Critical Conditions

Four

Late Sunday night, Marty Klein ordered Merritt off the ventilator.

The only break I had in my outpatient schedule on Monday was at lunch, so I wasn’t able to get over to the hospital to see her until shortly before noon. She had already been moved from the ICU to a private room.

Her hair had been washed and fell in long tawny waves past her shoulders. She looked fresh and young. Although her purple eyes danced at the activity as I knocked at her open door and entered the room, the whites of her eyes were still milky and dull. Her gaze seemed suspicious. I had spent a couple of hours with her already, yet I had no reason to believe she had any idea who I was.

Approaching the meeting with her, I had anticipated that she would appear defeated and full of ennui or embarrassment, but instead she looked to me to be defiant, the head of her bed up high, her posture erect and proud. The TV was on, tuned to local midday news. Not Channel 7. The only evidence of how close she had come to death was the infusion pump still sighing intermittently beside her bed.

The defiant posture concerned me. I had an instinctual fear, a healthy one, I thought, of entering into a power struggle with an adolescent, but especially with an adolescent who had already demonstrated that suicide was a viable part of her arsenal of weapons.

On the far side of the room, between Merritt’s bed and the window, a bored nurse sat on a chair reading a paperback book about angels. She was the staff member who was responsible for accomplishing the 1:1 I had ordered two days earlier. Suicide precautions should have dictated that she sit between Merritt’s bed and the door to provide a feeble impediment to an escape, but I didn’t say anything about it.

I walked to the foot of the bed and said, “Hello, Merritt, I’m Dr. Gregory,” then to the nurse, “Why don’t you take ten? I can give you a little break. I’ll stay with her until you’re back. Thanks.”

Merritt studied me but didn’t return my greeting. Her already parted lips moved a tiny bit. They were pale, almost the same color as her complexion. A small wound had scabbed over in one corner of her mouth. I figured it was treatment trauma. The tip of her tongue searched out the rough surface of the scab.

The nurse left her book on the windowsill, said, “Doctor,” and hustled out of the room before I had a chance to withdraw my offer.

I took a step closer to the foot of her bed to be certain I was at least part of Merritt’s peripheral vision. “I’m a clinical psychologist, Merritt. You may not remember me-I don’t see how you could-but I’ve been by to see you each day since you were brought into the hospital. I was hoping we could talk about what happened.”

No reply.

“May I sit?”

She shrugged her shoulders, touched her hair.

Merritt had a narrow chin and cheekbones still flush with the fleshiness of youth. In a year or two, maybe less, the roundness would give way to sharp definition and no one would dream of calling her a kid again. Pale freckles trickled down her face as though fine sand had spilled from the corners of her eyes.

She held her shoulders back against the pillow and brushed something off the lettering of her T-shirt with her left hand. In large letters, inside a burgundy oval, it read ROXY. My contemporary IQ was low and I didn’t know what ROXY referred to. I guessed rock ’n’ roll.

Merritt was wearing no makeup, and I was left to wonder whether that was typical for her.

I pulled a chair up and sat a few feet from the bed and waited for her to begin. Her expression was composed, even assured, although her eyes danced in a way that seemed bashful. For a long time, at least a minute, I felt she was arranging her thoughts, preparing how to deal with this stranger who was intruding on her most intimate and sanguine moments, and offering to help.

But she didn’t speak.

I wondered what her silence meant. Had the ventilator left her throat too raw? I prodded. “We’ve been really worried about you. I’m sure you know that.”

Her lips parted even farther and she licked the lower one and probed the wound in the corner of her mouth once more before squeezing her lips tight. I wondered momentarily if she was being gamey, but her eyes betrayed caution now, not defiance, and if I was reading the signals correctly, some shyness.

I waited two minutes or more for Merritt to find the trailhead that would allow her to begin with me. I listened to a long commercial break about antiperspirants, used cars, and a movie of the week.

Merritt didn’t speak. Her lips parted again, but she didn’t speak.

