Chapter 35: If You Insist

November 25, 1987, McKinley, Ohio

On Wednesday morning, I arrived at the hospital just before 6:00am, changed into scrubs, then went to find Maryam to get an update.

“Mike, your mother-in-law is in Trauma 2,” Maryam said. “Your father-in-law couldn’t wake her up this morning so he called the paramedics.”

“Do you know what happened?”

“We think she took several of her Seconal tablets, we’re waiting on the blood assay to see her levels, but she’s breathing on her own. Her pulse and BP are low, but no arrhythmia. Your father-in-law is in the waiting area.”

“Thanks, Maryam.”

I hurried through the doors to the waiting area to see Viktor, Geno, and Anna, who had baby Viktor with her.

“Mike!” Viktor exclaimed. “Have you seen her?”

I shook my head, “No. We’re discouraged from treating relatives, and until her blood work comes back, they won’t know anything. That said, Maryam said Yulia is breathing on her own and there doesn’t appear to be any trouble with her heart. Those are both good signs. Do you know how many she took?”

“It was time to refill, so I don’t think there were more than five capsules. I told the paramedics.”

“Five capsules would be 500mg, which is lower than a dose for anesthesia,” I replied. “How was she last night?”

“Upset about tomorrow,” he said. “She had really worked herself up.”

“What do you think about a seventy-two-hour psych hold?”

“But tomorrow is Thanksgiving!” Anna protested before Viktor could answer.

“Is that normal?” my father-in-law asked.

“She’ll have a psych evaluation and they’ll decide to recommend it or not. They can force it, but only if she’s a danger to herself or others. But if you object, most likely they’d release her to you.”

“What do you think?”

“I think she needs help, Viktor.”

“I won’t fight the doctors on that.”

“Dad!” Anna protested. “Thanksgiving!”

“Yulia’s health is more important than a holiday,” Viktor declared.

“Let me go speak with the medical team treating her,” I offered. “Did you call Father Nicholas?”

“Yes. He’ll be here shortly, I’m sure.”

I walked over to the door, and Nate buzzed me into the ED. I went to Trauma 2 where Yulia was being treated.

“You shouldn’t be in here, Mike,” Doctor Nielson said firmly.

“I have information which might be relevant,” I said.

“Step out; I’ll come out in a minute.”

“Yes, Doctor.”

I stepped outside, and he came out about thirty seconds later.

“What do you know?”

“I believe she’s clinically depressed and has refused any help other than the sleeping pills, which she’s been taking long enough to either be addicted or to have their efficacy reduced. Based on what my father-in-law said, she took around five 100-milligram pills last night. She was agitated yesterday about Thanksgiving. I believe you’re aware of the source of her clinical depression.”

“I am. You’ve sought counseling to prevent that.”

“I have. Viktor, my father-in-law, won’t object to a psych consult or a seventy-two-hour hold; Yulia, on the other hand, will probably refuse to even be interviewed by anyone from psych. She has the very common Russian ethnic distrust for mental health professionals because of how they’ve historically been used in Russia and the Soviet Union.”

“Do you think it was accidental or a suicide attempt?”

“I honestly don’t know, but if she had waited until Friday, she’d have had thirty tablets. I honestly wonder if she felt like the pills weren’t working, so she took more, or she was agitated and wasn’t thinking.”

“I’ll call for a psych consult, but you know the rules.”

“I do. I am positive she’s clinically depressed. I have my own experience with that.”

“Now?” he asked, suddenly concerned.

“No, about four years ago. That incident reïnforced the need for mental health counseling beyond what I’d already learned from working with my friend who suffers from schizophrenia.”

“I have the lab results,” Maryam said, coming up to us.

Doctor Nielson looked them over and nodded, “Her tox screen results are consistent with a mild overdose and about eight hours of metabolism. You can reässure your father-in-law that she should be fine. She’s coming around, and I expect her to be fully awake shortly, and then the Psych Resident will try to speak with her.”

“Thanks, Doctor Nielson.”

“You’re welcome.”

He went back into the trauma room and I walked to the waiting room, where I saw Father Nicholas with Viktor, Geno, and Anna.

