by Gulchin A. Ergun
It’s the end of a busy weekend, but I’m the gastroenterologist covering seven doctors, so hectic is what I expect. Sixty rings and beeps, fifty-three follow-ups, and twelve new consults claimed my attention in the past fifty-one hours. So it is 8:00 p.m. on Sunday, and I leave the hospital. Pens and pager are emptied from my pockets. Everything is taken care of.
At home I lean into the refrigerator and survey the skeleton of a roasted chicken, stemmy grapes, and some rounds of pita bread. I wish my husband were home. With flying bits of garlic and parsley, a sympathetic linguine with clam sauce would have appeared before I’d shed my scrubs.
I tear off a piece of pita, then pick at the clucker that never makes it to a plate. I pop a few of the less-wrinkled grapes into my mouth and flip through channels on TV. Between Iron Chef and the history of the Luftwaffe, I’m better off in bed.
I pick up the top book on my nightstand and find a starving Inman still struggling to get home to Cold Mountain. He’s just stolen dinner from ladies washing their clothes in a river and feasts on three pieces of fish and some undercooked biscuits. I think his dinner was better than mine and turn out the light. Forty minutes later the phone rings.
“Dr. Ergun?” someone says. “This is the answering service. You have a call from the ER.”
I don’t glance at the clock. I debate turning on the lamp but don’t since sixty watts will definitely wake me up. Most calls can almost be answered in sleep, a skill perfected by years of dealing with problems through REM-starved nights.
“Sure, go ahead and connect me,” I say in my monotone, you-just-woke-me-up voice and lean back into the pillow.
After most of Pachelbel’s “Canon,” someone picks up.
“Is this GI? Are you covering Dr. Keagan?” he asks.
“Yes,” I reply, not willing to add any extra words to keep the conversation going.
“Well, you have a thirty-one-year-old woman with a suicide attempt. She swallowed some razor blades and fish hooks.”
I raise myself up onto an elbow to listen a little better.
“When?” I ask.
The question is not small talk. Most think jagged objects hack a bloody path down the throat, but the esophagus and stomach are relatively resilient to damage. Provided sharps travel with the currents of peristalsis, foreign bodies can ride down the lumen without getting stuck in the banks. And since the stomach functions more like a lake or dam, items that can’t be churned into little pieces, or emptied, collect like debris at a bend in a river. The real problems occur when sharp objects navigate out of the stomach into the small intestine. That’s when they can slice through the bowels, severing blood vessels in their path.
I do a quick calculation. A normal stomach empties half an egg in under a hundred minutes. It’s now twelve hours past ingestion, so most of what she swallowed should be in the small intestine. If that’s the case, there’s nothing I can do. With luck the hooks and razors will pass on their own, cocooned in stool. If trapped in the stomach, though, we stand a chance of removing them before damage is done.
“What does the x-ray show?” I ask.
“She’s got razors and maybe a small screw or a nail in the stomach. Can’t tell exactly but they’re probably carpenter’s, single-edged. Maybe a few in the mid-abdomen,” he responds. “But she doesn’t have any pain, and the exam is normal. No free air.”
The news doesn’t exactly make me happy. This is something that can’t be pushed off until tomorrow. Even if it could be, my schedule wouldn’t allow it. The calendar is already jam-packed: a full day in clinic with meetings after.
“Did she take anything else? And what are the labs?” I ask.
“They’re okay. The tox screen was negative. The white count’s a little elevated, but the hemoglobin’s normal at thirteen,” he says. “Surgery saw her. They want to observe.”
Great, I think. Observe is code for not operating. They know she has sharps in her intestine, but they’re arguing they don’t need to operate until they have evidence of a puncture. They want proof that air has rushed out of the inner tube of the gut by seeing “free air” on the x-ray. That, pain, or bleeding would require an exploration. So, while the films get the surgeons a stay, my wait is revoked.
