by Robert Lanz, LCSW
“There is a fine line between self-directed violence and an ambivalence for life.” — Robert Bossarte, V.A. suicide expert
Most people who come to the emergency room exhibiting suicidal behavior don’t want to be dead. If they wanted to be dead, they would already be dead, and they wouldn’t have made it to the ER. They would have chosen a method that virtually guarantees death, such as a gun, which has an efficiency rating of about 99.9 percent. Jumping off a high place is almost always successful. Standing in front of a train, even a slow-moving train is just about sure to result in death (and for reasons unclear to me, is a favorite of depressed Viet Nam vets.) Setting yourself on fire and stabbing yourself generally are effective as are jumping into deep water if you can’t swim. Gassing yourself with carbon monoxide from your car’s exhaust works pretty well, too. Cutting wrists and taking an overdose of medication almost never work, yet minor wrist slashings and overdoses are the most common presentations of ‘suicidal behavior’ we see in the emergency room. The reason for this is that they are not very lethal, available to everyone and relatively painless.
Wrist cutting and overdosing are mostly seen as suicidal gestures rather than suicidal attempts, and these patients almost always return home unless there is a medical reason for them to be admitted to the hospital. Most of these ‘gesturers’ demonstrate the ‘cry for help’ that is so often quoted in the literature. The majority of them have no intention of dying, and if for some reason they actually did die, it would come as a surprise to them. Those who use these non-lethal methods may think they really want to die, but with enough time and gentle questioning, it becomes clear that they really just want to stop their emotional pain, and have come to a point in their lives where they don’t see any other way to do it. They fit into the classification of feeling ‘hopeless and helpless,’ one of the diagnostic criteria for clinical depression.
Another category of patients showing ‘suicidal behavior’ are those manipulators that have absolutely no intention of dying and are trying to get someone’s attention. Usually, it is someone specific, but a desperate person will perform desperate acts, and may settle for the attention of almost anyone, including the staff in the emergency room. There are those who believe that if they came to the emergency department and said, “I’m really depressed, pay attention to me,” that no one would take them seriously. Instead, they take fifteen aspirins or scratch their wrists and are ‘discovered’ by friends, family or neighbors who call the paramedics. Then, they’re brought to the emergency room where, of course, nobody takes their behavior seriously. We take their feelings seriously, but it is hard to take their behavior seriously when there is a bottle of fifty aspirins and only twelve are missing or when the patient tries to slash his wrists with a plastic razor that couldn’t cut deep enough to require stitches even in the hands of the most overzealous of surgeons.
I have no idea how many successful suicides there are in any given week, because if they are successful they don’t make it to the ER. I can say there are a few who shoot themselves and live long enough to show up, but not much longer. The same goes for jumpers and hangers. What I do know for sure is that men are three times as likely as women to be successful at suicide. Men are more aggressive. They kiss oncoming trains, put guns to their heads or in their mouths and jump from very high places. Women try three times as often as men but are less successful because they almost always use overdoses or wrist slashing. Even in deep depression there is a sexual difference that can be noted. I won’t try to explain it but it would be a mistake to not mention it.
Most patients displaying suicidal behavior, especially if they are adults, have displayed suicidal behavior in the past. Many will do so again. Our job is to try and help the patient get connected to someone who will help him or her find another way to express their feelings that is more direct and not as self destructive.
About five to ten percent of wrist slashings are serious enough to require stitches. But most don’t, and besides, it is almost impossible to kill yourself by cutting your wrists. Almost. If someone really wanted to do it, he could. It hurts a lot, and usually only highly intoxicated or psychotic people are able to withstand the degree of pain that results from a cut deep enough to cause death from loss of blood. One of the many wonders of blood is that it is able to clot even in large arteries, and bleeding stops on its own.
The vast majority of ‘slashers’ have no intention of dying, and are really going for dramatic effect, needing some acute form of attention. There’s nothing like a lot of blood to get everyone worked up, which is, of course, the intended purpose of the slashing. In that sense, it is highly effective behavior, and because it works, it is likely to be repeated. This will present a dilemma for the clinician who attempts to work with the patient and his/her family.
Most ingestions are the behavioral equivalent of wrist slashing, although they are much more common. Ingestions don’t hurt, and many of them, depending on the substance ingested, feel pretty good. People who have low tolerance for emotional pain also seem to have low tolerance for physical pain, and it’s just a lot easier to swallow a few pills than it is to actually cut a wrist. I’m not sure I understand why that is. I’m not sure I need to.
With all ingestions, our goal in the ER is to clear the stomach of the substance, give charcoal to filter out what is left, observe the patient’s vital signs and intervene if necessary. Finally, we test the blood and urine to determine exactly what and how much of anything the patient has taken. If we know what the patient has ingested, there are some immediate remedies we can take. If the patient has overdosed on some opiate like heroin or codeine, we can give them an antagonist drug like Narcane and immediately reverse the effects of the opiate. If they have taken an OD of benzodiazipines like Valium we can give them an antagonist that reverses the effect of that drug within a few minutes. Not as dramatic as Narcane, but benzodiazipines aren’t as fatal as opiates so the reversal doesn’t need to be dramatic.
The most common course of events for the overdosed patient includes what’s called a gastric lavage, commonly referred to as pumping the stomach. It is a very uncomfortable procedure, and the patient has to be close to unconsciousness or highly motivated to be able to do it without problems. A large tube is greased and put up the patients nose and guided down the esophagus into the stomach. A five-liter bag of liquid, called normal saline, is attached to the tube, gravity-fed into the stomach and then pumped out again. This is done over and over until the contents come back clear. Then the patient is given six ounces of charcoal slurry down the tube, chased with a bottle of magnesium citrate that speeds it through the stomach and intestines, where it absorbs whatever was not extracted by the lavage. Most patients find the experience very unpleasant, and it is not uncommon for that singular event to change the patient’s mind about ever taking an overdose again. As in many cases in the ER, some physical sensation will have a lot more of an impact on a patient’s consciousness and subsequent behavior than anything a doctor or social worker might say.
