To Be, or Not to Be

But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” Therefore I will boast all the more gladly about my weaknesses, so that Christ’s power may rest on me.

- 2 Corinthians 12:9

Suicide Attempts

The average life expectancy in South Africa is less than 50 years, one of the lowest in the world.  In addition to natural causes like HIV and TB, death by trauma and suicide are also common.  Everyday we see at least one patient who comes to the hospital after attempting suicide.  Most are medication overdoses – on everything from multivitamins to iron tablets to anti-epileptics to diabetes medications.  Oftentimes the patients are young Indian or black women between 14 and 25 years old, who have had an argument with a parent or a boyfriend.  One 16 year old patient tried to overdose on Tylenol because her high school boyfriend, and father of her 2 month old baby, wanted to leave her.  At home, we were taught that depressed people attempt suicide, but most of the ‘parasuicides’ here are not depressed and do not want to die.  Rather they are immature young people who are seeking attention.

Nevertheless, everyday we also see many patients who suffer from serious psychiatric illness.  Many are young but have already experienced a lifetime of trauma and tragedy.  Hangings are common amongst Indian girls, and more likely to be successful than overdoses.  Last month, I admitted a twenty year-old Indian girl with a history of depression, for suicidal thoughts.  She had previously attempted suicide by drinking gasoline the year before, and her mother had a history of depression and suicide attempts as well.  Her parents were going through a divorce, and the week before, her 16 year-old sister – by all appearances a happy, well-adjusted teenager – hung herself.

Patients and families like this are difficult to treat, but it is at these crucial moments when a doctor needs to stop, listen, and show compassion and empathy.  Doctors – in particular family doctors – have the privilege to care for an entire family and become privy to many family secrets. Our role is even more important in times of crisis.  After I admitted the patient, I continued to visit her in the ward, and her mother came to see me for counseling.  The following week they came by my office to drop off a chocolate bar, expressing gratitude for the time I spent with them.  The hospital here may frown upon doctors spending an hour with a patient and her family instead of seeing 6 patients in that hour, but there are critical, fleeting opportunities, in patients’ lives that doctors must recognize and use before they are gone.

Emergency Room

One 15 year-old girl (whom I will call ‘Lucy’) that I kept on my ward for over a month, had attempted suicide by overdosing.  Her father had left her mother when she was very young and then her mother passed away when she was five years old.  Her grandmother took custody of her, but her grandmother was an alcoholic who also smoked marijuana.  Her grandmother repeatedly told her that everybody hated her, and that no one could ever love her.  When her grandmother was drunk, she would physically abuse the girl—she even stabbed her on multiple occasions.  During this time, she was also raped by her step-grandfather.  When her grandmother died, she moved in with her aunt.  She was ten years old. 

Her aunt’s boyfriend, or “uncle”, had a drug problem he could not afford.  In order to pay for his habit, he would drug her and then invite to the house men to whom he owed money.  To pay back his debts, he would let them gang rape her.  This occurred over and over.  She still has flashbacks, in which she can feel and even smell the men who raped her.  Her uncle was eventually arrested and sent to prison, and she was sent to an orphanage with over 100 children.  To this day, she still receives calls from her aunt, who tries to pressure her to revoke her accusations against the boyfriend so he can be released from prison early.

Lucy has been diagnosed with post traumatic stress disorder, and is now showings signs of a personality disorder.  When I told her that she had been doing well on her anti-depressants and would soon be discharged back to the orphanage, she threw a tantrum, running around the ward screaming that she did not want to take her “ugly” medicine.  Later that same day, she lay in bed pretending she could not move, which alarmed the nurses.  Recognizing it as another plea for attention, I ignored her and soon after she got out of bed and acted normally again. 

Two weeks after she was discharged from the hospital, she attempted suicide again by overdosing on cough syrup and was re-admitted.  The night after her re-admission, she was found in the hospital bathroom, standing on the toilet with a rope dangling over her head, contemplating suicide again.  (I do not know why there was a rope left hanging from the 20 foot ceiling; I reported it to the hospital CEO.)  The next day, I had a long meeting with the psychologists, social workers, and orphanage director in order to come up with a plan for her care and safety.  Lucy and I had a long heartfelt talk and she told me that even though people at the orphanage, school, and hospital tell her that they love her and care about her, she does not believe them because her grandmother always told her that no one could ever love her.  It saddens me that this young girl is so bright and full of life, but at the same time is in so much pain.  She has little self-worth, and her thoughts have been polluted by the trauma of her early childhood.  Without conquering the demons from her past, she will not be able to grow into a healthy productive adult who loves herself.



Patients waiting in the outpatient clinic.

 

This story is not unique.  Another very intelligent 15 year old girl whom I admitted after she slit her wrists twice and drank tile cleaner, wrote me the following poem before I transferred her to the psychiatric hospital:

In my mind

I see scars.

In the sky

I see stars.

In the lie

I see the truth.

In a smile

I see the hurt.

In a cry

I hear the pain.

We’ve been pushed so hard

but still we act normal.

We have been through it all.

Through the pain

there’s no other road.

Pushing brings on a strain,

the clouds only bring cold.

I’ve given up my name

because it feels like stone

to know I can no longer reign

so still I try to prove that

In my mind

I see scars.

In the sky

I see stars.

In the lie

I see the truth.

In a smile

I see the hurt.

In a cry

I hear the pain.

I see no mercy passed.

Nobody sees me for me.

No one cares anymore.

Through the stress

I’ve been pressed

to keep pushing, still

In a smile

I see the hurt.

It isn’t over yet coz

in my mind

I see scars.

In the lie

lies the solid truth.

Midlands Meander

South African Fact:

Every year in South Africa, 150, 000 people commit suicide.  In the last 15 years, the rate among children between 10 and 14 years old has more than doubled.  A study from the University of Stellenbosch estimates that each year almost 20 percent of high school students think about fatally harming themselves.  Also, about 25 percent of all general practitioners' patients suffer from psychiatric conditions, not medical.

http://www.hst.org.za/news/mental-illnesses-rise-sa

(For those of you interested in reading more about South Africa’s current plight, please read The Economist from October 20^th-26^th 2012.   The front cover reads "Cry, the beloved country: South Africa's sad decline."  It covers many topics that I have been blogging about this past year.)