Call for help.

My clinician colleagues wryly observe that our medical practices differ. They believe that forensic pathologists are insulated from the “difficult” patient because our patient interactions are, strictly speaking, unilateral. I have patients who don't say a word, who are incapable of the oral recitation of chief complaint, past medical history, review of systems, etc. Matching my colleagues grin for grin, I bemoan my role as the consultant who must talk with anyone and everyone—angry, distraught, or confused family members, law enforcement officers, attorneys, insurance companies, the media, and people writing the next great mystery novel. But if the needling of my colleagues contains a kernel of truth, it is that forensic pathologists rarely handle “emergency” situations. My professional days were free of life and death urgency until... Our administrative assistant, Diane, informed me that a woman on the telephone line asked to speak with the pathologist who, a few years earlier, had performed the autopsy of her brother. The brother had hanged himself. The circumstances were not controversial. My colleague, who had performed the procedure in question, was now in another job across the country, so the call came to me. This kind of inquiry usually results in a pink message slip placed in the pathologist's mailbox. But Diane recognized that this woman (identified here as Jane, not her real name) probably needed to speak with someone right now, and she had already declined an offer to talk with one of our grief counselors. Diane quickly made a plan: she informed me that I must take this call and she would alert one of our grief counselors (Carol) to the potential problem. I picked up the phone. “Hello, this is Dr Nashelsky. May I help you?” A slow, soft voice responded. “How many antidepressants does it take to stop my heart? I just took 20.” I didn't answer immediately. Many thoughts crossed my mind. First, I didn't know the answer to her question. Second, I needed urgent help, almost as much as the caller needed help. Third, I had to keep her on the phone while the paramedics responded. My response was unimaginative and betrayed my experience as a frequent expert witness in court. “There isn't a single exact answer to your question.” That was a dumb, dumb, dumb thing to say. This wasn't an occasion for clinical detachment or physician-attorney gamesmanship. I started over. “I'll try to find an answer for you from a textbook in my office. While I'm doing that, please tell me where you're calling from and what you took. I'd like to call people who can help you.” That was much better. “I don't want to tell you,” she said. While cradling the telephone with my head and my shoulder, I used one hand to grab our standard toxicology reference text. But so far, I had no particular drug to look up. With my other arm, I was waving wildly in the direction of the hallway outside my office as I tried to get the attention of anyone walking by. Diane and Carol were on the spot. I mouthed “Trace this call!” Diane promptly called 911. Jane's speech was slow, staggering—much as one visualizes a stumbling alcoholic. Sentences were often difficult for her to complete, and there were lots of sniffles. Jane asked me about the autopsy performed on her brother. I took a moment to scan the case file and photographs, which Diane had located and brought to me. The autopsy had been performed during my fellowship. Something about the suicide note rang a bell for me (many are surprisingly distinctive and have memorable features). This case had not been my own, but some contents of the note were definitely familiar. I must have heard the circumstances recounted during morning report on that day several years ago. I told Jane that I faintly remembered her brother's death even though I hadn't personally performed the autopsy. This was a catalyst to continuing our conversation. Jane gushed details of their kinship at length, taking breaks to ask me why he had done this to himself. I paraphrased reasons given in his suicide note. Of course, what I told Jane wasn't new to her. Jane asked questions about the autopsy and then about the funeral. I gave answers gently and we stayed on the phone, for almost 30 minutes. At one point, she said she had to throw up. I told her I'd wait—urging her with raised voice to come back to the phone. “Please don't hang up!” I waited, and then heard the toilet flush. When she returned to the phone, she reported feeling better and that she thought she had vomited some pills. Her voice was steadier and the words flowed with more fluency. Finally, Diane slipped a note to me saying that the call had been traced to a rural address. Our conversation began to meander. Jane told me about her family. Her history and current circumstances sounded hopeless. Jane shifted to remembrances of growing up in another state. I was familiar with her hometown. We reminisced about the area—its geography, weather—even specific places that we both knew. These common experiences pleased her greatly. She was perking up. We'd now been on the phone for about an hour. I feared that I was Jane's best friend. I heard noises. Jane said, “Someone is outside.” “Go check. I'll hold.” I heard unintelligible voices for several minutes. Then Jane came back to the phone. “You called the police, didn't you?” she accused me. By now, her voice was steady and strong. I had “betrayed” her confidence for what seemed to me a greater good. “Yes.” I tried to explain, to make her understand that I was trying to help her through our long talk and by facilitating medical attention. She was silent as she considered my reasoning. “I don't want to go to the hospital. They'll make me stay there again. We can't afford it.” I suddenly realized that she'd been here before. Now who had betrayed whom? “Forget the money. I'm a physician, but I have no experience or training in helping people in your situation. Please let the paramedics and sheriff's deputies take you to the hospital. I think you need to talk with people who can help you.” I paused and then added, “I care about what happens to you. Please...” Jane went to the hospital. I hung up and sat at my desk, exhausted. Carol was across from me. She had been there for the whole 1¼-hour conversation. Now I needed to talk to someone. Carol recognized the issue. I had deceived Jane, kept her on the phone, feigned great personal interest, and talked with her about anything to allow time for emergency personnel to arrive. She said, “In this kind of crisis, it's OK to tell the person almost anything to keep them going. Getting the person to the right kind of help is the overriding objective.” Jane phoned me the following afternoon, about 24 hours later, from her room at the hospital. “I hated you yesterday. Today, I thank you.” I never answered her first question.