“Father, bless!” I said.

I received his blessing, kissed his hand, then turned to Viktor.

“She’s waking up and her blood work doesn’t show dangerous levels of Seconal. Doctor Nielson is optimistic, and said to let you know she should be fine. As soon as she’s fully awake, he’ll have the Psych Resident speak with her, but if she refuses, it’s unlikely they’ll put her on a hold, because she didn’t take enough to actually harm herself. She didn’t write a note, did she?”

“No. The paramedics asked, too. What happens now?”

“That will depend on the psych evaluation, assuming Yulia coöperates.”

“What do you recommend, Mike?” Father Nicholas asked.

“As her son-in-law and your parishioner, I would say she needs psychological counseling for what I believe is clinical depression. As a med student, I have no official position.”

Father Nicholas nodded, “I understand. Will they let me see her?”

“Probably, because clergy are afforded special access, and you’re on the official chaplain’s list. Let me have Maryam check, because I already was told not to go into the trauma room.”

“Why?” Geno asked.

“Because we’re related, even if not by blood, and it creates all manner of risk for the patient, the doctor, and the hospital. It’s assumed I can be dispassionate about patients, except for relatives or very close friends, where the opposite is assumed to ensure there are no problems.”

“But you would never do anything to hurt her!” Anna protested.

“I agree, but emotions play all sorts of tricks on us and can interfere with our judgment. That’s why I stood aside to allow Doctor Lindsay, Doctor Strong, Doctor Forsberg, and Clarissa to help Elizaveta.”

“That must have been difficult,” Geno observed.

“I’ve never felt more helpless in my life,” I confirmed. “Let me speak with Maryam.”

I went back into the ED and asked Nurse Julie to ask Maryam to come out. She did, and a moment later, Maryam came out.

“She’s awake,” Maryam said. “She’s very unhappy to be here.”

“I’m not surprised. Father Nicholas is here and would like to see her.”

“Let me ask Doctor Nielson.”

She was back a moment later, saying Doctor Nielson had approved. She went to the waiting room and brought Father Nicholas with her, and they went into the trauma room.

“You OK, Mike?” Doctor Gibbs asked, coming up to me.

“Yes, I’m fine. My educated guess is an accidental overdose, not an intentional one, but I’ll leave that to the Psych Resident, assuming Yulia consents to speak to him.”

“I saw your priest go in; maybe he can convince her.”

“He’s tried since Elizaveta died. The best he could get her to do is see Doctor Evgeni Petrov who prescribed Seconal to help her sleep.”

“OK. I need you to suture a forearm lac. Exam 3.”

“Yes, Doctor.”

I went to the door of Exam 3, took the chart from the rack next to the door, flipped through the pages, then went in to find Nurse Ellie waiting for me.

“How’s your mother-in-law?” she asked.

“Fine, thanks,” I replied, then turned to the patient. “Hi, Mr. Powers, I’m Mike. How are you feeling?”

“My arm hurts like a mother ... but otherwise OK.”

“Are you allergic to any medications?”

“Not that I’m aware of.”

“Any negative reactions to dental anesthesia?”

“No. Why does that matter?”

“We use the same drug to numb your arm that they used to numb your mouth, so if you’ve been OK with shots of lidocaine or Xylocaine, there won’t be a problem. How did this happen?”

“I lost an argument with an exposed screw at work.”

“OK. Let me take a look, please.”

I washed my hands, put on gloves, then removed the gauze from Mr. Powers’ arm.

“Suture kit with 4-0 nylon, please, Ellie,” I said. “Also saline, an irrigation syringe, a syringe with a 25-gauge needle, lidocaine times four, Betadine, and a stick swab.”

“Coming right up!”

“Mr. Powers, the edges of your wound are a bit jagged,” I said. “If I suture it, you’ll likely have a scar. I can call a plastic surgeon if you prefer.”

“It’ll match the one from the gash on my leg from three years ago.”

“Did you have a tetanus shot then?”

“Yes.”

“OK. We might update that, but I need to speak to Doctor Gibbs. If you don’t want a plastic surgeon, I’ll proceed.”

“Go on.”

