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The Art of Medicine


Godfrey, Alexandra MS, PA-C

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Journal of the American Academy of PAs: September 2013 - Volume 26 - Issue 9 - p 65
doi: 10.1097/01.JAA.0000433870.09154.4c
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In triage room 1 sits a desperate man. EMS brought him in from the local police department. The man threatened suicide when police arrested him for trespassing on railroad tracks. The police cannot ignore his threats: who wants to find a dead man in a cell? Local law enforcement knows him all too well—thefts, assaults, arson, and illicit drug use decorate his rap sheet.

In the triage doorway, a hospital security guard stands like a rock, his body motionless and unyielding, his face hardened from years of violence, his granite eyes trained on the man, watching for danger. The patient moves constantly in his chair, twisting his torso this way and that as he cranes his neck to see out the door. He barks angrily at the EMS tech, demanding she be gentle with the BP cuff, but then weeps pitifully as he talks to the triage RN. His volatile mood and uncut language attract the attention of the patients in the waiting room. His cerulean eyes flit back and forth as he answers the nurse's questions; he looks ready to run.

I ask him about his arrest and suicide threat. “I was minding my own business,” he growls. “I took a short cut. I never did nothing wrong!” He pauses to spit in the trash can. “They picked me up and said they'd lock me up. I didn't wanna be in a cell. I am claustrophobic. I told them I would kill myself because I had to get outta that place.”

His explanation seems plausible. I suggest to him that walking along railroad tracks might be understood as a high-risk activity. I ask him if he considered the danger and if this act reflected a desire for self-harm. The man gives me a half smile, seeming amused. “I self-medicate. I kill my pain with heroin. I don't need no railroad tracks. I got my own.” He points to his arms.

Red, parallel track marks run along his forearms. Cuts, bruises, and scabs mar his skin. His nose runs steadily, a watery rhinorrhea that he wipes away on a grubby sleeve. His skeletal form suggests starvation. His pants hang loosely at his waist, and his sagging shirt looks like it belongs to some much larger brother.

I persist. “I see that … but you have a history of self-harm. Your medical record includes suicide attempts, and your threat at the police department concerns me. I want to make sure you get the care you need. You seem agitated. Can I help?”

The man stops moving for a moment, his eyes still. He looks at me. “If I stay, will I get food? I haven't eaten for days.” Before I respond, he snaps, “No one here has ever helped me! The social worker I saw last time should find another job. She made me feel like crap. No one cares about someone like me.”

I tell him I am sorry he feels that way and that we can help him with his addiction and mental health. For a moment, he loses his pit-bull toughness and looks childlike, vulnerable, and dependent, but then he waves his hand dismissively. “I ain't suicidal. I was in the past but I don't feel that way now. I don't need no one.”

The man is competent, oriented, and provides a coherent history. I do not have sufficient reason to detain him although I know he may be telling me a pack of lies. I rely on my clinical gut and best judgment. The security guard ruminates as the man exits, “He knows how to play it. The police want him.”

Moments later, the hospital greeter tells me my patient is rooting through the trash cans outside the ED, looking for food. Outside, I find him desperately tipping over cans, picking through rotting garbage. A tech watching with me mutters, “These people are like stray dogs. If you feed them, they keep coming back.”

She may be right, but on my badge is the word mercy. I fill a paper bag with crackers, juice, and sandwiches. When I give the food to the man, he falls to his knees and cries. He devours the food sitting on the sidewalk under the hospital canopy. The security guard smiles softly at me as I walk inside; the tech shakes her head. I think I practiced with compassion, kept the patient from harm, and worked in his best interests. Sometimes, it is hard for us to know. Sometimes, there is not a right answer.

© 2013 American Academy of Physician Assistants.