I may not be able to get at the things in her intestine, but I do stand a chance of preventing damage if I remove whatever hasn’t emptied from her stomach. But even this has risk. While snaking a tube with a camera the width of an index finger to look around the guts isn’t that hard if you’re experienced, doing the same endoscopy as therapy, to take out razors or nails, isn’t as easy as swallowing them, no matter how strange it sounds. You don’t just vacuum stuff out. Suction channels of endoscopes aren’t big enough to accommodate objects. Pins and screws have to be oriented with the long side parallel to the hollow organ to avoid lacerating normal tissue as you pull them out. Razor blades are the same, but grasping the dull end using a rat tooth forceps isn’t simple when the blade is coated with mucus and blood. It’s like reaching for a greasy kitchen knife using tweezers. Expect it to slip or fall, so to protect the throat and esophagus from cutting edges, you have to put a plastic tube over the scope and slide it into the esophagus to create a plastic tunnel to safeguard flesh.
I open my eyes.
It is 11:20 p.m. Too late to get a good sleep, and too early to have it wait until morning. I know my team needs lead time too. They have to get out of bed, shake themselves awake, and drive in to get ready. By the time they get organized, it’ll be 1:00 a.m. If all goes well, we’ll be done in an hour, and if I fall asleep by three, I’ll get some rest before the alarm. But that’s being optimistic. Drowsiness doesn’t follow a schedule, but you get selfish about sleep. It’s a part of survival. The risk of coming up short occurs every time someone calls.
“I’ll call my team. We’ll get ready as soon as possible,” I tell him. “Which room is she in?”
“Thank you. I mean it,” he says. “She’s in twelve, the trauma room, but she’s being transferred to the MICU. The nurses just called report.”
That screws us. Transferring the patient will take more time, and tucking her in the unit could stretch into another half hour, more distance the blades can cover.
I call the operator and ask them to page the endoscopy nurse. When I get the call back, I try to be gentle.
“Denise,” I say. “I know you’re going to hate me, but we have a lady who swallowed some razor blades. How long before you guys can get here?”
“Well,” a foggy voice replies, “Michael is the tech on call. I’ll let him know. I live in Willowbrook, so I think I’m the farthest away. It’ll probably be about an hour and a half before we can get everything together,” ending in a voice far kinder than mine when I’d answered the phone with the same news.
“Okay,” I say. “Call me when you’re fifteen minutes away from being set up,” and I give her the name of the patient and the location.
In my neighborhood, no one is on the roads in the middle of the night, but as I cross from Weslayen onto Bellaire, I revise my thinking. The swaying Nissan, the trio in the Cruiser with the thunderous bass, and the uniformed man in an SUV suggest that the only people on the road are drunk drivers, late night partiers, people who work weird shifts, and me. After hitting a string of green lights, I make it to the hospital in ten minutes.
People ask if I get nervous going to the hospital in the middle of the night. Parking is in the basement, and from there it’s a ride up an isolated elevator and a badge wave into a restricted passage. But I find the hospital comforting. Inside you’re safe. It’s sort of like home. No matter how early or late, as family, you have a key. You can slip in and out, and the routine is always the same.
At the entrance is a security guard who nods and waves hello. On the floor, a sweatered secretary sits at a desk. A monitor only partially obscures a Diet Coke and microwave popcorn that wouldn’t be seen during the day. A nurse might sit nearby, thumbing a worn Good Housekeeping during a free moment. But if it’s a floor I go to often, a clerk might hand me a chart before I’ve even asked for it. The nurse anticipating my arrival might say, “I checked her vitals and hung the saline,” then add, “We just made some fresh coffee. Want some?” You have the feeling that they’re your friends, your allies, even if you’ve never met.
I turn the corner to reach bed eighteen, ready to smile seeing the team gowned and gloved standing outside the door, all set up, exactly as expected. But as I approach the room, I see Denise fiddling with her left earlobe, a habit she falls into when she’s worried or anxious.
“What’s up?” I ask.
“She says that she doesn’t want to do this with regular sedation. She’s had it done before and won’t fall asleep.”
“That puts a kink in the plan,” I say. “Let me talk to her.”