If I do think a patient is truly suicidal, then it is my job to figure out what to do with him. Due to the ever-changing face of health care since the nineties, this can get more and more difficult. If a patient has insurance and wants to go into a psychiatric facility, then there is the nightmare of getting approval from his insurance carrier. If the patient has insurance, doesn’t want to go into a facility and is a danger to himself, as in still feeling suicidal or threatening to hurt himself further, the patient can be locked in a facility against his will for three days while being evaluated. If, at the end of the three days, the patient is still a danger to himself, he can be held for two weeks. After that it takes a court order to keep him confined. Court orders are rare, especially if the patient has no insurance.
If there is no insurance, I can try calling the police, and they can transport the patient down to the county hospital for a psychiatric evaluation. This is a nightmare of another sort, as the county hospital is almost always full, but they cannot refuse to evaluate the patient. They know they will have to evaluate several patients on any given night, so they are reluctant to give up any of their beds. As a result, a patient without insurance who exhibits a certain set of behaviors and feelings might get released from a county facility while a patient with those exact same behaviors and feelings would not be released from a private hospital where his insurance company is paying six or seven hundred dollars a day. This is a classic example of the two tiered system. It would be a real tragedy, except for the fact that most of the people who are being evaluated and treated didn’t really want to die in the first place. If they had, they would have killed themselves instead of showing up at the emergency room with a non-lethal OD or some minimal wrist cuts, saying they wanted to do die.
Having to evaluate a suicidal patient, or rather a patient with suicidal behavior, is an almost nightly occurrence in the ER. I’ve done about two thousand of them, and to my knowledge, no one I have sent home has ever killed himself or herself. To my knowledge, only one whom I have ever sent to a hospital and was subsequently released from that facility has ever committed suicide. I guess that is why a successful suicide always makes the news, because it is really rare.
Jimmy O. came to the ER for multiple lacerations and abrasions, road rash he sustained while riding his bicycle down the street in front of his parents home. He was intoxicated, going at a high rate of speed and went through two stop signs before his big time crash. Because of his intoxication and confusion from the head injury, I was not able to interview Jimmy, even though his history was suspicious. He knew the area; he had ridden his bike there for years, yet he was going too fast to have had control over the bike even if he had been sober in broad daylight. He was thirty-three years old, probably an alcoholic and living at home with his parents. Just before he crashed, I was to learn from his friends, Jimmy had had another argument with is parents. He went out and got drunk then Kamikazied past their house just before he crashed.
This seemed like really self-destructive behavior to me, so I brought it up with his friends. They denied ever seeing him do other self-destructive things. They denied ever hearing about any plans to hurt himself. I knew that they were lying. We generally feel in the ER that the odds are against catching somebody the first time they make these big time errors in life. It’s the same with the cops. When they catch a bad guy, they never think they caught him the first time he did something illegal. More likely, this is merely the first time he was caught doing something illegal.
Jimmy O.’s friends did tell the truth about Jimmy’s wild streak, but downplayed it or misinterpreted it. No one thought he was suicidal but me. His family didn’t. The doctors didn’t. The friends didn’t. Jimmy entered the hospital for medical treatment of his concussion and despite my observations, no mental health person saw him for suicidal tendencies while he was in the hospital. He denied having a drinking problem, and that was about as far as our mental health interventions got. When I found that out, I went up to his room myself and confronted him.
Possessing the average amount of insight of a typical alcoholic, he denied having suicidal thoughts or plans or any problems at all. He thought I was just a spoilsport for trying to get him to pay attention to the pattern of his drinking. He was released from the hospital in a few days, and everyone thought it would be business as usual when he left. I didn’t think so, but there was nothing I could do about it. I had brought it up with his friends and confronted Jimmy openly. No specific suicidal attempt, no specific suicidal plan, no strong suicidal ideation. No criteria for involuntary hold. I knew he would be back.
A week after his duscharge, Jimmy found a pistol, an old thirty-eight that his father kept around to protect his home. One day, Jimmy got drunk, put the pistol under his chin and pulled the trigger. The bullet tore through his jaw, took out most of his teeth, blasted away half his sinus cavity, traveled between his eyes and through his frontal lobe, the part of the brain where personality is located. Jimmy didn’t die from the hot lead that seared his brain, but his personality did. At least the depressed and alcoholic part of it did. In that sense I guess Jimmy was a good shot. He managed to blast away all the pain, the need to drink and a lot of his adult memories and cognitive processes. In effect he knocked himself back to a happier place in life, the mental age and temperament of a ten year old with no problems. He went home and lived in peace with his parents, the child they had always wanted.
Some time later, one of his friends ran into me in the hall outside the ER. He remembered me from the first night, the night of the bike crash. He said he was feeling guilty because he didn’t tell me about how depressed Jimmy had been and how he often talked about being better off dead. And then Jimmy shot himself, just like I told him he would. He tried to apologize.
“Save it,” I said: “Jimmy got what he wanted and he didn’t have to die for it. He just killed the part he didn’t like.”
Most people who think they are suicidal would probably settle for that.
Note-this is an old story and the treatment for overdoses has changed significantly with activated charcoal replacing the dreaded gastric lavage most of the time.