I went through the usual steps, and managed, using nine interrupted sutures, to get what I thought was good approximation of the wound edges. I excused myself to speak to Doctor Gibbs, and she came back to examine the sutures.

“Very nice work, Mike,” she said. “There should be minimal scarring.”

“Thank you. Do we want to update his tetanus? He had one three years ago when he had a similar wound on his leg.”

“Three years? That should be fine. Let me sign the discharge papers and Mr. Powers can be on his way once you go over wound care with him.”

“Yes, Doctor.”

She wrote on the chart, signed it, and then I went over the wound care instructions with Mr. Powers. Once I’d done that, I escorted him to Patient Services and let Doctor Gibbs know I was done. On my way back to the lounge, Ellie came up to me.

“I have a gash that could use some attention,” she smirked.

“I don’t think you’ll be happy with me suturing it closed!” I replied.

“That’s mean!”

“And you’re being rude, Ellie.”

She frowned, “Sorry, I thought maybe it was OK to tease.”

I shook my head, “No, it’s not.”

“You won’t say anything, will you?” she asked nervously.

I decided to tease her just a bit, but not the same way she’d teased me.

“I might be convinced not to say anything,” I said.

“Oh?” she asked hopefully.

“If you promise to never make an inappropriate comment of any kind to me ever again.”

Ellie frowned, “I promise.”

I turned and went to the lounge and studied until Maryam came to find me.

“The Psych Resident came down, and on Doctor Nielson’s advice didn’t introduce herself as a psychiatrist.”

I nodded, “A wise course of action, but she’s smart enough to figure it out. Who is the Resident?”

“Doctor Baxter.”

“Would you do me a favor?”

“What?”

“Ask her to come see me, please.”

“Mike, I’m not sure you should.”

“As family, not as a medical student.”

“Doctor Nielson won’t like it,” Maryam protested. “You could get in real trouble.”

“And if she doesn’t recommend a psych hold for my mother-in-law, the next time she’s here might not end so well.”

“I know, Mike,” she said, gently touching my arm, “and if you were an Attending, or even a Resident, you might get away with it. You’re a med student who was told to stay away. Don’t interfere! Speak with your father-in-law or Father Nicholas, but please don’t talk to the Psych Resident.”

Maryam was right, and I’d already been told not to be involved. The problem was, I was positive that Yulia would talk her way out of a psych hold, and I was afraid of what would happen if her clinical depression went untreated.

“You’re right,” I said. “I’ll speak to Father Nicholas.”

Maryam smiled, “Thank you for listening to me. You know I only want what’s best for you.”

“I know. And I appreciate it.”

I went back to the waiting room to talk to Father Nicholas and Viktor.

“Do you know anything more?” Viktor asked.

“No. The Psych Resident is with her now. I’m afraid Yulia is going to talk her into releasing her.”

“She should!” Anna interrupted. “Nobody should be put in a psychiatric hospital!”

I turned to her, and spoke firmly, “This is not the Soviet Union. You need to stop affirming Yulia’s rejection of mental health care! The US does not have «психу́шки» (psihúški). She would simply be in a room in this hospital.” (“Soviet ‘psychiatric hospitals’ used to ‘treat’ dissidents”)

“But...” she began to protest.

“No buts,” I said firmly. “Please stop. You’re helping prevent Yulia from seeking the treatment she needs.”

“Anna,” Geno said. “Come with me, please.”

He led her away.

“Father,” I said to Father Nicholas, “somehow we need to convince Yulia to check herself in.”

“Why can’t they hold her? Or why can’t Viktor check her in?”

“Because the rules are clear, and she could check herself out immediately. According to the statute, she has to represent substantial risk of physical harm to herself, and that has to manifest as threats of or attempts at suicide or serious self-inflicted bodily harm. She didn’t take enough Seconal for it to be called a suicide attempt. They’ll rule it an accidental overdose.

“The other criteria don’t apply, because she doesn’t present a substantial risk of physical harm to anyone else, which also needs to manifest by violent behavior or threats of violent behavior or a desire to harm someone. She’s also capable of caring for herself in a basic way and has all of us to care for her. That means the only real option is for her to voluntarily check herself in.”

