She is tall, thin and wears torn jeans like a mannequin. A silky top flows around her, masking the thin torso, the exposed ribs. Her hair is long, fine and the ends are perfect. Her face is smooth, drawn, a bit careworn, but that is why she is here. She carries herself with an aristocratic bearing that is not learned but genetically endowed over generations. She is rich, entitled and she expects to be treated well. She is not sleeping. She does not eat. She is struggling. All the money in the world does not offset true 21st-century angst. She asks for sleeping pills, as her nightly regimen of cannabis and cocktails is no longer working. Batting her natural lashes, and giving a gentle but directed toss of her corn-silk-smooth hair, she expects to get them. When asked to settle up at the end of the visit, she pays with cash.
She is lying on the hard floor of the seclusion room, stark naked, legs akimbo, her belly flopped over onto the floor like a sack of flour. She has been given intramuscular injections of an anxiolytic and an antipsychotic, so she is drooling, sedated and uncoordinated. She cannot stand. Her speech, such as the vitriolic outpouring of expletives and sexual references is, is slurred and marked with staccato streams of spittle. She is actively hallucinating, screaming back at the demons who mock her and tell her to kill herself. She has a college education. She is a beautiful woman, engaging, smart and witty when she is not being torn apart by the illness that has run rampant in her family. When she comes to see me in a few weeks, after she has weathered yet another psychotic storm, she will be mortified that I saw her this way. We will talk it through, and we will do our best to make sure it never happens again.
She sits quietly in the chair in my office, listening to her mother. Detail after detail of how bad she is, how she constantly acts out at home and at school. How she is not like her mother’s four other kids, how she is a disgrace to her family. How her mother is almost ready to give her up because she can no longer tolerate or handle her. A single tear rolls down her smooth brown face. She asks if she can play with the toys. She looks at her mother. She looks at me. I nod. She gently holds a small doll, stroking her hair. She has been abused since the age of two. She is now six. She never smiles.
She is short, wiry, with skin tanned like leather. Her clothes are dirty, torn, and mismatched. Her hair is matted, a black-brown tangle of exposure to the sun and nights spent huddled in a cardboard box. Her face shows the telltale pockmarks and acne that help confirm the diagnosis that was already surfacing in my mind five minutes after our visit started. She bravely tries to connect with me via humor, a bad street joke and when she smiles her teeth are rotting in her head. She tics and jerks and can’t sit still. She looks at the door, then back at me. She has places to go, dealers to meet. How much longer will this take? Would Valium help, maybe? Xanax, then? She knows that she will not get what she came for, and it makes her angry. I am a safe target. She explodes.
He is older than me by eleven years. He is a handsome man, robust and tanned with a perfectly coiffed head of thick, smooth, snow-white hair. His face is clean shaven. He wears a lime green Polo, khakis by the same designer, and Italian leather loafers with no socks. He has a simple gold wedding band on his left hand, a college ring on his right. He fidgets, clasping and unclasping his fingers. He sits slumped in the plastic emergency room chair, and I know that this is not his usual posture without even asking. He struggles to lift his head. Eye contact seems painful to him. His voice is a raspy, tired whisper. They were married for forty-nine years. She was sick for the last five. Yes, he has several guns at home. Yes, he has thought about it. Yes, he drinks, every night, four bourbons instead of two. Could he just go home, please? Could he just go home? He is so, so tired. Could he just go home?
All patient lives matter.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
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