...Perchance to Dream.

In which I confront a suicidal teen, and consider my own thoughts and feelings toward depression and despair

Like many kids of the boomer TV generation of the nineteen-sixties, my first exposure to the great works of western civilization was by watching Bugs Bunny cartoons. Who hasn’t enjoyed the classics interpreted by Looney Tunes? Whether it was first hearing Rossini’s Barber of Seville, or Bizet’s Carmen, we relied on cartoon characters to be our cultural guides. I remember one cartoon where Daffy Duck played Hamlet in the iconic “To be or not to be” scene, followed by Elmer Fudd’s answering shotgun blast. When the smoke cleared, Daffy’s face was blackened, his frilly collar was opened like burst barrel staves, and his bill was blown backwards. It was hilarious! “Shoot the Duck! Shoot the Duck!”… Cartoon violence and an education! We had it good.

Of course when I was confronted with the consequences of a real life shotgun injury as an anesthesia resident on the trauma ICU rotation at Seattle’s Harborview Hospital, it wasn’t so funny. A teenager in some particularly dark moment in his young life had decided to just end it. He managed to position the barrel of the gun so that it aimed just under his chin, the cold steel pushing into the soft skin below the mandible. I imagined he used his toes to pull the trigger, or he had it rigged somehow that he could fire it with a stick. Needless to say he must have given it some thought - but clearly not enough. When it fired, the shotgun kicked, and he survived the blast of buckshot that blew off his jaw, his tongue, and the entire front of his face, leaving him speechless, sightless and grotesque - his brain, and dark suicidal thoughts intact. I spent the better part of four weeks in a cold and wet Seattle winter on my trauma rotation rounding on that boy in the ICU, and then on the ward. My job as the resident on the service was to gather and report the results of all the daily lab tests in order to track his condition. “What is his blood count today, Dr. Swisher? What is his acid-base status? Are his electrolytes normalizing?” I learned about a condition known as SIADH, or “Syndrome of Inappropriate Antidiuretic Hormone” secretion, that can occur after a concussive blow to the head. Serum levels of the electrolyte sodium go out of whack, and when the level gets too low it can be lethal. 

So I was a meticulous record keeper, and was diligent in following every drop of fluid and electrolyte that went into his veins and later through the feeding tube that snaked down the hole that used to be his nose, into his stomach. I learned a great deal of physiology and medicine from taking care of him and still remember my feelings of pride and competence after replacing an infected central line, or working inches away from him with surgical magnifying loupes, carefully debriding the damaged flesh that used to be his face. I did this every day for a month. To me, it was the ultimate doctor patient relationship. It was practically intimate.

But many years later, when I think back to him lying alone in his dark, gloomy corner room in Harborview hospital in the thick of that cloudy, cold and wet Seattle winter, unbidden and intrusive questions well up from a deep place in my mind. Did anyone know how troubled and alone he felt in the months and days leading up to his attempt to abruptly and messily end his existence? Who were his friends? What was his childhood like? Most importantly, who was he? At the time I had neither the maturity nor the courage to ask these questions myself. It is to my regret and shame that I don’t have a single recollection of actually talking to him about things other than what I was about to do to his body, though I must have. I would like to think I did, and hope I did, but I am not so sure. 

Although he could not speak, he could hear, and certainly was capable of listening. I am most afraid that even if I did try to carry on what would have been a one sided conversation, it wasn’t about anything important, anything relevant. And now, over twenty years later as a father with teenage boys of my own, I have so many questions and so few answers. Why did he feel that life at sixteen was no longer worth living? Did he have any idea what his actions would do to his parents? Was there not a single person in whom he could confide? I will never know what he might have said, and it still haunts me. So I try to squeeze my memory like a dry sponge for clues. I barely remember his mother and I never once saw his father. She was a small, pale, quiet woman who sat in a chair just inside the door to the room but far from the bed of her son, afraid to venture any closer. It was as if he had a disease that she could catch. She hardly spoke, and when she did it was only in reply and then in brief monotone whispers. She didn’t seem sad as much as burdened and defeated. Now she was facing a cruel and uncertain future that held in its grasp a blind, mute and faceless son. How would she care for him, and in what way? I was certainly of no immediate help, and even less use to her in the long term, so I didn’t try.

