Q & A
The interview had lasted fifteen minutes so far, and we'd made minimal progress. I was a medical student doing a rotation at a physical medicine and rehabilitation clinic back in my home state, Wisconsin. It was the end of the day; to save time, the senior resident, Paul, had joined me in the exam room so that we could hear Leora's medical history together.
A year earlier, Leora, in her mid-fifties, had suffered a stroke. After a few weeks in the acute-rehabilitation hospital, she'd been discharged, and she and her husband, Ellis, had been lost to follow-up. Now they were back, hoping to resume Leora's care.
Sitting in her wheelchair, Leora looked tough but weathered. The food stains on her T-shirt and sweatpants were telltale signs of the stroke's effects--one-sided paralysis and difficulty swallowing--or possibly of caregiver fatigue. Or both.
"Have you been feeling down since returning home?" I asked her, working my way through the list of questions I'd been taught to use during these interviews.
Leora looked at Ellis, who had been doing the talking so far. A wiry, alert man in blue jeans and a sweatshirt, he looked capable and energetic.
"That's one I can't answer for you, honey," he said, with a hint of weary exasperation.
"Yeath," Leora said reluctantly, her speech slurred by the paralysis.
This answer dictated my next question: "Have you thought about harming yourself?"
Again, she gave Ellis a look. He kept silent.
"Yeath," she muttered.
This startled me. Ellis seemed surprised, too. He looked at Leora with dawning curiosity.
I asked the next question, not wanting to hear the answer.
"Do you have a plan for how you would harm yourself?"
"Do you intend to harm yourself?" I asked, alarmed.
Seemingly resigned that Ellis would not, could not answer for her, Leora said, "Yeath."
Clearly, Ellis shared our alarm. He told us how, being unaware of Leora's state of mind, he had been leaving her home alone during the day. There were firearms in the house, and despite Leora's disabilities, she could have used them.
Now Paul took over, explaining gently how often strokes can lead to depression. We examined Leora, then excused ourselves to discuss the case with the attending physician and the nurse.
This was always the drill, but it felt different now. I'd seen suicide attempts on the medicine wards; this was my first such experience with an outpatient.
We decided that Leora should be admitted to the hospital--with or without her consent.
The attending physician, Dr. Patel, came with us, introduced herself and said, "Leora, we are worried about you. As you know, you're no longer able to do the things you could a few months ago. You're no longer using full sentences, you're not able to walk as well, and you are unable to dress and groom yourself as you did before. We'd like to admit you to the hospital and begin some intensive therapies. But, more importantly, we want to help with the depression and make sure that you do not harm yourself."
Leora made it clear that she disagreed--emphatically.
"NOOOOO," she moaned laboriously.
"I understand that this is not what you expected when you came in, but we're concerned about your state of mind," Dr. Patel continued, gently but inexorably. "You've mentioned intending to harm yourself, and you have a clear plan. We're worried about this."
"No. No. No," Leora repeated.
Dr. Patel turned to Ellis. Tears stood in his eyes.
"I had no clue," he said quietly. "I feel horrible. I just had no clue."
Agreeing that Leora needed to be hospitalized, he warned that it wouldn't be easy. "I can try to convince her, but she's stubborn--I know she won't change her mind. And if you're asking me to sign forms to commit her, I can't. She'd never forgive me."
"Okay, we understand," Dr. Patel replied sympathetically. She turned to Leora. "We will need to seek legal means to have you hospitalized against your will, Leora. I know you don't like this, but--"
"Nooooo. No. No. No. No. No!" Leora interrupted. Using her one functional leg, she propelled her wheelchair through the door and into the hallway--then stopped. Without Ellis's help, she wouldn't be able to make it out of the clinic.
She sat there silently, facing away from us.
Ellis wiped his eyes.
"I had no clue she felt like that," he said. "I just thought she was tired and in pain...How didn't I know?"
"It can be very difficult for someone in your position to see the symptoms of post-stroke depression," Dr. Patel reassured him.
As Ellis tried to persuade Leora to agree to hospitalization, we called the EMS staff to pick her up, speaking in hushed tones although the clinic had been closed for an hour or more.
The EMS personnel arrived, then left with Leora.
I took a deep breath, thinking, Well, that's that....
Then Sue, the nurse, suddenly broke down in tears. Sobbing inconsolably, she slipped into an exam room. Dr. Patel followed, gave her a hug and spoke kindly, then left her in privacy.
"Her daughter committed suicide a few weeks ago," she whispered to me.
I was speechless. Only now did I sense how many powerful emotions this episode had sparked.
Ellis felt shocked by the news that his longtime wife, whom he'd helped to nurse back to health, wanted to end her life.
Sue had remembered her daughter's suicide, wondering what clues she'd missed and whether anyone could have done something to save her.
I had tried to hold onto my medical-student role, learning as much as I could about functional regression, aphasia, post-stroke depression and suicidal intent in stroke patients. But I'd also felt anxious, overwhelmed and relieved that it wasn't up to me to handle this all by myself.
Later, at the acute-rehabilitation facility, I cared for Leora as an inpatient. Though initially wary, she gradually began to speak more openly, and I'd like to think that she forgave us eventually.
As jarring and upsetting as it felt to have Leora committed against her will, when I saw how devastated Sue had been by her daughter's suicide, and how grateful Ellis felt for our intervention, I knew that we'd done the right thing. And as awkward and anxiety-provoking as it was to force myself to ask those questions and hear the answers, I'm convinced that I need to stay willing to do that.
I hope that, going forward, I'll find it easier to have those difficult conversations--if ever, and whenever, they're needed.
About the author:
Kyle Bernard is a fourth-year medical student at the University of Minnesota-Twin Cities. After graduating from the University of Michigan with a bachelors degree in business and political science, he worked for a healthcare software company, where he was first exposed to the medical profession. Astounded by the impact physicians have on their patients, and the relationships they form, he decided to go into medicine. He intends to pursue a residency in emergency medicine. "Traveling the world in my free time, I developed a penchant for writing. I enjoyed the challenge of describing the exotic sights and sounds I was experiencing to my friends and family, half a world away. Now I hope to convey to nonmedical readers the unique experiences involved in being a clinician."