Suicide and Its Victims

The holiday season can bring joy and celebration with family and friends. It can also bring sadness, loneliness, and depression. According to The American Journal of Preventive Medicine, the economic cost of suicide and nonfatal self-harm events averaged $510 billion (2020 USD) annually, and this is only the monetary cost.1 The true cost is far greater. There are two self-inflicted, gun-related suicides that remain embedded in my memory. Both were fatal before the patient arrived in the emergency department (ED). The first occurred during the holiday season and was a man who had shot himself in his abdomen while in his apartment. He was discovered about a day later, and while he was obviously dead, the police called EMS, who felt they needed to attempt resuscitation and transport him to the ED. It was a very emotional event for them. It appeared that he had survived for several hours as documented by additional entries he had made in his suicide note after he shot himself. The second is memorable for a different reason. A man arrived, obviously dead from a gunshot wound to his head. It was a classic suicide, at least in the movies, of discharging a gun in the mouth directed upward toward the hard palate and the brain beyond. He was transported to the ED at the request of the police. There followed an exam that revealed a man who was dead with a gunshot through his palate, but with no exit wound. The police were anxious to document that the bullet was in his brain for reasons that were not at all clear. I was not involved in this case at all, just an observer working a shift in the same ED, so the decision was made by one of my co-workers. A plain X-ray confirmed what was obvious: a bullet went into his mouth, into his brain and didn't come out. The autopsy, required for any deaths by gun, confirmed this as well. It is sometimes difficult to remember the respect all patients deserve. They are not demonstration pieces. Perhaps this was the staff's way of dealing with anxiety and depression at the gruesome death of a fellow human being—the emotions they deal with daily. Not all suicide attempts are successful, but that does not avoid the cost. This next suicide attempt was not initially treated by me, but was a frequent visitor to my ED. He had attempted to end his life by lying on a railroad track in front of an approaching train. As the train approached, he changed his mind and tried to crawl off the tracks, but he moved too slowly and too late. His legs were amputated above the knees. He expressed regret that he hadn't crawled faster or that he had crawled at all, saying either would have been better. I had reason to wonder how the engineer of that train was handling this, in part because of the next patient. This man had succeeded in his attempt by waiting on the side of the interstate and stepping in front of an 18-wheeler. He was killed instantly, and the paramedics didn't bother transporting him to the ED. They did bring in the driver of the truck. He was hysterical, repeatedly telling everyone that there was nothing he could do. He had no injury. He was evaluated, given lorazepam, and then talked to the psychiatric counselor. He finally agreed to be discharged but said he would never drive anything again. A friend picked him up and promised to stay with him for a few days until his outpatient counseling was set up. I never heard anything more about him, but I hope he did well. He was simply caught in another man's solution to an unsolvable problem. The cost of suicide extends beyond the victim. It affects family and friends, many of whom feel that they could have, should have done more. The ripples of the act involve the bystanders, the ED staff, and in fact, all of us. For Whom the Bell Tolls by John Donne No man is an island, Entire of itself. Each is a piece of the continent, A part of the main. If a clod be washed away by the sea, Europe is the less. As well as if a promontory were. As well as if a manor of thine own Or of thine friend's were. Each man's death diminishes me, For I am involved in mankind. Therefore, send not to know For whom the bell tolls, It tolls for thee.2