The following essay is based on an actual encounter I had while I was in residency training. Names and other personal characteristics have been changed to protect the privacy of the patient for whom I provided care late one summer night. As a resident physician, one has the opportunity to begin to practice the skills acquired in residency, which is the four year postgraduate training that follows medical school. As a resident, you know a lot, but the actual practice of medicine in the specialty of psychiatry, in particular, takes a few years before one starts to have a true trust in one’s abilities. Moonlighting is the term that is used to refer to working outside of the required daily duties of the residency training program. After a full and demanding day in residency training, one may work an additional five hours late into the night at a different hospital, thus the term, moonlighting.
She started crying when I entered the room. Splotchy, red patches suddenly blossomed across her neck. “Please, you can’t keep me here,” she blurted out.
Sobbing, all her words rushing together,”This is going to be so much worse for me. It’s not going to help me. I have a statistics test on Monday. If I have to stay here, it will look bad for me trying to get into medical school!”
I take in a long slow breath, and observe her while she snuffles and wipes her swollen, reddened eyes on the sleeve of her blouse. She uses both hands to replace her thick black framed glasses, pushing them up high on her nose, while a few inches lower, a simple silver metallic ring pierces through the left nostril. Her shortish ginger hair maintains the hint a stylish cut, and her perfectly white teeth appear perfectly straight. She is wearing the latest hipster clothing. I discreetly push a box of Kleenex towards her.
I sit down across from her and introduce myself. I let her know that I am the admitting physician at this state hospital tonight.
Cathy says nothing, averting her eyes, still sniffling.
“You almost died.” More silence.
I gently ask her, ”How do you think dying might affect your chances of getting into medical school?”
She darts her eyes at me and quickly looks away. Her posture is closed and rigid.
Thirty six hours ago, this attractive twenty-one year old woman had been intubated in an intensive care unit for acute respiratory failure. In short, her brainstem had stopped sending signals for her lungs to breathe.
The story captured by the emergency first responders states that Cathy’s out-of-town friends had returned from a night of partying on the town and found her in the hotel room they were all sharing. When they were unable to arouse her, they had called 911. EMS had arrived and swiftly brought the unresponsive young woman to the emergency room where life saving procedures had been aggressively started, including putting Cathy on a respirator.
Seventy two hours ago, she had driven into town from a neighboring state with her boyfriend and a few other close friends, eager to enjoy a three day music festival that attracted bands from all over the world. The festival had coincided with her spring break, so she and her friends were primed to let loose and have a good time.
After arriving at their hotel on the first day of the festival, Cathy and her friends started drinking alcohol, walking around downtown from bar to bar, listening to bands while dancing, laughing and having a good time in the beautiful spring weather, surrounded by hundreds of like-minded young people their own age, all of them enjoying being alive and celebrating.
Several hours into the partying, with the alcohol flowing freely, Cathy distantly remembers getting into a heated fight with her boyfriend. She doesn’t remember what the fight was about. Her boyfriend and the other friends she was with abruptly abandoned her, or at least that is how it seemed to her. Significantly intoxicated at this point, she suddenly felt very alone, disoriented and overwhelmed in a city with thousands of party-going strangers, all having a great time, all of them except her.
She remembers that she became very angry and distraught. She continued to drink alcohol. She blearily decided to make her way back to their hotel, but was unsure where the hotel was located. She recalls wandering into random bars along the way and ordering drinks, listening to the band that was playing, talking with strangers and then moving on to the next bar. Close to blacking out, she recalls at one point getting in to a car of a male stranger with the understanding that he would give her a ride to her hotel. She remembers chugging a mixed drink she had in her hand while in his car. And that is the last thing she remembers.
Her next memory was waking up in an intensive care unit intubated and on a respirator. She vaguely recalls struggling with staff, crying and trying to yell while intubated that she wanted to be released from the hospital. She recalls pulling out her intravenous line. She faintly remembers having been put in four point restraints, tied down securely to the hospital bed to decrease the risk of harm to herself or medical staff, and of course to prevent her from escaping and stumbling through the halls of the ICU.
Eventually, once it was established that she was able to breathe on her own, the staff removed the breathing tube, but removing the restraints took a little longer.
A social worker had been paged, and when she arrived, she sat at Cathy’s bedside after the breathing tube had been removed. The social worker spoke at length with Cathy as Cathy was regaining more stable conscious awareness.
According to the social worker, Cathy had tearfully recounted how desperate and unhappy Cathy had felt after being abandoned by her friends at the festival. She had felt totally alone. Cathy went on to say that for most of life, she had felt that she never really fit in anywhere.
Cathy also explicitly told the social worker several times that she didn’t want to live anymore. She also told the social worker that she had tried to kill herself previously by an intentional overdose of medication some years ago. The social worker listened while documenting the conversation. Next to the social worker, there were documents from the emergency medical service first responders who had arrived at Cathy’s hotel in time to save her life.
As it turns out, according to the EMS report, when Cathy’s friends found her unresponsive, they also found an empty bottle of Ambien next to Cathy on the bed where Cathy lay.
