Mary S. was in a catatonic stupor when she was admitted into our hospital. If you were to consult just about any ol’ medical dictionary, it would describe her physical state accurately: “In a catatonic stupor, the patient’s motor activity may be reduced to zero. The patient may avoid bathing and grooming, make little or no eye contact with others, may be mute and rigid, and initiate no social behaviors.”

Her husband, Tom had to give us her psychiatric history while Mary sat silently in a chair, eyes open lazily, fixed on the floor. Her bizarre posture made her look like an adult sized, discarded rag-doll. Her head hung down with her chin resting on her chest. She was slumped forward with her arms hanging limply at her sides. Her legs jutted out in front of her, as if she couldn’t bend her knees. She even looked pigeon-toed. I had never seen anyone in such a condition. Her posture and slack facial expression made Mary look a few years older than her age of 35. She had fair skin, a medium body frame and light brown, pixie style hair. She was dressed nicely, which made her posture look even more outlandish. Tom told us that he had begun dressing Mary when her depression became unmanageable. He told us that by the time her depression gets to a point where it completely consumes her, she is unrecognizable to him. Dressing her himself gave him a tiny bit of comfort and semblance of normalcy, and helped him hang onto hope. She had been in a catatonic state going on 2 weeks now.

Tom was such a sweetheart. He was patient and kind to his sick wife. He spoke gently when talking about her. The couple had 2 little girls, Sara, four and Tiffany, six. Tom told us that when Mary was doing well, she was an excellent mother, totally present as a parent and doted over the girls constantly. The girls, Sara and Tiffany, would eventually come with Tom on the weekends to visit their mother, where they were fawned over by staff and patients alike. The four of them made a lovely family. Tom said that Mary had a long history of being admitted into many different psychiatric hospitals on many different occasions. He admitted that there had been several suicide attempts made by Mary in the past. He could not tell us about any one specific event that may have been a catalyst for her depression, all he could say was that Mary was “just sad a lot of the time, for no apparent reason.” He was able to list off all the things that she should be happy about; two beautiful children, a nice house in a nice neighborhood, family and friends that cared about her. He just couldn’t understand how she could be so depressed. He was scared, as he’d never seen her this bad, in a state of catatonia. As he was leaving, we did all we could to assure Tom that Mary was in good hands and that we would keep her safe in our hospital until she was better.

From that moment on, it was our job to make sure Mary was taken care of. We finished up the nursing assessment with her height and weight and checked in her belongings. Tom had packed one small suitcase full of nice clothes for his wife. In the hospital, we document the items brought in with a patient so we can make sure the items are still with the patient when they check out. A patient in a depressed or even catatonic state could be taken advantage of by the higher functioning patients, so we always try to discourage patients from swapping clothes or borrowing any personal items. Another situation we try to keep an eye on is patients and their jewelry. Patients have a right to keep their jewelry on, but we encourage them to take off expensive jewelry and put it in our safe until they are discharged. When they want to keep their jewelry on, we have them sign a “release of responsibility” which means that if their jewelry is stolen, it would not be the hospitals responsibility to replace the item. We noticed that Mary wore a small pair of gold hoops in her ears and a beautiful diamond wedding ring on her left hand. Because she was unable to sign the release herself and her husband had already gone for the day, we left her jewelry on. When her husband came to visit next time, we would try and remember to have him sign the release.

After the nursing assessment, Mary saw the doctor for a psychiatric evaluation. She was diagnosed with Major Depression and started on an antidepressant and a mood stabilizer. After that, she was immediately placed on a “one to one” (1:1) by the doctor. Most patients are placed on a 1:1 when they are unpredictable and dangerous to themselves or others. Mary was placed on a 1:1 because she could not care for herself properly. We had to do everything for her. The 1:1 policy is that a nursing staff is delegated to the patient 24 hours a day. The patient is to be in the nurse’s sight at all time, not more than one arms length distance away. This means the patient will be dressing, eating, using the bathroom and showering in front of a nurse. Under no circumstance is there to be a door closed between the nurse and patient. The patient must always be within the nurse’s line of sight.

With Mary unable to help herself, we would wake her up in the morning, dress her, feed her, and make sure she took her meds. She never fought us, or the situation. She just shuffled along silently, our little rag-doll, as we guided her to the next activity. All the while, we talked to her and tried to engage her in conversation as she continued to stare through the floor.
Mary continued in a catatonic state for more than 3 weeks with us. Slowly, over time, she began to improve. During the 4th week, she was making moderate eye contact and feeding herself. Never mind that she looked like she was moving in slow motion, it was a huge improvement! We all continued to encourage her and engage with her. Mary didn’t say much, but when she made an effort to speak, her speech was halted, low, and monotone. She sounded a bit like a broken robot. Soon, she was forcing herself to talk more about her favorite subject, her sweet girls, waiting for her at home. She knew she needed to get better for the sake of her daughters and she pushed herself towards wellness, like a trouper. Within another week, Mary was smiling wanly, conversing moderately and attending therapeutic groups and simple activities. Her movements were still slow and deliberate and she walked as if every muscle in her body was sore, but at least she was moving on her own.

