I was trailing my second year and Chief Resident, like the intern pup I was, as we entered the Emergency Department to begin our 11pm to 7 a.m. shift. We took report about the patient cases in progress from the three man team that was finishing their shift. Notes were exchanged, short verbal reports given. Cal, the second year, looked up at the whiteboard triage display and groaned.
“Oh no, Slice and Dice is here again!”
I followed his gaze and saw the board notation: Evelyn Minter, age 25, Lacerations.
“Hey,” remonstrated the Chief, “No complaining.”
“I’m tired of seeing her every other weekend. Let Lyons do it, she needs the practice.”
Heading to the treatment cubicle and darting a look inside, I saw a thin young woman about my age, sitting quietly on the exam table with her arms in her lap, a clean plastic-backed absorbent pad under them. She was bleeding from three full thickness lacerations on each forearm, each about six inches long, oriented parallel to the forearm’s long axis. She wore a pretty sundress covered with daisies. Her face was a closed fist.
I ran back to my team. “This looks intentional! She’s a suicide attempt! Shouldn’t we call Psych to see her too?”
“Lyons, she’s not a suicide, she’s a cutter. We see her all the time. We’ve had Psych in about five times. She won’t talk to them.”
Astonished and alarmed, I returned to my patient. I introduced myself.
“I’m Dr. Lyons. How did this happen?”
Nothing. She stared at her hands. An awkward silence lengthened. Bewildered, I decided to try to treat Evelyn Minter just as I would someone who had sustained these lacerations accidentally. I turned her thin forearms over and assessed the wounds, noting also the tracery of old healing cuts and thin white scars. I had her flex, extend, and pronate, supinate her arms, assessed her motor strength. I made her go through range of motion of the wrists, hands and fingers. I tested sensation to light touch and light pinprick. She was limply cooperative.
“Well, these will need stitches, but no big vessels are injured, and there is no damage to the nerves or muscles. You should heal just fine.”
It took me, a novice, about an hour and a half to clean, anesthetize and sew her wounds. She remained silent, and I continued a bland patter.
“Okay, a little stick and a sting, and then you’ll be numb.” “Can you roll your arm towards me just a bit?” “I’m going to pad the bandage over your arm bone so it won’t hurt to lean on the arm.” “It will take about 10 days to be ready for the stitches to come out. I can prescribe some ibuprofen for pain.”
Evelyn remained wordless throughout the procedure, the bandaging, the instructions.
“Ok, you did great. Very brave. You are good to go and please come back right away if you see the signs of infection we reviewed.”
She got up to leave and for the first time made brief eye contact. “Thanks.”
Evelyn returned for suture removal in 10 days on my nightshift. I was assigned to see her. The staff told me that she came about twice a month, always with forearm lacerations.
I chased down the Psych resident who had seen Evelyn last. The resident told me about their attempts to interview Evelyn and about her stony silences. The psych residents had asked questions, offered her a period of observation in the day ward. No answers or reaction from the uncommunicative patient. Afterwards, I read up about the causes of such self-mutilation. They were sobering.
I tried a different tack than Psych had. Clearly, I reasoned, Evelyn Minter didn’t want to discuss her cutting. She just wanted sutures. Beyond my “what happened” question the first night, I asked Evelyn nothing about the “whys” of her cutting. It seemed to me that she should be treated as “normal”.
Two weeks later, Evelyn returned, again on my nightshift, and appeared for suture removal on my dayshift as well. Soon, the staff was calling her my “private patient” as she seemed to know my schedule and align it with hers. The triage nurses told me she no longer appeared on random days, and never showed up on my days off.
Eight weeks later:
“Hi, Evelyn. I like your new perm! Okay, let’s take a look. Hmmm, not too bad. Let’s get started.”
Eventually Evelyn began to verbalize, tentatively, a few wan words here and there. A little trust got built. One day, I got up the nerve to say,
“You know, if you ever want to stop doing this, there are ways to help that happen.”
Evelyn burst out angrily, “I hate this! You know how awful this is? Everybody here looks at me like I’m a piece of shit. ‘I don’t wanna see her, this one’s a fucking freak!’ You think I want to do this?”
This was the longest speech I’d ever heard from her.
“I don’t know,” I answered. “You’ve never told me.”
So, we began to talk. A little. And then the next time, a little more. Evelyn’s cutting intervals started to lengthen. She followed me to my real private practice when I graduated residency, and eventually saw a therapist, one that I had told Evelyn I knew and liked. I made it clear to my office staff that there were to be no nicknames, and that there was to be no eye-rolling, no tone or expressions of annoyance or contempt when Evelyn called to be squeezed into the schedule for an “urgent” visit.
“Hey, you guys, you know the saying, ‘There but for the grace of God…’”
Our relationship became warmer and more comfortable. She spoke about her job, her Mom, her therapy. Now, Evelyn only relapsed into cutting once in a great while, at times of high stress. I congratulated her on her success. Things were looking up.
That fall, Evelyn stopped coming. Her number had been disconnected. Her therapist had no clues.
“She seemed fine last visit, and then just missed her follow-up. Never called.”
The letter our practice sent to Evelyn’s address, asking her to call us, went unanswered. I was concerned, but also busy. Other patients’ problems filled my mind, but when I read the local paper’s accident and suicide reports I caught myself looking for her name to appear. It never did.
So, did we help? Was it enough? Would nothing have been enough? Was Evelyn alright somewhere else, in remission from her compulsion, or just frequenting the Emergency Department in another town? I had to resign myself that sometimes, you just don’t get to know.
Being Evelyn’s doctor broadened my mind about cutting, and by extension, other behaviors. You know the ones. The behaviors that make our first impression, in Evelyn’s words,
“This one’s a fucking freak.”
My memory of Evelyn helps remind me that there is a real person underneath, in pain.
Companion Poem, Cutting the Surface
Paula Lyons, MD
May 25, 2020