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.”