“What does that entail?” Viktor asked.

“It’s basically the same thing — seventy-two hours of observation, counseling, and, if warranted, medication. At the end of the period, they’d present a proposed course of treatment, which could range from long-term inpatient care to short-term outpatient counseling.”

“What happens if she doesn’t get help?” Father Nicholas asked.

“Half of all suicides are people with what’s officially called ‘major depressive disorder’, but is commonly referred to as ‘clinical depression’. I’m sure you remember that my friend Jocelyn attempted suicide when she was severely depressed. And you know I had my own bout of depression four years ago, for which I sought counseling from you and Doctor Mercer. And you know I’ve seen Doctor Mercer since Elizaveta died, in addition to the spiritual counseling from you and Vladyka.”

“How big is the risk?” Viktor asked.

“Roughly 5% of people diagnosed with major depressive disorder commit suicide.”

Doctor Nielson came into the waiting room and walked over to us.

“She’s ready to be discharged,” Doctor Nielson said. “We believe she’s in need of psychiatric or psychological counseling, but she’s not an immediate risk to herself or others. You can take her home as soon as she’s dressed.”

“Thank you, Doctor,” Viktor said.

“You’re welcome,” Doctor Nielson replied. “Mike? May I speak with you?”

“Yes, Doctor.”

I followed him to the consultation office, where he motioned for me to shut the door.

“You know why you can’t be directly involved, right?”

“Yes.”

“I sympathize, Mike, but you could easily influence the Psych Resident, or even one of us here in the ED to bend the rules, and if that were ever discovered, the hospital could get into serious trouble. It’s why we don’t treat family and we avoid treating friends — our judgment is clouded by the relationship. And if you’re going to object saying that you’ve seen Residents or Attendings do it, I’ll acknowledge that happens.

“But realize this — if anything at all goes wrong, there would be a full inquest and every single judgment call will be scrutinized in a way that wouldn’t happen with some random patient who presented with the exact same symptoms or condition. As an Attending, you’d probably get away with it; as a Resident, you might; as a med student, you’d not only take yourself down but the Psych Resident and possibly me if we did you a favor, for lack of a better term. Please acknowledge I’ve explained this clearly and that you understand it.”

“I do.”

“Do what?”

“Acknowledge that you explained the rules about treating relatives or friends, and I understand what you’ve said.”

“Good. Now, off the record, you need to do everything you can to convince your mother-in-law to check herself in.”

“That’s what I was doing with my father-in-law and my priest. I also asked my sister-in-law to stop affirming my mother-in-law’s rejection of psychiatric care.”

“What’s the problem? You’re clergy, well, you were, and you clearly don’t have a problem with it.”

“She feels psychiatric care is just like the «психу́шки» (psihúški) in the Soviet Union. I’m sure you’ve heard that they used psychiatric hospitals as prisons, and sent political dissidents there to torture them, and if the torture wasn’t effective to get them to change their minds, then to discredit them as mentally ill, because in Marxist/Leninist theory, no sane person would reject socialism.”

“You mean Communism, right?”

“The terms are, in effect, interchangeable for the Soviets. They promoted ‘world socialism’ as well as ‘socialism in one country’ at various times. And what that has meant has changed. Now, with Gorbachev in power, and his attempts at reform which they’re calling «гласность» (glasnost) and «перестройка» (perestroika) — transparency and restructuring, it means something very different from Stalinism or Leninism.

“Anyway, the Communist Party used the «психу́шки» (psihúški), which is an ironic use of the diminutive, similar to my sister still calling me ‘Mikey’, to silence internal opposition. Anna’s grandfather was a part of the dissident community and taught her. Many other ethnic Russians learned the same thing. My maternal grandfather is skeptical for the same reason, though he’s not more skeptical than the average person who’s never needed psychological or psychiatric care.”

“That explains her negative reaction to Doctor Baxter. It’s not actually religious?”

“No. It’s ethnic. You’re probably thinking of the fundamentalist evangelicals who object to psychology and psychiatry as ‘covering for’ or excusing sin.”

“That was the only context I had, and it didn’t make sense, which is why I asked. Before I let you go, you understand why I was a hard-ass, right?”