A Lesson in Pain Management
I stood in amazement and horror as my next patient was wheeled into the ED triage room. A long nail protruded out of his right arm.
“Please help me”
While replacing a ceiling fan for his next door neighbor, he accidentally hammered a nail into his arm. His neighbor had called 911 and told the operator he was a veteran.
Thirty-five years old, afflicted with post-traumatic stress syndrome; he had been deployed five times to Iraq and Afghanistan to work as an army mechanic. I noted he had no past medical history on records; indeed, he told me this was his first visit. He knew he was eligible for VA care, but thought others might be less fortunate and needed the system more than he did. The man had a history of depression, hypertension and chronic back pain. He said he was recently hospitalized for alcohol intoxication, couldn’t afford his blood pressure meds, and was at risk of losing his support system after testing positive for opiates.
I asked him if we should call his wife, as he said he was married with one child. He quickly responded that she would worry too much; he preferred not to call her at the moment or have her visit.
We wondered if we should we just remove the nail, or get an MRI first. The former might cause bleeding into his arm and compression symptoms that would result in him losing his arm. We finally decided to transport him to a trauma unit.
I wished him luck, and call me if he needed to. I moved on to my next patient. Yet, a strange feeling was nagging, a sense of missing something that I could not put my finger on. I denied the feeling and kept going.
A nurse called to tell me that the first patient’s wife accompanied by their twelve year old son were standing outside and would like to speak with me. I told her the story about him helping his neighbor. She looked at me and said,
“He is not a carpenter. He does not know how to change a light bulb and we do not have a next door neighbor”
Did I miss diagnosing a suicidal patient? I may have saved his arm but failed to save his life. Desperately calling the trauma unit; with no response I decided to drive there myself. The thought of my patient hurting himself was killing me. A two mile drive felt like eternity.
At the trauma unit, I pulled his curtain and saw him half asleep. He looked up with a smile on his face. “i made it here”
I sat down on the edge of his bed and held his hand, told him about my encounter with his wife and told him I came to listen and help.
He admitted the suicidal attempt, and said he was too embarrassed to talk about it. His mother had told him suicide is the ultimate selfish act, but he was in so much pain. He gets angry and easily upset; admitted he frequently yells at his wife, who he feels is unable to understand him and his situation. His wife handles the money which makes him feel controlled. Unhappy with his smoking, his wife wants him to quit. Sometimes they both get into a serious verbal altercation. His wife also starts throwing things and he threw the penny jar at her the last time they were in altercation. “Leave me, I don’t want you, just leave this place, just get away from me”. Such altercations increased his anxiety and craving for cigarettes. He stays in homeless shelters for days and then returns home.
Suicide is the tenth leading cause of death in the United States, with more than 100 suicides occurring each day. In 2013, over 40,000 people died by suicide alone. After cancer and heart disease, suicide accounts for more years of life lost than any other cause of death. Furthermore, the rate of suicides among those utilizing VA healthcare (as well as other veterans) is estimated to be higher than the general population. A recent analysis found a suicide rate among veterans of about 30 per 100,000 population per year, compared with the civilian rate of 14 per 100,000. An estimated 6,500 former military personnel committed suicide in 2012. And more veterans succumbed to suicide than were killed in Iraq. In 2012, 177 active-duty soldiers committed suicide, conversely 176 soldiers were killed in combat. In 2012, the study also reported that Army had the highest number of suicides compared to any other service branch. 31% of these suicides were by veterans 49 and younger while 69% were by veterans aged 50 and older and mostly male.
In response to this national public health concern, several major clinical initiatives were implemented and a significant growth in research funding for suicide prevention was ensured.
The department of Veteran Affairs has implemented comprehensive, suicide prevention programs, including treating depression and adjustment disorders, fostering supportive relationships, a toll-free Veterans Crisis Line, placement of Suicide Prevention Coordinators at all VA medical centers and large outpatient facilities, and improvements in case management and reporting. The Veterans Crisis Line, online chat and text-messaging services offer free, confidential support, 24 hours a day, seven days a week, 365 days a year, to Veterans, their families and friends.
In 2015, the Clay Hunt Veterans Suicide Prevention Act passed in the Senate and was then enacted on February 12, 2015.
My patient did well. He had a closely supervised surgery and subsequently was transferred to inpatient psychiatry where he was treated for suicidal thoughts and depression. Eventually, his suicidal thoughts abated and he was discharged from the hospital, though still followed closely by mental health and social work services. He applied for several jobs and finally found an employment in a peer support group. Perhaps most importantly, he communicated to me that he felt an overwhelming sense of relief hearing stories of others and helping them out in their individual struggles.