Mary had been with us for a while now, and many of the nurses who worked closely with her were growing very fond of her. In the world of psych, “getting attached” to a patient is a no-no. We are trained to be compassionate and professional. We are not to get “attached.” We are taught that attachment leads to manipulation. Manipulation leads to disruption and chaos on the unit. A quiet, uneventful shift is the unspoken goal between nurses everyday. I say unspoken because there is a funny little superstition among nurses; the word “quiet” is forbidden to be spoken out loud on a unit. If a nurse comes onto the unit and announces, “Wow! The unit is so quiet today!” she will immediately be “Shush-ed” down. It’s been my experience that the word “quiet” does not have to be uttered for a unit to completely spiral out of control.

It had been about 6 weeks since Mary’s admission into our hospital when I reported for duty on the day shift and was told that I would be her 1:1 for a few hours. The morning routine was easy enough. Mary was dressing herself now, making her bed, taking her meds, eating breakfast on her own, all with minimal assistance from us. She was making great progress. I looked forward to my assignment and went into Mary’s room to relieve the night shift nurse of her duties. As the morning flew by, Mary and I chatted together about her life and her future. She loved being a mother and her girls were her greatest glory. She talked about how much she adored her husband and how grateful she was that he was willing and able to take care of her. She confessed that she had been struggling with depression her whole life. She felt powerless over it. It scared her that she could get so sad. Her meds helped keep her depression at bay, however, she didn’t want to have to take meds. Sadly, a lot of psychiatric patients feel that they don’t need their meds once they start feeling better. They will stop taking them and as a result, they begin to deteriorate and become depressed again. It’s a vicious cycle I’ve seen hundreds of times as a nurse. Mary was no different, but when I encouraged her to stay on her meds she seemed really motivated to do what she needed to do. After all, her girls needed her, she said. I surprised myself by how proud of her I felt. It was as if we could have been friends if the circumstances were different.

As we sat in the dayroom with the other patients watching T.V, waiting for lunch to be called, Mary told me that she needed to use the bathroom.“No prob!” I said, “Let’s go.” We got up from the couch, walked to her room and went into the bathroom together. Her doctor was close to discontinuing the 1:1, she was making such great progress, but she remained on a 1:1 for now. One arms length distance away. Always to be in the nurse’s line of sight.

As Mary was about to use the bathroom, she paused and looked up at me. “Brandi, can I please use the bathroom by myself?” She quietly asked, “I promise I won’t tell anyone. I’ve been so good. Please?”
I tried to respond quickly, but I know now she saw me consider it for a split second. “No, Mary.” I said. “ You know I can’t do that.”
She surprised me and pushed the issue, “Please. I haven’t used the bathroom by myself in weeks. Please. I promise. It will be our secret.” This time she knew she had me. We locked eyes for what seemed like minutes. Her eyes pleaded with me and I felt bad for her. I wouldn’t want someone watching me use the bathroom for weeks on end. In that moment, I had completely forgotten that I was the nurse and she was a psychiatric patient. I softened. My guard was down and she knew it.

My intuition, which a nurse should always listen to, warned me and then called me a sucker as I told her in a hushed, agitated tone, “You have 90 seconds, and then I’m opening the door. I am trusting you this one and ONLY time! You cannot tell anyone I did this! Do you promise me?” Mary gave me a slow smile and said, “I promise.” I weakly reassured myself as I reached for the key in my pocket that would unlock the bathroom door in case of an emergency.

With each inch of the door slowly closing between us, my anxiety level went up. When the door finally locked, it sounded as loud as the crack of a shotgun in my ears. I instantly had a sinking feeling. I quickly pressed the side of my head against the locked door, knocked and reminded her she now had 80 seconds to finish up. I could hear the smile on her face when she said through the door, “I’m fine! don’t worry.” My intuition was screaming at me to get her out of there. I impatiently looked at my watch’s second hand and warned her, “You now have 50 seconds.” I heard a quiet, “Okaaayyy.” I tried to settle my mind down. I told myself she was all right, after all, she PROMISED me! What could she POSSIBLY do in there to hurt herself? All she had in there was toilet paper. C’mon, Brandi, RELAX….All the while I watched her bedroom door out of the corner of my eye hoping no other staff would walk in and catch me breaking serious nursing  rules.

The seconds ticked away like minutes. What was I doing? This is crazy! My ear, still pressed against the door strained to hear any normal bathroom sounds. She had 30 seconds left when I just couldn’t take it anymore. I knocked urgently and demanded that she come out right now. “Mary you need to open this door. I’m not comfortable about…” I stopped to listen. This time, there was no response. I knocked harder now, not caring anymore about who would hear me. “Mary! Open this door NOW! Do you hear me?” Nothing. Failing miserably at trying to keep my panic under control, I fumbled the keys trying to get them out of my pocket. As they fell to the floor, I remember thinking that I had a lot of keys. I had a lot of keys because I was a good employee. I was trusted to have certain, important keys that other nurses didn’t have. I was considered “responsible.” and an “excellent employee.” My illustrious job as a psych nurse flashed before my eyes.

