The suicidal patient who couldn’t be placed

Mr. Fine is in for the eleventh time in less than a week. I work as a social worker in a hospital emergency psych unit. Mr. Fine is suicidal again. It is kind of late in the evening when I see him, although it is my first time, I am the only social worker on tonight.

This is the usual situation, one social worker per shift.

The psychiatrist takes me aside, quietly gives me the patient’s history with a special emphasis on how many times he has been in to see us. He was in that very morning, evaluated, then released. He threatened upon release to go someplace and cut his wrists. He did that, too. He went to a Walgreens, bought a package of razor blades, and in front of a horrified clerk, began slashing his wrists. Police were called. He was brought back to the emergency room, then on to us in emergency psychiatry where I am located.

Mr. Fine is a man past 60 by a year or two, average height, with dark hair, but not much of it. He is well-spoken and tells me he went several years to college. He also says he lost his job as a salesman. He does not present as psychotic, but instead as very sad. And very determined to die. “Nothing to live for. I have no hope.” He sobs and covers his face with his hands. He is wearing a loose-fitting gray sweatshirt, and on both sleeve cuffs is dried blood.

When the psychiatrist spoke to me earlier, the patient was still in the ER getting his wrists sewn up. She said, “They tell me in the ER that if the cuts are more surface cuts than deep if the injury is not too substantial, we won’t get him back over here.”

How things work in our world is that once the patient is checked in. And if he or she is not drunk or high on other substances, he is evaluated by a doctor, then a social worker (me), then he sees the doctor again, usually a resident. If the patient is difficult, as this one promises to be, the attending is called. Before the evening was out, the medical director herself was contacted.

Mr. Fine, by the way, is younger than me by several years. It seems everyone I deal with these days is, be they staff or patient. I am sixty-six.

I will do my evaluation of Mr. Fine as if he had not already been seen ten times or more in several days. I know from the chart that before these marathon visits, he had been a patient in our unit. He was sent one time to the state mental hospital, Central State, and kept there for a week.

He was released with a diagnosis of bipolar, which represented a change from his previous diagnosis of severe depression. It was believed at Central State that the patient was seeking a manic episode. So he was taken off of the antidepressant medicine to prevent that from happening.

Mr. Fine took his hands from his face and raised his head and began to cry again.

“I don’t want to die. I just want to find a little hope.” Well, that was someplace to begin, I thought.

“So, what is it you want?” I asked.

“Just a room to be off by myself. I can’t deal with a lot of people. Shelters are awful for me.”

Shelters are necessary, but terrible places, just as he said.

“So how about your family? Can they help?” He shook his head.

“They gave up on me years ago.” I could believe him.

“You ever been to the crisis stabilization unit?” I asked.

“I’d love to go there,” he answered. “I called them once, but I didn’t get anywhere.”

I decided I would try this fellow I knew at the crisis stabilization unit, which is a step down from hospitalization itself. The man who runs the place, Patrick, might consider Mr. Fine, even though Mr. Fine has no benefits, no payer source, and CSU — like everyone else — is looking for paying customers. But the CSU will take an occasional nonpayer in an effort to look like a charity. Worth a try, but it would require some cooperation from the psychiatrist. She would need to agree to admit Mr. Fine (again) while the CSU paperwork was processed. Yet I knew she was not inclined to do this. She shook her head as I approached.

Sometimes, as a man … and an older man, the residents cave in and do what I recommend. The way the system is supposed to work, the resident and social worker should be in agreement for what follows. The truth is the doctors’ opinion counts for more.

I said I appreciated the degree of annoyance Mr. Fine represented, but I had only seen him this one time. And my recommendation was to keep him overnight as CSU transfer was explored. There were several empty holding beds in our unit.

“No way,” she said at last. The request went clear up to the medical director, and she flat out refused to admit him again.

“OK,” I said, “understand though I want to see on the record I wished he be admitted.”

“Of course,” she replied. I don’t mean to make this exchange sound angry, for it was not. The conversation was pleasant overall. Well, maybe a little frosty.

A couple of hours later, I finished my shift. It was midnight, and Mr. Fine was still in our waiting area. He could not leave, nor could anyone once put there, not until released by a doctor. He didn’t want to go. It is a secure holding area with a guard. My guess was that before very long, Mr. Fine would be released and pushed out, really. And he was. I didn’t find this out until several days later when I asked about him. Upon release, he immediately tried to overdose on some pain pills he got hold of.

Come Monday evening, he was back in the unit, and this time was kept overnight, which suited him perfectly.

It turned out the CSU unit did not accept Mr. Fine. Why? No payer source coupled with a troublesome history. Not a good combo. But had Mr. Fine a payer source, to begin with, a benefit, the story I tell about our psyche unit might have ended other than the way it did, repeated evictions. Then again, it might not have.

Raymond Abbott is a social worker and novelist.

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