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The Art of Medicine

On the brink

Godfrey, Alexandra MMS, PA-C

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Journal of the American Academy of PAs: November 2015 - Volume 28 - Issue 11 - p 66
doi: 10.1097/01.JAA.0000472557.50124.9a
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I sense her fear the moment I walk into the room. Perched on the edge of the exam table, the patient teeters on the brink; wavering between stability and instability. Her smile betrays her: fleeting and forced, it is not an authentic expression of happiness but rather an overzealous attempt to appear content. I smile back at her while considering the possibilities: did she miss a pill, then a period, and go on to recoil at the sight of two bars of blue on a dipstick of life? Has a cell in her body replicated and gathered its forces to form a palpable mass that speaks only of death? Or did a boyfriend of years leave her for a beautiful Twiggy without an ounce of character?

I introduce myself, close the door, and settle on a stool 3 ft away. The girl glances at me and seems to be making a study of my character. Her discomfort is apparent. She fidgets; picking holes in the paper covering the table, not knowing how to proceed. After a short while, I take the initiative:

“Anna, tell me why you are here today.”

She looks up and then turns away. Eventually, she gulps:

“I think I am going crazy. I'm so frightened.”

“Anna, you are safe here. Can you tell me about your fear?”

She turns to look at me. In her eyes there is hope overlying desperation.

“Two weeks ago, my neighbor shot himself. I saw the police, heard the gunshot.”

Anna shudders then pauses for a moment, drifting off someplace. Tears collect in the corners of her eyes. She wipes them away with her shirtsleeve. I want to wrap my arms around Anna, couch her in the security of a whole soul, enough to soothe the trauma. Instead, I give her Kleenex: four perfect rectangles of softness, each comprising five layers of synthetic yet accepted comforting conformity.

I think about women of ages imprisoned in attics or condemned to lives lived in Bedlam; no Kleenex then, just handkerchiefs to knot and fold into never-ending confabulations of answers to questions about human suffering. Anna wipes her eyes; then crumples the tissues in her hand. In her fingers, she holds her own tears as if not yet ready to part with her sorrow. We sit in silence.

Anna watches me, staring into my eyes. I suppress a desire to turn away. She is looking for stability and safety. For a short time, this is how we stay; she both judge and juror, and I the defendant, permitting Anna to check the integrity of my soul. Suddenly she relents:

“My neighbor—he was in his basement. I was in my kitchen washing the dishes. The distance between us was maybe 50 feet. He called the police, but they arrived too late. He was a good neighbor. I liked him. I should have known.”

Anna's words hang in the air, each syllable suspended for a moment as if caught on the ethereal pillars of a confessional but then released to spiral down to earth, creating in their united effect the verses of that ubiquitous elegy to the guy next door: my neighbor, he was a good man, I never suspected; we are shattered. Anna drifts again as she contemplates the trauma; this time, I pull her back:

“Anna, being close to a violent death is very traumatic. Why do you think you are going crazy?”

“I barely knew him. Now, I see his face all the time: in my dreams, in my yard, and in my kitchen. I hear the gun over and over...”

Anna and I talk for a while longer. I want to be certain that she is not suicidal or a danger to others. I explain that trauma can knock us off balance and that seeking help takes courage. I suggest a referral to a psychologist and prescribe some medicine.

On her way out, Anna stops in the doorway of our office, wavering on the threshold; I signal to her to come in.

She whispers; “Alexandra, thank you.”

I smile: “Anna, anytime.”

As Anna leaves, she stops by the trash can; she opens up her hand and releases the ball of crumpled Kleenex. The tissue plummets, disappearing into the debris; leaving no trace of the tears within.

Anna is not the only one who sees the faces of lives lost. The challenge of medicine is we are forever working on the brink. Sometimes patients, like neighbors, need to be invited in.

Copyright © 2015 American Academy of Physician Assistants