Gently, she scratched her face and ran her fingers through her long hair, leaving it carefully arranged over one clavicle. She picked again at that annoying something on the X of ROXY, and then she examined her fingernails.

I noticed that the red polish I had seen in the ICU had been removed and that the broken nail had been filed smooth.

Each time the story changed on the news she looked up briefly at the tube, then away. I wondered if she was waiting for some update about her sister or whether she was just using the program as a distraction so she didn’t have to deal with me. Perhaps both.

“You tried to kill yourself. And came incredibly close to completing the process.”

Maybe a deeper than usual exhale, not quite a sigh. When she inhaled deeply her breasts took on definition and her shoulder bones were pronounced and sharp.

No words.

“You almost died.”

She smoothed an eyebrow with her index finger and I heard Adrienne’s voice in my head saying, “I think she’s really pretty.” I reminded myself to keep in mind that for many young women beauty was burden as well as blessing, and I tried to stay focused.

But Adrienne was right. Merritt was lovely.

I didn’t know what to do next. I hadn’t been prepared for her silence. It made the determination of suicidal risk a little awkward.

A nurse, a different nurse, entered the room after a perfunctory knock. With much too bright a smile, she said, “I’m here to pull that IV, babe. Good news, you don’t need it anymore.”

Merritt looked at me, terrified, as the woman set her tray down on the bedside table and pulled on latex gloves. Merritt’s eyes screamed, “Do something.” I was sure she was about to break her silence in order to mount a protest or to scream, or something. But all she did was bite her bottom lip while the nurse began to peel away the tape that was covering the catheter in her wrist. When the tape was removed and the thin catheter that snaked into a vein on her arm was exposed, Merritt turned her eyes away, reached out with her free hand, and squeezed mine with poignant desperation.

The nurse said, “Here goes, babe, this won’t hurt a bit, promise.” She laughed as though she didn’t expect to be believed. Two seconds later she pressed a gauze dressing over the site and, in a smooth motion, slid the catheter free from Merritt’s arm. I was acutely aware of Merritt’s terror, could feel her tremors of fear. I was also touched by her desperate use of me for comfort.

The nurse eased a cotton ball and a Band-Aid over the IV site. Merritt watched. The nurse said, “All done, now that wasn’t so bad, was it?” Merritt stared at the bandage, then lifted that hand and spread her fingers in front of her open mouth. It didn’t seem to me that she was even aware that she was still holding my hand.

When, finally, she looked back down and saw our hands intertwined, she tensed, looked once at my face, and hesitated before removing her hand from mine. She pulled free with great deliberation, allowing her fingers to graze along the skin on the soft part of my palm.

I said, “I’m glad that’s over, Merritt. I bet you are, too. I get the feeling you’re not very fond of needles.”

She opened her eyes wide and nodded. I wanted to hear her cry or laugh or giggle as the tension melted away, but she didn’t.

So I waited, hoping the brief intimacy we’d shared would shake something loose between us. Something verbal. But Merritt composed herself quickly and returned her attention to the noon news.

I needed to let her know where things stood before I left. “Merritt?” I waited until she looked my way. “One of my jobs is to help everyone-you, your doctors, your parents-decide how likely you are to try to kill yourself again. It will be difficult for me to do that if you don’t talk with me.”

She swallowed.

The nurse doing the 1:1 poked her head back in the door. “You need me yet?”

“Uh, no, not yet. Do you mind waiting at the nursing station? I’ll be out in a few minutes. I do have some questions for you.”

She mumbled, “I bet you do,” as she closed the door.

Merritt raised her chin a little and focused again on the news. A cute story about a cat in a tree and a swarm of bees and engine company six.

I was absolutely certain by then that Merritt wasn’t anxious about not talking. Given the clarity of her reaction to the removal of the IV, had she been suffering a neurological impairment that precluded her being able to speak, she should be terrified by the disability.

I asked, “Do you feel able to talk? Physically able?”

