Saturday, June 24, 2006

No Exit

Her calls are consistent in their regularity and in their production of stress hormones in my body. They are consistent in other ways as well. Dramatic. Tearful. At times explosive with anger and frustration (on her part) and quiet frustration (on my part). She almost always calls on Friday afternoons as we are beginning to wind down the week. Inevitable and fruitless for us both.

She suffers from doubtlessly debilitating illness and pain. She's been abandoned by friends and family. She is utterly alone. With a history of addiction to pain medications, Borderline Personality Disorder, depression, social anxiety, and a host of other physical complaints, the mix is volatile. She has no car, hates to take public transit, but lives within walking distance of the Emergency Room where she's a very frequent flyer. Her isolation is devastatingly complete, yet she abhors psychotherapy and psychiatry and chronically skips medical appointments. It's my job to keep her from falling through the proverbial cracks. Yet fall she does. Those aren't cracks---they're caverns.

The calls are mostly identical:

"I'm in so much pain."

"I know. What would you like me to do for you?"

"I don't know." (Sobbing.)

"It's 4:30 on Friday afternoon. I can't get you seen here. Do you feel like hurting yourself?"

"No. I'm in so much pain." (More heart-wrenching sobs.)

"Do you want to call Emergency Psychiatric Services?"

"No! I need you to admit me to the hospital." (A hint of anger now.)

"For what?"

"For my pain. Admit me for my pain."

"I can't do that. They wouldn't admit you for that. Do you want to go to the ER?"


"What do you want me to do?"

"Nothing. Nothing. You don't understand my pain. Thanks alot." (Click.)

She'll often call back after hanging up on me, contrite and sweet, but still crying. The second call is mostly the same and we finally agree that she can go to the ER where she'll wait a few hours, get an injection of morphine and a Rx for 30 Percocet. The next night, around 2am, she'll call the on-call Nurse Practitioner who will have basically the same conversation with her that I did on Friday. The following week will be mostly the same.

This person is a failure of our system. I have failed her. We don't keep her out of the ER. Those visits cost thousands, not to mention her numerous calls to 911 and the dispatching of needless ambulances. Her pain and other symptoms are often precipitated by isolation, angry telephone calls from her hateful mother, and occasional visits from her estranged husband who asks her for money to buy cigarettes. We spin endless variations of the same conversations and go nowhere. Progress is nonexistent. Her doctor, of whom I am exceedingly fond, has no answers for us. It's a revolving door of frustrating calls, anger for her and frustration for me. My impotence in this arena is obvious and painful.

As I sit here in bed late on a Saturday night, my heart goes out to her in her suffering. There is nothing I can do to assuage her pain. Her past is a shadow to me which I have not explored and could never penetrate. I am not a psychotherapist and have not touched on those realms with her because I know I am too unskilled to handle what might be exposed to the light of day. Her suffering is her own and I acknowledge my helplessness in its powerful grasp upon her troubled psyche.

There are those who we can help, who we can lead to healing, to wholeness. There are others---and they are many---whose healing is beyond our ken, and whose shadows of past wrongs and abuses are beyond our capacity to understand or rectify.

Does compassion fatigue set in during interactions with this patient? Do I feel powerless and impotent in her care? Can I see no end to this merry-go-round of suffering, reaching out, and the failure to change anything which might be alterable in this woman's life? I chose the title for this piece by borrowing a title of a play by Jean-Paul Sartre, that cheery existentialist in early 20th century France who created such masterpieces of human drama and suffering alongside his comrade and lover Simone de Beauvoir. No Exit is a fitting title for this clinical conundrum in which I find myself, and the ambiguity of that title underscores the pain which the human beings on both side of this real-life drama must bear.
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