Heart stops. Restarts. Stops again. And then keeps beating.

In the last two days I've wrote and rewrote this post, in the hopes of somehow consolidating the thoughts and emotions, crises and victories of the week.

MONDAY
Over the course of last weekend I actually spent a lot of time reflecting on the successes of the last week. I bounded into work on Monday only to be smacked in the face with the biggest cream pie ever. I walked back from the mail room, having mailed Sweet Aurit a letter detailing some of the progress made on internship with patients....I nonchalantly started my voicemail up as I gathered my bag to head out to the cranial facial clinic. An unknown voice of a night nurse informed me that one of my patients attempted suicide on Saturday night and had been swept up to the acute unit. I hadn't even taken off my sunglasses yet, I was basically already en route to the main hospital. My friend Shawn comes into my office and tells me that he was on call over the weekend and has updates for me, asks if I'm ok. I was shocked. This kid held my hand crossing the street on Friday. That night we had a breakthrough family therapy session. The next night the police were called and she was forcibly taken to the ER and then admitted to the acute unit on the highest suicide precautions there are. After I was shocked, I got really sad. I walked away from Shawn down the hall to the exit to get my ass to my next task: seeing 10-15 cleft lip and palate kids. He tailed me, giving details and the pertinent information as to my patient's status. He volunteered to go to the acute rounds to check in and gather more info for me because I would be tied up til 1:00. My sunglasses/goggles were firmly pressed to my face, knowing that the eye make up I had so carefully applied was already gone. Shawn walked me to the first set of locked exit doors and again asked me if I was ok. He hugged me before I could reply and I went out into the real sunlight. Even the homeless guys on the street looked at me weird.



The trite series of thoughts flashed before me...how could this happen (duh, Diana, patient had a history of suicidality)...what were the precursors....could I have seen it....and worse yet, could I have prevented it. But there wasn't time to dwell. The cranial facial clinic coordinator Ruth got two sentences out of me and I just had to get to work. Of course, the clinic kids that day had to be the most dysfunctional group I've seen yet. Everything ran late, I was several hours into a tension headache before I had to leave for my own treatment team meeting. I saw my client finally at 3:30 and learned that she mainly just wanted to die. She refused her meds, food, liquids and all hygiene. Her thinking was cloudy and she was withdrawing from her medications that had helped her stay glued together.



Suicidal ideation can be a broad spectrum on its own. The extent to which a person wants to die, intends to die, has a plan, and has access to that plan all factor in. There is no art to risk assessment, its a science. Specific questions yield answers that lead to a conclusion about risk. This particular client wanted me to know that she was in control of whether she lived or died, which is absolutely true. On acute inpatient units however, there are so many ways in which control is removed from the patient, digging an even deeper hole.

TUESDAY
At rounds on Tuesday (my first appearance on acute rounds) I stood my ground with the attending psychiatrist and gave the clinical opinion that my patient gave no indication she was capable of functioning on lowered suicide precautions. That afternoon she was moved to a different unit for administrative reasons. At 3:00 pm I was running a girls' process group, and my patient attempted to swallow a water bottle cap. I heard the "Dr. Atlas" call to her unit, which is a simple message broadcast on the PA. All staff know to respond to the location of the call if they are available and not with children. I wasn't, and stayed put. Fifteen minutes later our unit secretary pulled me out of the group because I was needed on the acute unit. I knew it was my kiddo, and my heart stopped again.



When I arrived, There were 5 police officers and one staff holding my patient on the ground. She was screaming. My supervisor was there and filled me in. I had been contacted because the thought was that my presence might help calm my kiddo down. As Aurit pointed out to me, that's a terrible feeling. And a tall order. It didn't work. I laid on the floor within inches of her face for an hour, and the screaming didn't stop. I wiped her face, cleaned up mucus, said inane things over and over again but there was no focusing. At one point I emotionally detached from the event and mentally pulled back, observing the scene for what it was. I watched sweat run down the foreheads and noses of the police, I watched a nurse bravely stick a finger, then a Bright Yellow Highlighter in my patient's mouth to prevent her from biting her tongue. I heard my kid scream "Just let me die" again and again. I watched the staff coordinate so they could flip my patient from her tummy to her side when she started puking. I willed myself not to cry. The holding of a teenager seems so much more violent to me than the holding of a child. The poundage and physical body mass makes this task so much more difficult, particularly when the teenager in question is completely out of control physically and emotionally. I equate therapeutically holding children with tantrums, a seemingly more benign event. I still need to send a thank you email to the police. They rocked.

Three shots later, she calmed/got sedated and one by one the officers released her limbs. Ativan did the thing that neither I nor anyone else could do. I learned, as she lay face down on an empty unit floor (all furniture had been removed by the surrounding staff amidst the melee), that she had nearly succeeded in killing herself because the bottle cap blocked the airway and it took the 6'6 admissions guy quite awhile to get the Heimlich maneuver to work. The staff, police included, were a bit traumatized. I went into action to contact the family, and then suddenly there was nothing else to do. My supervisor Farah is the greatest. Not only was she there the entire time, but she was encouraging without being patronizing. She was confident in my competence. She gave permission for this to feel terrifying. She asked if I wanted to talk then, given that Monday was a bad day as it was, and this bottle cap scenario had never happened before in the hospital. I opted for distraction instead and went to my car. Before I left she told me that the day would hit me at some point, because inevitably it does, and I will most likely feel crappy. I agreed.

WEDNESDAY
I took a stand in rounds on Wednesday, again. This time, I wanted forced meds on my patient because no one who becomes psychotic ever resolves suicidal ideation without medication. It's just a set up for failure because linear, rational thought just isn't possible. Consent obtained, and a shot to the butt administered.


THURSDAY
This morning in rounds, my favorite nurse and I ganged up on some misled staff who basically wanted to sabotage my treatment plan. Diana and Tess emerged the victors. I HAVE to blog about Tess later, as she is a force to be reckoned with. I went to the acute unit and spent the morning on the floor talking, listening to, and tending to my kiddo with the simple agenda of building motivation for her to take medication on her own, and to do some simple hygiene stuff, since medically we were in the clear. We had waited 3 days to see if this kid could produce urine on her own, and thankfully, the kidneys were working. There was no longer need to think about hauling the patient to the PICU in the main hospital against her will. It was hard for me to explain to the attending how I got the following things to happen, but happily my patient 1) took meds voluntarily (insert discussion about how the shot in the butt would be a daily thing, and no court order was necessary. Mom consented.) 2) ate some breakfast and lunch 3) took a shower (flash forward to me standing in the doorway of the girls' shower holding the shampoo) and the big finish....4) declare willingness to return to her residential unit, and thus continue to live. Thank goodness for 2 days worth of antipsychotic medication. Some semblance of rational thought appeared and the patient was able to move in another direction.

Secretly, I'm waiting for the next cream pie. Overtly, I am more hopeful, yet cautious.

Among the things I have learned is the fact that I work with a tremendous group of people. My fellow interns could not have been more supportive and non-hovering around me. Caffeine, ibuprofen, adrenaline and endorphins have been the chemicals that have been the most important to my functioning in the last four days. The physicians believe what I say.

FRIDAY
To be determined.