She didn’t respond. She wasn’t going to help me. I had to consider the unlikely possibility that Merritt’s silence was hysterical, not volitional, and that her lack of apparent anxiety was actually “la belle indifférence.” If the right constellation of previous experience, serious trauma, and secondary gain came together, Merritt could be suffering from a hysterical inability to speak that would have no physiological basis.

The odds were extremely low that her silence was hysterical, maybe one in ten thousand. I had seen conversion symptoms only twice in my career.

In a soft voice, I said, “This is important. I need to let you know how things are going to work between you and me. You’ll talk to me, I figure, when you’re ready. Or you won’t. That’s okay, and it’s up to you. Until you decide to talk, though, I’m going to have to make a decision about your risk of attempting suicide again. Regardless of how you feel about not having died a couple of days ago-and I’m not making any assumptions that you’re thrilled about that-we, all of your doctors, are going to do everything we can to keep you alive so we can try and help you with whatever was going on that made you think eating all those drugs was a good idea.

“In the meantime, if you continue to improve medically as quickly as you’ve been improving since last night, and I certainly hope that you do, your medical doctors will be ready to discharge you from the hospital and send you home soon.

“That’s where I come into the equation. If I judge you to be at risk of further suicidal behavior, or if I’m unable to determine the level of risk of further suicidal behavior because you won’t talk with me, you won’t actually go home at all. You’ll be transferred from here to a psychiatric hospital so that we can take whatever steps we need to take in order to protect you until the risk of you hurting yourself diminishes.”

She had lowered her eyes from the TV screen and focused them on the bandage on her wrist. I thought her parted lips were quivering, just a little.

“Do you understand what I’m saying, Merritt?”

She moved her eyes up slowly until they met mine. They opened wide and brightened. Her focus had narrowed to include only me. Her upper body seemed to deflate. Her lips tightened into narrow pink lines. I read her expression to say, “You wouldn’t really do that to me, would you?” But this was someone accustomed to the dictates of authority. This was a kid who still attended when her parents spoke. This was a good kid.

I played the best card I had in my hand. “And before I go I want to tell you how terribly sorry I am about what’s been going on with your sister, Merritt. It’s very sad, and scary, and it must be difficult for you.”

Her eyes filled with tears. She wiped them instantly with the fingers of the hand that hadn’t been tethered to the infusion pump.

I waited, hoping that I had catalyzed something. She crossed her arms over her chest in an X and rested her chin on one wrist. She seemed incredibly sad.

“I’ve spoken briefly with your mother to get some history and I’m hoping to meet with her or your stepfather sometime later today or tomorrow. I’m planning on talking with your father as well.”

I watched for a reaction but couldn’t find one. I reached into my wallet and withdrew one of my business cards, scribbling my home phone number on the back, something I’m usually reluctant to do with patients. I said, “Call me anytime, for anything. I’ll be back to see you again soon.”

I asked the nurse who was doing the 1:1 to stand outside Merritt’s room with me while we talked. I didn’t feel comfortable leaving Merritt unobserved.

The nurse was a plain woman who wore nursing whites. She seemed like the old-school type who had suffered philosophical angst over the fact that nurses were no longer required to wear little white caps attached by bobby pins.

She didn’t wait for me to query her. “I don’t know if you’ve read them, but I put everything in my notes. I’m a comprehensive note taker. Some of these new nurses just like to put down the numbers and do the checklists, but I write notes. Real notes. And like I said in my notes, not a word from that child. Not one. She’s pointed at a few things she wanted me to get for her, but no, she won’t talk, and no, if you’re wondering, she won’t write anything down, either. And she’s not upset about it. I think she’s decided not to talk, that’s what I think. She just flips around on that clicker looking for news on the TV. I saw how interested she was in the TV news, so I brought her the newspaper up from the cafeteria after my morning break. She tore through it like I had delivered the Bible and she knew she’d better study it because it was almost her time to meet the Lord. I’ve never seen a young person care so much about the TV news. With the killing and the raping, to be honest, I’m not sure it’s a healthy pastime.”