When I met with Cathy to evaluate her, I met a bright, articulate young woman who elicited within me an almost paternal feeling. I had earlier in the evening heard Cathy’s voice in the background, talking with the staff (orderlies whose job was to maintain order) in the locked waiting room, and her voice had a pleasant perkiness to it, very polite, very upbeat.
‘Likable,’ was the fleeting thought that went through my mind on hearing her voice some twenty yards down the hallway, as I sat in the small, featureless office where I was finishing up paperwork and signing orders for a patient I had seen earlier.
Upon initially meeting with Cathy, there was a part of me that wanted to find a way, right away, to release Cathy from this ancient psychiatric hospital to the care of her family.
In the waiting room of this psychiatric hospital, where Cathy had been escorted to from the previous hospital, there were other people waiting to be evaluated who were intoxicated, psychotic, homeless, yelling and in restraints. Quite a contrast to this nicely dressed young woman who sat before me. It was not clear where Cathy’s family was presently, or if they even knew what had transpired over the last 48-72 hours.
However, even a superficial risk stratification for Cathy, considering the seriousness of the events of the past 36 hours and also the social worker’s report documenting Cathy admitting to past suicide attempts, it became clear that she needed to be in a safe and stable situation, and that safe place was most likely going to be, at least for tonight, in this psychiatric hospital.
Cathy had arrived at the psychiatric hospital on an OPC, or order of protective custody, that had been initiated at the ICU. An OPC is essentially a temporary way of legally depriving a person of their civil liberties. Those documents had been approved by a judge who said, in effect, that Cathy was unable to make decisions for her own safety or that of others, and that were she not involuntarily committed to a psychiatric hospital she would likely be at high risk of harming herself.
While it is possible for a psychiatrist to release a patient from an OPC, it rarely happens, in recognition of the acuity of what has led to having the patient brought to a psychiatric hospital. Better safe than sorry, the thinking goes.
Part of the decision-making, frankly, is the psychiatrist in admissions wanting to avoid being the person who is responsible for releasing a patient who was actively suicidal less than 24 hours ago and who could quite possibly go out and complete the suicide if they were to be released.
“I was wasted, that’s all,” Cathy says, suddenly full of earnestness, looking intently at me. “People say all kinds of provocative things when they get drunk.”
I nod my head, and respectfully respond to her, explaining that in my experience, people are usually significantly less guarded when they are intoxicated and often say exactly the kind of things they have on their mind at the time. I share with her that it seems counterintuitive to me that she would be telling hospital staff that she wanted to kill herself as part of a strategic plan to get released from the hospital.
Cathy feebly tries to argue me out of this assertion, but it is the argument of a scared, embarrassed, and increasingly resigned person, beginning to realize that the consequences of her earlier actions are now taking shape and form.
There is a shift in the mood and conversation as she adjusts to the reality that she will likely be admitted for further observation and evaluation.
Cathy reveals to me that she has been abusing alcohol for quite some time. She admits to having legal problems related to alcohol, public intoxication convictions, as well as minor in possession of alcohol charges. Without guise, she reports what she calls ‘social drinking’ with her friends 3-4 nights a week, (drinking anywhere from 4-8 drinks per night) as within the ballpark as far as her drinking pattern over the past few years. Yes, she admits to having blackouts in the past, but was quick to add that she currently has a 4.0 GPA average in her post-baccalaureate program, offering that as a kind of counterbalance to show that things could not be that bad, even with the drinking.
She reveals that she had been getting Ambien prescribed to her by her primary care physician. She tells me that she was unaware that taking that medication with alcohol is a potentially deadly combination and could lead to respiratory depression, causing the brainstem to no longer give orders to the body to breathe.
As we continue to talk, she says that she has no recollection of swallowing the entire contents of the prescription vial of Ambien when she arrived back at the hotel. “I really don’t think I did,” she says with determination.
When Cathy was brought to the hospital her blood alcohol level was 270. That means that her level was likely much higher prior to the EMS arriving at her hotel room and rescuing her. A blood alcohol level of 350 means the person is at the level of surgical anesthesia, meaning that sensation and awareness are sufficiently suppressed that surgery could be performed and the person would not flinch. At a blood alcohol level of 400, coma and death are imminent.
Whether she had tried to kill herself or not hardly matters at this point. She had nearly died, and had her friends not found her and promptly called 911, she would surely have died.
It is remarkable how little insight Cathy displays regarding the events leading to her arrival here, another poor prognosticator for her ability to stay safe. She had a previous suicide attempt that she described in a minimizing, almost flippant way.
As we continue to talk, I find less and less reasons to release her, and more and more reasons to have her more thoroughly assessed and offered treatment, both here at the hospital and also after discharge as an outpatient.
“I’m afraid you’ll be here overnight for sure,” I tell Cathy. “You’ll be meeting with your primary team in the morning…a psychiatrist, psychologist, social worker and nurse.”
She is looking at me with a blank expression on her face.
“You’re part of that team, too…obviously,” I quickly add, hoping to leave her with some sense of agency, of having a say about how things will progress from here.
At this, Cathy again burst into tears. I slowly lead her back out to the waiting room.
I write the orders to admit her to the hospital. I catch the eye of the nurse at the admitting desk, and handing off the clipboard, say, “We’ll keep her…”
My pager goes off, letting me know there is another patient waiting to be seen…