I swipe my badge, log onto the computer, and review her chart and x-rays. It’s just as they say. I step in to introduce myself.
“Hi, Candii. I’m Dr. Ergun. They asked me to see you because of your x-ray. What happened?”
I guess I could have broken the ice a little more gently, stuck to the traditional open-ended questions, but I didn’t see the point. She’d already met three nurses and a couple of doctors, and I was probably the fifth or sixth medical person asking her questions.
She’s in a hospital gown and swaddled in blankets that come up past her neck, like a poncho in the rain. The only visible parts are her cheeks and eyes. Although she is leaning back in the bed, propped up on the pillow, she is clearly doing her best to avoid eye contact.
“I felt like the suicide thoughts were getting stronger, so I came in.”
Her tone is surprisingly apathetic. There is no hesitancy, no gaps in her speech, barely reluctance as the words leave her lips. Sounds rehearsed, I think, then ask, “What exactly did you do?”
“I crushed up a glass and swallowed it. After that I swallowed some razor blades and fish hooks.”
“Can I ask why you did this?”
“Like I said, the suicide thoughts were getting stronger, so I came in.”
“Have you ever done this before?”
“Yeah, a couple of times. I was here last month. I had surgery.”
“What happened then?” I pursue.
“I swallowed some razor blades; then they operated on me after a couple of days. They took out part of my small intestine,” she says.
“Did you swallow anything else?” I probe.
“Not this time,” she answers and sneaks a glance at me. I can see smudges of mascara around her puffy, red-rimmed eyes.
“Do you mind if I examine you?” I ask and look in her mouth for nicks or burns when she nods her assent. I listen to her heart and lungs, then lift her gown to examine her abdomen, noting no tenderness, just the presence of several scars. Some are silvery and faded, but standing out is the one that runs down the center of her belly. Still red and angry, it has a row of perfectly parallel dots on each side where the staples have recently been removed.
Her chart is filled with all the things you expect to see with someone with suicide attempts. Multiple psychiatric diagnoses: bipolar disorder, schizophrenia, anxiety, depression, borderline personality. She was removed from a drug addict mom and grew up in foster homes. There is no mention of other family, although a note says she was sexually abused by her father as a child. A recipe for being screwed up. She is unemployed, unmarried, without kids, and alone. On top of that, she is on a boatload of psych meds, none of which she takes regularly. Her allergy list is longer than her med list and includes a page of psychiatric medications suggesting she’s been on all of them, at one time or another, in her thirty-one years.
“Candii, your x-ray shows that you’ve got a few razor blades in your stomach. The glass isn’t showing up.” I pause, searching the blanket for a reaction. “They need to be removed. Have you ever had an endoscopy to remove things you’ve swallowed?”
“Yeah,” she says, almost perking up. “But they can’t put me to sleep with the regular stuff,” she adds. “You have to use the Michael Jackson juice.”
Interesting way to put it, yet a legitimate issue. Endoscopy is not easily done with someone awake. A wriggling patient with sharp objects dangling from a scope isn’t safe, but divulging this last minute hints of manipulation, and the obstacles and inconsistencies are mounting. There is a twelve-hour delay in coming in after a suicide attempt, and a discrepancy about what’s been swallowed. To say she’s an unreliable historian is an understatement, but we have to believe her. There’s no way to corroborate her story, and unleaded glass is invisible on x-ray.
Add her claim that she can’t be sedated with standard medications. In Texas, propofol can’t be given unless you’re an anesthesiologist or a nurse anesthetist, so they have to give the sedation while I do the endoscopy. But anesthesia doesn’t come to the MICU at night. The only way to sedate her quickly now is to have the intensivist give her propofol, something they are allowed to do, provided the patient is intubated and on the respirator. This is really getting complicated.
I ask her nurse to page the intensivist. “Hey,” I say. “This lady with the razor blades can only be sedated with propofol. Can you intubate her and sedate her so we can do the endoscopy?”
“I’ll come up,” he says. “Shouldn’t be a problem.”
