Hands Intertwined

On this fall Friday afternoon at 4:45pm, many providers in the ambulatory practice of the family medicine residency were beginning to pack up for their weekends. As Dr. Levy walked down the hall to the door, a nurse called her: “There is a patient we might need you for.” During a well-child visit, an adolescent patient had just shared thoughts of suicide.

Dr Rumball was relieved to see Dr Levy. Dr Rumball explained her 13-year-old patient, Niema, had a history of cutting her arms and threatened to end her life only the night before by overdosing with acetaminophen. Dr Rumball had dealt with too many behavioral health crises of late. The pandemic had heralded huge increase of patients seeking help for behavioral health concerns.

The turmoil in Niema’s life predated COVID-19. Niema’s father, the glue that held the family together, had died 2 years earlier. Recently, her emotionally disruptive and violent siblings were removed from the home. Niema, previously an A student, struggled with COVID’s required virtual learning. She missed her teachers and friends and the support they provided.

After Dr Rumball debriefed Dr Levy, the two women greeted the timid young girl sitting on the exam table. Scars can be a roadmap to the severity of trauma. Niema’s arms formed crossroads of the scars, old cuts and fresh wounds of new ones. Peppered with tears wiped by her small hands, Niema tentatively shared about the loss of her father, her chaotic home and her ongoing behavioral health struggles.

With Niema’s permission, Drs Levy and Rumball called Niema’s mother, Joyce, from the waiting room. As she listened to Drs Levy and Rumballs’ concerns about Niema’s suicidiality, Joyce held her daughter’s hand tightly and rubbed her back. Joyce choked back tears when she confessed that she was aware that her daughter was depressed but was unaware of the depth of the despair.

Drs Levy and Rumball decided that a trip to the emergency department for further psychiatric assessment was the necessary and safe next step. With Niema and Joyce, they decided as a team to walk across the street to the hospital rather than calling for the usual security for escort. No one wanted Niema to feel punished for admitting to feelings that were out of her control. The emergency room would be difficult enough.

When the group stepped outside well past clinic closure, the sun was already setting. Dr Rumball instinctively reached out to Niema’s empty hand, the other held by her mother. Niema reciprocated Dr Rumball’s grasp. They walked as their own little, tightly knit community with Dr Levy trailing behind closely. As they entered the hospital, Joyce whispered to Dr Rumball that the last time Niema walked this hallway was to say goodbye to her father who had died in this very hospital. Dr Rumball squeezed Niema’s hand a little tighter. The three women gently ushered Niema on her first step toward recovery. Three strong and different women who had their own pain reached out to this soul to say, “it’s ok to not be ok.” The moment felt right, but 2020 was not done with Niema.

Niema received evaluation by emergency department professionals, but she downplayed her symptoms for fear of admission. Given her revised story and a full behavioral health hospital, Niema was discharged.

One month later Niema attempted suicide by an acetaminophen overdose, the very means she had threatened a month earlier. This time she was admitted to the acute care hospital to receive IV medication to prevent liver damage. Dr Rumball was incredibly disheartened when she learned Niema had been admitted for a suicide attempt. She gathered her strength and said a quick prayer, she visited Niema. Niema, who was dressed in hospital scrubs and watching TV, was happy to see Dr Rumball. She worried about being taken away from her mother, the one person who offered stability in her life. Trust allowed Dr Rumball to assuage Niema’s fears and help overcome her reluctance to obtain inpatient behavioral medicine treatment.

A few months later, Niema was doing better. Not well, but better. Her home situation had not changed. She struggled to be compliant with formal counseling due to what she described as “trust issues.” She didn’t always remember to take her medication, but she never missed an appointment to see Dr Rumball. Together, they found comfort in that.

2020 had been a tough year. The COVID-19 pandemic had exposed and deepened the cracks in the flawed behavioral health system. Dr Levy had begun her new position as the residency’s behavioral health director. As a recent graduate of her own training, she did not feel comfortable in the expert role. Niema’s case only highlighted the complexities guiding residents and patients through the behavioral health maze. System failures seemed like personal failures.

Dr Rumball spent 2020 worrying about the responsibility of caring for severely ill patients, contracting COVID, or bringing it home. She, like other health care workers, had paid the price for pushing these anxieties aside to focus on patients. Dr Rumball relied deeply on her faith that anchored her for the tidal changes of resident life. At different gatherings during the pandemic, bundled in heavy coats and warming hands around a small backyard fire in the middle of winter, Dr Rumball would testify that not being able to feel her toes is a small price to pay for the benefit of support and prayers of close friends.

What will happen to patients and providers without similar support structures? At the family medicine residency clinic all providers must navigate these difficult waters, but with residency graduation on the horizon, Niema helped Dr Rumball deepen her commitment to advocating for those who need support the most.

Throughout 2020, a year marked by upheaval, fear, social isolation, and disease, the importance of behavioral health needs has never been greater. Handholding is not just for patients. It is ok to not be ok. Please ask for help. We can get through this together.