closing time / weltschmerz

Closing time 
Time for you to go out go out into the world. 
Closing time 
Turn the lights up over every boy and every girl. 
Closing time 
One last call for alcohol so finish your whiskey or beer. 
Closing time 
You don't have to go home but you can't stay here.

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What do angels understand about being in hell?


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"So is your man going home?"

I wanted to say yes, but I couldn't. It wasn't that simple, unfortunately.

"I mean, he should go home... the question is how to get him to do it."

I gave R a look of exasperation and she grimaced back in sympathy.

"Maybe if I subtly nudge him closer and closer to the exit until he's out of the department..."

"Just say, 'sorry sir, we're closed.'" She said.

I laughed, but I really did feel sorry for the guy.

He was 67 years old and had backed his car into a fence after drinking two bottles of brandy. The police found him in his car, intoxicated. He reeked of alcohol and lived alone, so they brought him to Chorley to be assessed. He told me he was having trouble coping with the chronic pain in his knees so he decided to drink today. Didn't mention anything about his history of depression and intentional overdoses. Denied being actively suicidal. And after I had concluded there was nothing medically wrong with him, he told me, "when you get me to the ward, could you give me a sleeping tablet, so that I can just rest and see how I feel in the morning. I think I would like to just go to sleep and forget about all this." I told him there wasn't anything we could do for him in hospital. I tried explaining that he would be better off at home. "Please," he said. "I'd prefer to stay a night in the wards. The nurses will look after me."

When I admit a patient, I always ask myself - how will this benefit the patient? What will this admission achieve? Will it cure his substance abuse? Probably not. Will it help him feel better? Maybe. Will it deprive another patient of a vanishingly scarce and invaluable hospital bed? Absolutely.

One of the hardest parts of being a junior doctor is learning that you can't fix everyone - and that some people aren't looking to be fixed. What my patient wanted was palliative care, an opiate in the form of a hospital bed, a holiday from being himself. Corporate policy is to get rid of these patients in a benevolent manner. To reject them mercifully. To kindly decline.

The word 'triage' comes from the French word 'trier' which means 'to separate out'. The term was used during World War I by French doctors treating soldiers who had been wounded on the battlefield. In its earliest form, victims were divided into three categories.
1. Those who are likely to live, regardless of what care they receive
2. Those who are unlikely to live, regardless of what care they receive
3. Those for whom immediate care might make a positive difference in outcome.

It was a way of deciding how to allocate scarce resources to achieve the greatest good for the greatest number of people. The same principle applies to triage systems in use today for dealing with natural disasters or crises. In advanced triage, there is an expectant / black category. The only reason this would exist is that we believe that in certain situations, allowing some people to die will ultimately allow for more people to live.

Maybe the right thing to do was to kick him out because he would be fine and get better on his own. Maybe he was the walking wounded, and all that was required to heal was time. Or maybe it was the right thing because he was irrevocably terminal and admission would have had no effect on prognosis. Maybe he was expectant; beyond help, beyond hope.

Or maybe he didn't fit into any triage category. Maybe the natural history of his sickness dictated that he would keep repeating this cycle of behaviour, oscillating in a kind of limbo between living and dying, recovering and relapsing and recovering and relapsing irrespective of any treatment - before ending up in hospital for good.

But none of this made a difference to the patient in front of me. This man was trapped. He was  suffering and desperate to escape it, pleading. And what I do to cope is think about abstract principles that justify my actions so I don't have to think about the feeling I got when that man looked at me. Why doesn't he understand and just go away quietly? I'm doing my best to explain the logic behind my decision, as if logic held any sway over his actions.

How must it have seemed to him? How unfair. How unmerciful.

But I didn't understand a thing about the man in front of me, what drove him to act this way, what demons he was trying to escape. If I did, it would be harder to turn him away, and I had decided I was going to turn him away. When did humans become arbiters of mercy and justice? What gives me, a green as grass junior doctor who knows only the barest of details of this man's life, the right to decide whether he stays in hospital or goes home? Why does my decision automatically overrule his? Does the fact that the hospital institution backs me up suddenly make it ethical to turn these patients away? When did I get to decide that some lives are worth more than others? When did I get to decide that some lives cost too much to save?

We are taught that capacity is decision specific. "Do you understand that staying in hospital will not make you better? Yes. Do you understand that you are depriving another patient of a bed, who will likely benefit from it more? Yes." What do I do then?

We have a duty to protect our patients from harm - and that includes the potential harm that exists as a corollary of choices that other patients make. Choices that are sometimes illogical and selfish. To protect them from negative externalities even if it means placing an embargo on compassion. If we admitted those who were medically fit for discharge, we would have less room for the septic, the fractured, the at risk of exanguinating.

Our job is to care for these people, to give them everything we can afford, to bend over backwards to meet everyone's needs - but it's also our duty to understand that some people don't get better no matter how much you give, and that we can only afford to give so much.

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As doctors, we hone our empathy. Learn to focus it, harness it. Train it to palpate the psychological distress of the person in front of us, identify tender spots and strategically deploy sentiments that will be maximally efficacious / analgesic / palliative. We use empathy to deliver targeted therapy, but sometimes also to profile a patient's mental health, patting down its outline - nothing too invasive. We make sure they aren't carrying any sharp objects, ligature wires, explosive devices. And once we are satisfied they don't pose a risk to themselves or others, we reel in the acumen, holster our empathy somewhere between frontal cortex and amygdala until it's needed again. We don't probe any further or venture deeper. At most, we offer a little squeeze on the shoulder as we withdraw our feelers - a consolatory touch implying the embrace we don't allow ourselves to give. A brief, brusque nod of vulnerability as we retreat to a safe distance.