Quiet Moments

During one of my last days as a fourth-year medical student, I was asked to suture a laceration on a patient's forearm. I would normally have been delighted for the opportunity to improve my suturing technique, but the more I learned about the patient, the less enthusiastic I became at the prospect of approaching him with anything sharp. He was a prisoner, brought to the hospital by corrections officers after obeying voices in his head that instructed him to swallow three razors and slash both forearms (deeply enough, as it turned out, to cause arterial damage and significant blood loss). He had a history of psychiatric problems, had attempted suicide many times, and readily admitted to hearing voices that told him to hurt himself—and yes, other people, too, but only sometimes.

I was happy to see a corrections officer stationed by the door to his room. I walked in, introduced myself, and began setting up the suture supplies. Going about my business, I noticed out of the corner of my eye that the patient was shooting me a look of theatrical suspicion. I looked back at him squarely, trying not to betray my uneasiness. The guard kept to his station, watching both of us with raised eyebrows as though entertained.

The patient licked his lips, then asked, "Do you know how to ride a bike?"

I was caught off-guard; I answered that I did.

He waited a moment, and then he broke into a smile, explaining as though it were obvious, "I just wanted to make sure you're good at something that, you know, requires some coordination. Before you get those needles up in my arm." And with that, both the patient and the corrections officer burst into giggles.

I smiled. The patient had done for me what I was supposed to do for him: set me at ease in an edgy situation, let me know everything was going to go smoothly.

I went about my work, grateful to him for his oblique reassurance, and he watched quietly, occasionally asking me questions about what I was doing, joking lightly or commiserating with his guard about how hard it was for honest, hard-working men like them to get a date. When I finished and was bandaging him up, he looked at me seriously and broke out in rhythmic verse: "Death has gotta be easy, 'cause livin' be so hard." I stopped what I was doing. "It'll fill you with heartbreak, leave you damaged and scarred."

"Is that slam poetry?" I asked.

He looked at me with sympathy and amusement. "It's called rap," he said gently.

He stopped me on my way out, wondering if he could have some pain medicine stronger than the ibuprofen he had already received. Both arms hurt from the cuts, he explained, and also from all of the squeezing and pinching that had been required to stop the bleeding. I sympathized with him and promised him I would let the attending know. But when I relayed his request, her response was swift and certain: "I'm not giving him pain meds—he did this to himself!" Then, she asked protectively, "Is he giving you trouble? Let me talk to him." Before I could set the record straight, she was off, shaking her head and reminding her surroundings as she walked away, "He did this to himself."

I do not know what the right answer was in this case. Most patients with lacerations—even deep ones—do not require narcotic pain medications. Certainly, precautions have to be taken against prescription drug abuse. Then again, most patients with lacerations have not just made attempts on their own lives and do not rap about the sweet relief of death. I cannot begin to imagine the pain this man was in. My inclination was to give him a stronger pain medication, but I may have been blinded by his warm demeanor and good nature to an obvious attempt to scam me for narcotics. The attending may have been right to deny him a prescription, but for me, the fact that his pain was self-inflicted remains an...