The intern had already signed off on the chart when I got to the room. He stood proudly over his work: seven stitches.
"How'd she do that?" I asked him.
The 16-year-old patient answered: "I cut it on the edge of a garbage can. I was putting the trash out."
"No, you didn't," I said.
The intern looked up, startled. The girl turned her face away.
"Look at that cut," I said, folding my arms in front of me.
The bewildered intern peered at it again. An inch and a half long, the cut traced a short course along the underside of the girl's right forearm. Another, well-healed scar nearby, almost twice as long, ended just before her palm crease. The girl turned her hand over to hide the cut and revealed her fingernails, green with polish, bitten down to the quick.
"What am I worried about?" I quizzed the intern.
"Infection?" he asked.
"She needs to be seen by a specialist," I said. "Tell me which specialist."
He doubtfully guessed: "Orthopedics?"
I turned to the girl. "Honey, who's your psychiatrist?"
Now it was my turn to be at a loss. Dr. Pong had died recently. He had been a wonderful psychiatrist, but three weeks earlier, he had checked himself into a motel on the south side of town and then taken a massive overdose of pain relievers. They found him two days later. A tragedy - many tragedies. What were we to tell his patients? His death even shook the hardened emergency-room staff.
"Okay," I said, "the specialist we need to call is a psychiatrist. Now, what's the other important question to ask?"
The intern shook his head.
"Are you right- or left-handed?" I asked the girl.
"You're right-handed, aren't you?"
She shrugged again.
I turned back to the intern. "Why is that important?" I reached down and slowly pulled the sleeve up on the girl's left forearm. The intern stared, his mouth ajar.
Her arm was a maze of scars. Lines crisscrossed every way. Short, thick scars and great long gashes lined with suture marks ran her forearm's entire length.
"You did that?" whispered the intern.
The girl looked away, embarrassed and proud.
Now it was the intern's turn to ask the pertinent questions. "Why?"
"I dunno," said the girl.
We needed to call for her chart, but I knew what it would contain. She would have been diagnosed as borderline, as in borderline personality disorder. Self-inflicted injuries are a common feature of this psychiatric syndrome. Borderlines live in a no-man's-land where features of cognitive disorders - disorders of thinking, such as schizophrenia - overlap with features of mood disorders, such as depression. Many health-care workers who deal with borderlines feel their disorder combines the worst features of cognitive and affective disorders. The patients are extremely problematic to treat - unpredictable, manipulative, and exasperating. Treatment usually combines both therapy and a medication such as Prozac or Zoloft.
Not all patients who cut themselves are borderlines. Some otherwise well-functioning people use the pain of a cut and the sight of blood as a way to cope with an emotional problem. Somehow it seems to provide a temporary relief from the inner turmoil they feel. And many borderline patients "dissociate," removing themselves, body and soul, from the world. They are very difficult to treat. After all, how do you talk with someone about something he did when he wasn't there?
I squatted down so that I could look at my patient from a nonthreatening position. "Tell us what happened today," I said, as gently as I could.
She shook her head.
"What's going on at home?" I asked her.
Her shoulders started to shake. She looked away, trying not to cry.
"Who's at home with you?"
"My brother and my mother."
"How are they doing?"
She shrugged. "They're O.K." No spark there.
"You go to high school?"
She looked at me. "It's summer vacation," she said.
I tried again. "You have a boyfriend?"
She looked away, somehow managing to look both tearful and bored.
The intern had asked "why?" I thought about what I usually tell residents about borderlines. I thought about self-mutilation, dissociation, cutting. I had to ask myself: In all honesty, how could that be a comfort?
Then a thought occurred to me. It was so obvious I felt like an idiot. "Dr. Pong," I said.She stopped looking bored and started to cry in earnest. "He left me," she said.There was that same question: Why? Dr. Pong was married to an anesthesiologist, a lovely woman; they had three kids. He had a good practice, and his patients adored him. What dark place had he sheltered within, invisible to us? How could all of us who lived right beside him, talked to him a half dozen times a day, admitted patients to him - how could we all be so oblivious?
He had been on call that weekend. We had tried to reach him all day Saturday and then again on Sunday. We ended up calling another staff psychiatrist to admit the patients. Monday afternoon, while she was working in surgery, his wife got the news. Eventually it filtered down to us in everyday life's matter-of-fact indifference to tragedy. Dr. Pong, we were told, would not be taking calls this week. We were to call another psychiatrist.
I thought of his children, his patients, this patient. Once upon a time, this girl probably couldn't see an inch beyond her own pain and suffering. Dr. Pong had given her, perhaps, a tenuous connection to other people, to the rest of the world, and with that he brought all the joys of such connections - and all the pain.
I stood up, trying to find comforting words. I thought again of the explanations I always give the residents about cutting and its paradoxical relief of tension. Then the causes: sexual abuse, poor parenting. But can we ever explain anything? Do we really have reasons or just rationales? To be honest with myself, I would have to confess that no matter how much I might try, I could never really pick out the path that leads a patient from childhood to this place. If I were honest, I would have to confess that other than knowing a few buzzwords, I was as clueless as the intern.
He was standing to the side, shaking his head at his own stupidity. I knew that feeling. I had been there many times myself.
I left the patient to the intern. He gathered himself up and stepped closer to her bedside. He was the kind of person who felt terrible when he made mistakes that might hurt a patient. It was a feeling that would make him a first-class physician someday.
The two of us crossed paths on the way to the door. "By the way," I whispered to him. "Great job on the sutures."