“Thanks,” I reply. “It’s actually better this way,” I say, thinking out loud. “If she’s intubated, her airway’ll be protected, and I won’t have to worry about her aspirating broken glass or anything else she’s swallowed.”
Denise stands outside the patient’s room, and I flash her a thumbs-up as I tell everyone that we plan to intubate the patient and that they need to call respiratory therapy. By the time I get back to tell Candii what we’re planning, it’s 1:40. Denise is now shaking her head and sitting glumly in a chair outside the room. Michael stands next to her, arms crossed in front of his chest.
“Now she’s refusing,” Denise says. “She says she doesn’t want to do anything.”
“No way,” I hear myself say. “She can’t do that. Someone who just tried to kill herself can’t be competent to refuse therapy. You’ve got to be kidding me.”
I am irritated. It’s bad enough we’re behind the clock, but now we have to intubate her and call psych. That’ll take even more time. They’ll send a resident who needs to run it by senior staff.
“Call psych, and ask for the attending,” I say. “We need to figure out if she can refuse this. If not, she needs to be declared incompetent so we can do this emergently,” I say and go back into the room.
“Candii, what’s this business of refusing endoscopy?” I ask. “I thought you came here for help.”
She answers the question through the muffle of her blanket. “I’ll have surgery, but I won’t do this.”
I try not to roll my eyes, though I know she can sense my annoyance. Besides, the glass doors don’t hide Denise and Michael, both slumped in chairs, their body language screaming, “We’re wasting time sitting here! We came in for nothing!”
I lower my voice, look at her buried face with my best compassionate stare.
“Do you know what you’re saying?” I reiterate, worrying that the more I push, the likelier she might be to resist. “Do you understand the consequences of refusing help? Does it make sense that you’re turning down the only chance you have of preventing something that might kill you?”
She lifts her head enough that her eyes can be directed at me. She says again, “I’ll have surgery, but I won’t do this,” then recedes like a turtle into the shell of her blanket.
The intensivist arrives and I fill him in on the situation. Then I ask, “Can someone who attempts suicide be competent to refuse therapy?” He gives a that’s-a-good-question bob of the head and directs himself to the nursing station.
In the meantime, we assemble and wait for resolution. Michael, the youngest of the team, asks, “How do you swallow stuff like that? I mean you’d have to throw up, right? It’s not like she’s an alligator. I know they find all kinds of stuff when they cut them up. Shoes, cans, even license plates. How does a person do that?”
Denise, a veteran nurse, puts her hand on his shoulder and says, “Michael, you’re a baby. You have no idea what people do. Dr. Ergun, tell him the kind of stuff we’ve taken out. I know you’ve had some crazy cases.”
“You start. You’ve been a nurse longer than I’ve been a doctor.”
“Well,” she sighs as she settles into a chair, smoothing the wrinkles of the plastic gown over her hips. “Razor blades are pretty common, but oh, we’ve taken out all sorts of things. Nails, dentures, partials, toothbrushes, straws, even gloves. And I don’t need to go into what we’ve taken out from the bottom end.”
“That’s it?” I ask. “Then I have you beat,” and tell them about a man I’d seen who swallowed razors, several feet of rubber tubing, a watch, pen, chain, and, after pausing for effect, a computer memory board. I tell them how we were perplexed by something shaped like a box on his x-ray, until we did a rectal exam and saw string coming out. That was when we identified it as dental floss.
“Oh my God.” Michael giggles. “Butt floss,” and we try to curb the laughter you don’t usually hear in the ICU.
“Who does this?” asks a respiratory therapist.
I give them my standard lecture on the three P’s of foreign body ingestion.
“Three groups of people do this. Pediatric patients, well, because they’re little kids. They take in the world through their mouths, and they swallow things: M&M’s, toys, little batteries, coins. The second group is prisoners. Mostly trying to get out of jail. The last P is psychiatric, like what we have today. Once in a while, though, you get accidents, like carpenters or painters swallowing nails between their teeth. And sometimes you get impulsive gestures. Once I had a lady who swallowed her engagement ring after she got into a fight with her fiancé. I joked, ‘finders keepers,’ when I took it out. They didn’t think it was funny.”