My hand shook as I put the key in the door handle. I continued to plead, “Mary! Open this door NOW!” The lock clicked open and I yanked hard to open the door, but Mary was holding it shut. We went back and forth a few times and I remember being surprised at the strength she was using to keep me out. When my panic finally overpowered her, the door flew open to a sight I will never forget. The next few minutes that passed are still kind of a hazy memory. At that moment, all of my senses slowed and nearly faded to black. I had swung the door open to something that resembled a murder scene. The blood coating and dripping down the side of the sink caught my eye first. So much dark red blood contrasting with the bright, clean, white of the sink. It was surreal and difficult to comprehend what I was seeing. As my eyes slowly scanned up from the small puddles of blood on the floor, to Mary standing in front of me, it was then that I saw the blood dripping from both of her elbows. She held her arms like a surgeon after scrubbing up and I could see her dark red life’s blood oozing thickly from the jagged gashes on both inner forearms. I sucked in my breath and didn’t breath again until I started to scream. I remember everything happening all at once right then. Me, screaming “What did you do!” Mary hoarsely whispering, “Let me die…” and my co-staff running in, pushing me aside and starting emergency procedures.

I don’t remember the ambulance coming. I don’t remember her being taken away. I just remember the heavy, heavy feeling of dread. A patient possibly dying on my watch because I’d been manipulated. The cardinal sin of trusting a psych patient was going to end my career.

I don’t think I need to explain just how much trouble I had gotten myself into. In the hours that followed, through tears, I had to do a lot of explaining, a lot of documenting and a lot of apologizing. My director of nursing threatened to revoke my nursing license. The hospital administrators were furious. The story spread quickly throughout the hospital. My co-workers didn’t know what to say to me. Everyone looked at me with such shock and disbelief. I was so completely humiliated and disappointed in myself. I was It was going to be a long road back to my comfy spot in good graces.

Meanwhile, in the E.R., Mary’s arms were sutured up. Approximately 15 ragged stitches on each arm. Her diamond wedding ring, that we never took away from her when she was admitted, proved to be an adequate makeshift shank she needed to try to end her life that morning. It took her less than 90 seconds in that bathroom to do major damage to her body. As fast as she could, she dug in and tore at her skin from her wrists to her elbows using that princess cut diamond ring. She knew just cutting across her arm would take longer to die. She knew what she wanted to do and exactly how to do it. She just needed the help of a perfect sucker, which ended up to be me, to help carry out her death wish.

The next day both Mary and I were back on the unit. Both of her arms were heavily bandaged and ace wrapped. I found that I could not talk to her or make eye contact with her. I was hurt, humiliated, and mad at her. I soon found myself being embarrassed and ashamed at myself for being mad at a psych patient. She was the ill one, not me.
After her suicide attempt, she continued on a 1:1 for being a danger to herself. I was not allowed to be her 1:1 again. Eventually, Mary tried to apologize to me for what had happened, but I stopped her and told her she didn’t need to say anything. It was not her fault. I had failed at keeping her safe. I failed her husband, I failed her girls, the hospital, myself. She did not know the extent of trouble I was in. I didn’t want her to know. I just wanted her to get better.

The unit continued to function, and as the weeks went by, Mary’s mood brightened and she seemed in great spirits. She was finally close to being able to go home. Her husband was happy with her progress and discharge plans were being put in place. They would include medication management along with weekly therapy sessions that Mary promised to attend.  In the mean time, my emotional wounds and her physical wounds both improved. The healing would continue, and by the time she left our hospital there were hugs all around and a few tears. We all wished her well and told her to keep in touch. As she walked out the door, we had no reason to believe that this time she wouldn’t succeed.

Mary had only been gone from our hospital for a couple of weeks when we received the horrible news that she had finally succeeded in the one thing that was most important to her. Taking her own life. Her devastated husband called us to say that she had deliberately stepped out in front of a moving train the day before, near their house in Paso Robles.  The shock and grief on the unit that day was overwhelming. The feeling of helplessness debilitating.

In Psychiatry, we  nurses learn that it is common for a person suffering with depression to appear happy, even cheerful right before they commit suicide. Sometimes they will give away their most precious belongings to people they love. This action doesn’t usually seem suspicious at the time, because, maybe they are “better” and they “look good” or we feel that they’ve conquered their depression. Unfortunately, their behavior is, in reality, a huge warning sign. It’s their way of saying goodbye. They have already made the decision to end their own life and no matter how wrong it may come to feel to us, they, themselves are at peace with it. Afterwards, when a person does succeed in taking their own life, sometimes we have a tendency to say, “Well, at least the poor thing is out of her misery, no longer suffering.” The sad truth is that suicide does not take the pain away. It just gets passed on to someone else. To her husband. To her children. To her friends and family. They will all carry with them a heavy, quiet blackness for the rest of their lives. Sometimes that blackness will sit, then fester and infect the host. Sometimes not. It’s a gamble the suicidal person is willing to risk. We psychiatric nurses come to the sad realization sooner or later that we cannot, by any means, save the ones who do not want to be saved. Ultimately it is in the control of the suicidal person. In the psychiatric field, that is the nature of the beast.