“Has she spoken to anyone on the phone?”

“No. Won’t touch it. Acts like it’s gonna bite.”

“Any visitors?”

“Her mother was here early, then she went to Denver to see the other child, you know, Chaney, the sick little girl from the news. My dear Jesus, I’m afraid I’m going to spend half my time praying to the Lord for this family. What troubles, oh my, what troubles.”

“Just the mother came, not the father?”

“That’s right. Some other man came to see her, though, an uncle or something. She seemed surprised to see him. But he only stayed a few minutes. I mean, what’s the point, the baby won’t talk.”

“She didn’t speak to either of them?”

“Not a word that I could tell. Do you know why I get the call to come in when there’s one of these suicide watches? I worked ten years at the state hospital in Pueblo”-she pronounced it Pee-eb-lo-“then did ten more years with teenagers at Fort Logan, you know, the state hospital. So I know crazy when I see it. But this girl’s not crazy. Want to know what I think?”

“Please.” I knew I was going to hear her opinion whether I really wanted to or not.

“That child’s in bed with some demon, some evil, evil force-mm-mmm-and she’s decided that if she talks, that demon is going to raise his ugly head and have his way with her. That’s what I think.”

Through the small window in the door to her room I could see Merritt’s face. Her eyes were glued to the tube. She was still embracing herself, her arms crossed over her chest, no one else available to do it.

“That’s an interesting thought,” I glanced at the nurse’s name tag, and added, “Ms. Hayes. I’ll keep it in mind. Thanks for your help. I’m grateful that someone with your experience is available for this. I’ll be back later, this evening, probably around the dinner hour. If there’s any change in the meantime, please give me a call, especially if she begins to speak to anyone. I’d like to know that immediately.”

I gave the nurse my business card and watched her rejoin her patient. I returned to the nursing station, fished around for Merritt’s chart, and paged through it, looking for a recent note from neurology. The neurologist had seen Merritt only an hour before I had. Her note was the last one on the record.

Merritt’s neurological exam had been normal during rounds this morning. I wasn’t surprised by the news. I added my chart note to the long list of progress reports and renewed the order for the suicide precautions and the one-to-one monitoring.

Behind me, I heard, “She’s gotcha, doesn’t she? We real doctors did our part, boychik. She’s alive. Now you have to do your part, and keep her that way.”

I swiveled on the chair. “Hi, Adrienne. How you doing?”

“I’m doing.”

“You know she won’t talk?”

“I know.”

I tapped the chart. “No medical reason?”

She said, “Sorry. That would be convenient for you, wouldn’t it? I’m sure her throat’s a little raw from the ventilator, but no, most patients can’t wait to chatter after that hose comes out of their throat.”

“If she won’t talk, I can’t judge how dangerous she is, Ren. If you’re ready to discharge, I’m going to have to transfer her to a psych hospital.”

“I know. Maybe it’s what she wants. Poor kid’s been home alone a lot since her sister got sick. Maybe she just needs some TLC.”

I smiled. “I have an idea. If that’s all she needs, why don’t you take her home, Ren? She could babysit for Jonas. That would be great.”

“You get her better, Alan, and I’ll not only grant you a one-year moratorium on making fun of your profession, I’ll also gladly foster-child this one forever. There’s something really, really good inside Merritt Strait, I feel it.” Adrienne pressed hard on her own chest. “It took some of our best work to keep her alive over the weekend and, you know what, it makes every miserable day of my residency worthwhile to see her skin pink and her kidney functions almost normal.”

“Are you ready to discharge?”

“We’ll watch her for another day or two. But soon she’ll be ready to go.”

“I may need you to go to bat for me with MedExcel, Ren. Marty called this morning and told me they’ve already complained about the expense of the one-to-one nursing. They want it d/c’d. You know they’re going to scream if I try to transfer her to a psych unit.”

“I’ll talk to Marty. We’ll work something out with MedExcel or the hospital or something. Order whatever’s necessary, Doctor. Not to worry.”