Denise chuckles and asks, “Do you have that guy who swallows bottle caps and lighters all the time?”
“No, but I know who you’re talking about,” I say. “I hear he’s a nice guy. He comes in early so you can work him into the day shift. Kind of thoughtful that way.”
I see the intensivist angle toward me, phone in hand. “Okay, I understand,” I hear him say. “As long as she understands the risks of refusing therapy, she’s competent to refuse.”
I look at him, jaw open, as he gets off the phone.
“Did I hear you right?” I question. “She’s competent to refuse therapy?”
“That’s what they said.” He repeats part of the conversation. “As long as she can communicate, reason, and understand the treatment and consequences of refusing treatment, she’s competent. We can’t do anything else.”
“How is this possible?” I ask. “She has tried this so many times and has the scars to prove it. How can someone who attempts suicide be competent to refuse help when they come to the hospital? It’s totally contradictory. Why bother showing up?”
“I agree,” he says, “but they know her, and this is what she does. It isn’t new. They said they’d come down and see her, but it probably wouldn’t change anything.”
I shake my head as we walk toward the room.
“So, we’re just supposed to watch her, then call surgery when she finally perforates?” I ask.
“What kind of a system is this? Since when is it better to rack up the bills waiting for a surgery? What happened to prevention? She should be in a psych unit where she can be watched and get some intensive therapy. Whatever they’re doing now isn’t working. How many times can you swallow glass or razor blades? One of these days she won’t make it in time.”
“Well,” he says, “she came from an assisted facility. You could argue that she was watched closely but knew how to get around it. It’s manipulation or persistence. Either way, she gets what she wants.”
“Maybe she can’t be fixed. If that’s the case then someone needs to teach her how,” I heard someone mutter. “Remind her to stay at home or use a gun. More permanent.”
I am so stunned at the comment, I pretend I don’t hear it. But it reminds me of a man in a Pinto I watched riding a rim into a parking lot. The driver got out, checked out the flat tire, then poked around the trunk to find a spare. He got the car jacked up, took off the hubcap, and attached the tire iron to loosen the nuts. The first two came off easily, but he struggled with the third. It must have been rusted on because he was really putting his body weight into the iron. He finally decided to stomp on the wrench as he was torqueing it. With the third stomp the iron snapped. This was followed by a loud “Shit, fuck, shit.” He screamed and yelled, cursed some more, and kicked at the ground. He picked up the broken tire iron and proceeded to pound the asphalt, the tire, then the car.
Like that guy, we’re aggravated and angry. We beat our frustration with cruel comments, but we are also being manipulated by someone who doesn’t care to live. The resources of a whole hospital are called together to keep this lady going, to give her a chance at living, and she is throwing it away with no regard for our efforts.
“Denise, come in with me. Someone has to document this conversation. Let me try one last time,” I say and walk up to the bed. “Candii, we’ve spoken to the psychiatrist on call. We want to make sure that you understand what you’re saying.”
A Medusa gaze is cast in my direction, and she speaks in an even, intractable manner. “I understand what I’m saying. I can die. I don’t want to do anything. I don’t want you to look in my stomach.” Then, as she turns her face away, says, “I told you before. I’ll have surgery. Nothing else.”
I think about the immediate issues. Of course she has a right to autonomy. But autonomy is irrelevant without acceptable decision-making capability, and since her toxicology screen is negative, we can’t even blame drugs for her poor judgment. She is capable of reasoning, and she is communicating clearly. Her speech is not distorted, and while her sparse words are inflected with misery, her deliberate language tells me that she understands the consequences of refusing treatment.
For me, this is the heart of the problem. Her decision to do nothing is on a collision course with mine to do everything. All the drugs she’s been taking, the stream of visits to psychiatrists, psychologists, and social workers, none made enough of a difference in the most important desire we are there to support: the will to live. I cannot understand how she can starve for the pain of broken glass or surgery, yet live in a limbo between caring and indifference for her own life.
