing its gravity.) Then there was another time when he actually did jump off the bridge in October of 2003. And the time he walked into the ocean fully clothed. He’s left suicide notes in the past, or a message
on the answering machine saying he was going to jump off the Staten Island Ferry. But Kathie says this time there’s no note.

“I don’t know what to think. All I know is, if he did it, or if he’s just pretending he did it … I don’t think I can do this anymore.”

“I know, Kathie. It’s horrible, what he’s putting you through. And the kids. It’s not fair. He’s been miserable for such a long time. But I thought he was getting better.” Again, I don’t say what I’m thinking, which is that it’s when depressed people get a little bit better that they finally have the energy and the wherewithal to complete the suicide they’ve been contemplating. “I’ll call the ER and the ME’s office and call you back if I find out anything.”

I call the AES and ask if they have any unidentified white males in their sixties. They don’t, and I dial the city morgue next. They’re on the next block, just north of Bellevue, and I’m tempted to walk over there. It’s probably easier than getting someone to pick up the phone, if it’s anything like Bellevue. I’m placed on hold, and I really have to pee. I dance around my office with the phone cradled in my neck. I’m six months pregnant now, so I have to use the bathroom every few hours at least. It’s hard not to think about Spalding’s kids while I’m waiting. I imagine they’re all sitting around, watching the door, hoping he’s going to walk in so everything can go back to the way it was before.

Only it hasn’t been the way it was for years. Kathie has been through hell dealing with Spalding’s depressions, and there have been a handful of phone calls to me along the way, especially since his car accident in Ireland the summer before 9/11. He had two psychiatric hospitalizations in 2002, the first at Silver Hill in June and then at Cornell in September. The Cornell admission lasted for months and months. I remember Kathie calling me to complain how she couldn’t get them to release him, because Spalding wouldn’t tell them he wasn’t suicidal anymore. Basically, he was, and he didn’t know enough to lie. I bet his Cornell psychiatrist knew what a lot of us pushed to the back of our minds: He was absolutely going to kill himself eventually.

For the next few weeks, I drive home on Sunday and Monday mornings, my car covered with snow, heading north on the FDR, the East River on my right. Spalding’s out there somewhere, I think as I glance at the ice. If he did jump off the Staten Island Ferry, then his body is most likely in the East River because of the currents. And all the evidence is pointing to the Staten Island Ferry. The call to Theo came from the terminal
there. Someone who works on the ferry reported that they saw him the night before, on Friday night, when he placed his wallet on the bench and walked over to the boat’s railing. Maybe it was a dry run, or maybe he just wasn’t quite ready, but I’m afraid he did jump into the river the next night. The police tell Kathie that his body will probably turn up in the spring, when the ice thaws. I think about that every time I drive home.