Being an emotionally helpless resident on a trauma service confronting the problems of the world is hard, but being an isolated teenage boy is much harder. I remember that time in my life all too well. Emotions are intense but lack the substance of experience. The desire to act is strong, but knowing which direction to go is nearly impossible. I have read Hamlet many times now and have it practically memorized.  Like Hamlet, I abruptly lost a father and then watched helplessly as my mother hastily re-married a man I did not trust; whom I also knew did not trust me. As a teenager, I was dark, and moody and like Hamlet full of unrealized thoughts of revenge. After I first read the play in Mrs. Shepard’s high school English class I was struck dumb with self-recognition! I imagined myself confronting my father’s accusatory ghost on the ramparts of my suburban Long Island home, and desperately wanted to believe my stepfather had poured poison into my father’s ear, stealing my mother. I secretly longed for vengeance, but didn’t know how to act. I also suppose like many a depressed teenager, I morbidly fantasized about taking “…arms against a sea of troubles, and by opposing, end them”. But unlike my faceless patient at Harborview, I never would have actually tried.

And so I have become the father now, a man tempered by time and experience. I am no longer filled with rage and passion, but have settled into a comfortable and safe existence. As many a parent who lives in this privileged corner of the world, I carefully watch my sons for signs of depression. When they seem down and alone I really try to talk to them. Sometimes I am successful at getting through, but my fear is that many times I am not, and they regard my counsel as irrelevant. I cannot be like my father, like the absent elder King Hamlet, doomed to walk the night as a pale ghost commanding his son to take up the sword against an uncertain enemy. I am all too real and disappointingly human. I think I am more like Polonius, the foolish and bombastic father of Ophelia and Laertes, dispensing dim advice and watching from behind the curtains as the world and its intrigues unfold. 

Jeffrey L. Swisher, M.D.

Larkspur, California - March, 2012

I originally published this story on my PokitDok blog back in 2012, and I have thought about it many times since, for both personal and professional reasons. This young teenager, attempted to erase himself and his own life and succeeded in quite literally erasing the most prominent part of his physical identity, his face. His attempt led undoubtedly to a markedly different world of pain and suffering for himself and his family. It is not a story with a happy ending. Truth be told, I don’t know how the story ended, or if it even did, as I lost contact with him and his family after the conclusion of my Intensive Care rotation at Harborview Hospital in Seattle. I struggle still to this day, more than thirty years later, with unwelcome but persistent thoughts of guilt over what I did not, or could not do for him and his family.

One of the problems with medical training seldom discussed, is that young physicians are often put into emotionally difficult situations for which they are ill equipped to handle due to their lack of maturity and experience. I often wonder how I would have comported myself differently after having the experience of a long marriage, or of having raised three children to adulthood, or of having been diagnosed with a long term moderately debilitating medical condition of my own. Our perspectives change as we grow older. We watch our children go from babies, to toddlers, to elementary school students absorbing the world like a sponge. They become awkward adolescents, achingly aware that the world isn’t always a kind and magical place. They encounter peer pressure, bullying, and an intense desire to fit in and to be socially accepted. And inexorably, they drift from the comfort and security of home and family, growing more distant and inscrutable. They pass through tempestuous teenage years, finding their own place in the world, and their personalities harden, giving the first solid glimpse of who they will become as adults. They take risks and get knocked down. Hopefully they get up, and learn from their mistakes and misadventures. They discover attraction, attachment, sex and love, while we as parents watch, sometimes helplessly from the sidelines. They frequently make errors in judgment that we see telegraphed from a mile away, and yet we can often do little to stop the occasional emotional or physical carnage. Yet through all this they have moments I can only describe as divinity. They amaze us with their insight, talent and acts of becoming. Every now and then, however, some don’t make it. It seems more and more a modern affliction that younger and younger adolescents see no way out and thoughts of self harm, and even suicide bubble to the surface from some deep well of sadness and despair.

I come from a close family, that was supportive on the one hand, and demanding on the other. My sister, brother and I were always expected to do well academically and in life. There wasn’t a lot of talk about emotions or happiness, or lack thereof. But we were mostly happy despite the devastating loss of our father at a very young age. Despite this, or maybe because of it, we survived and prospered. None of us however, had depression. True depression - the kind that is seemingly impossible to emerge from. I still watch my now adult children very carefully, as my concerns for them have deepened. Their problems are no longer childhood problems, but ones that adults face, hence more complex and capable of leading toward paths of greater darkness and uncertainty.

This has been a hard year for young people at the very genesis of their adult lives. Early careers, and nascent dreams have been upended. Critical socialization has been put on hold. In my children’s case, a Senior Year and college graduation simply vanished like smoke, the idea and promise of it tantalizingly real, yet unfulfilled. My daughter and her friends drifted away from each other at one of the most important times of her life. My middle son’s dreams of returning to a job in Japan after having studied there in college, were also dashed as travel was curtailed. And my eldest son, a world away living in Australia cannot visit home, and we cannot visit him. These problems, I realize, are not unique to me, and I am so thankful we are all healthy and have been spared the greater tragedies of COVID, but there is a sadness I sense in all of us. So, again, feeing more like Polonius or Prufrock, I wait to see what the next year brings, and hope that equal measures of joy and fulfillment are waiting for all of us around the bend.