“Okay, team,” I say, “we’re at a standoff. She’s refusing, and psych says she’s competent to do it. I’m sorry I woke you up and that you had to come in.” I put my hand on Denise’s shoulder. “Go home and try to get some sleep. We’ll reassess in the morning. If the stuff is still in her stomach, and she’s not in the OR, we can see if she’s willing to give endoscopy another shot.”
I go to the chart and sit down to document my visit and her responses. I start with May 13, 2010, but my annoyance resurfaces when I realize the date is wrong and that I’ve made a mistake. I draw a line through what I’ve written. Technically it is the next day, with most of my sleeping time shortchanged for a pointless consultation. I trimly describe my history and physical and stutter the pen above the paper before writing the last line: The patient was counseled regarding the risks and consequences of refusing endoscopy. The phrasing is consciously chosen to be neutral and economical, yet the whole story could never be told in these words.
I wonder if she might have been different had she grown up in a less hostile environment. Her life was so alien to mine. I’d grown up sheltered by the advantages of a two-parent household, protected with devotion and education. What if her mother hadn’t been a drug abuser? Would she have been okay if Candii-fetus hadn’t been bathed in a cocaine or crack wash? Or was this the aftermath of neglect and inattention, something I equated with drug-abusing parenthood, since no addict I’d ever encountered put anyone, or anything, ahead of a high? And what about the father? All I saw were the consequences of mistreatment and abandonment until an unsuccessful adulthood. So who was left to be her advocate now? No one else was around, just us, aggravated adversaries in a hospital, perhaps too pleased to end the night and go home.
I glance in her room before signing my note. The young woman sitting inert under her blanket has been in a custodial system and seeing mental health workers longer than she has lived with her own family. She’s been admitted close to twenty times in the past year alone, a frequent flier in suicide attempts. So where was the weak link in this chain of failure?
I blamed her upbringing and the system, but maybe that was too simple. Maybe my presumption was wrong and she couldn’t be cured. Perhaps she was like someone with cancer who had the right to die when treatment failed. Or maybe she wasn’t much different than a patient I’d seen years earlier, when I was starting out. Then it was a homeless man who’d been admitted with a terrible infection of the leg. I’d cleaned his wound, ballooning with pus and maggots, gagging behind a mask as I teased out dead from live flesh. As his cellulitis improved, I made a job of finding a place to accept him, hoping to provide a safe place for a man whose problems were fueled by the lack of a sanitary habitat.
On the day of discharge, he gathered up his dirty pants and mud-crusted shoes but refused to go to his new home. He said he wouldn’t go where he couldn’t get a good grilled cheese sandwich. I tried to reason with him, finally arguing when he said he preferred to live on the streets rather than in a nursing home. I was incredulous and irritated at him and the situation, which was as ludicrous as the one we faced now. No wonder we turned on them, our reactions misguided projections of helplessness and frustration when it seems like not everyone values life the way you think they should. I’d been the one joking then, sarcastically asking how to write discharge orders for dressing changes in a dumpster, a remark as pitiless as the one I heard about this woman.
I push away from the counter and ask the nurse to get another x-ray in the morning. I had talked to Candii, tried to establish whether she was competent to refuse endoscopy, called in everyone to help. I did my best to honor my oath, to do whatever I could to help, while balancing her autonomy with my medical beneficence. But in the end I was left with only her choice, not mine. I couldn’t make her a partner in my decision. Disappointed, angry, revolted as I was at the thought that I had the potential to save her from a painful disaster, I had to do the accommodating. She was tethered to her razor blade providence, and I had to live with it.
I swing my purse over my shoulder and retread the steps that brought me there. I wave good-bye to the secretary and smile at the guard as I push through the door into the parking lot. I slide into the car and lift my foot off the brakes, suddenly squinting as the headlights brighten the cracks in the mortar. The soft incandescence of the hospital logo rolls by then fades into the rearview mirror.