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How not to commit suicide

© Art Kleiner

This article arose from a conversation among the directors of our foundation, Point. Michael Phillips and I wanted to publish information on how to commit suicide. Hiding such information is a vicious taboo, we opinioned in high libertarian dudgeon. Richard Baker, abbot of the local Zen Center and one who sees a lot of disturbed people, remarked drily, "If the information were generally available, a fellow I talked to last week would be dead now. He wouldn't do it this week I think. The information that people need is how NOT to commit suicide. They think if they take an overdose of sleeping pills they'll just go to sleep and never wake up. Instead they wake up choking on their vomit, and there's the emergency room and stomach pumping and brain damage, and it's the opposite of relief for their suffering. People try all sorts of things that don't work, all horrible."

CQ staffer Art Kleiner got the assignemnt and immersed himself in with his customary zeal. (He wants noted that "four people who have worked with suicidal people helped me articulate the article, even though they weren't directly quoted in it- Mary Deems, Ron Jones, Larry Cohen and Ben Campbell.") Journalist Kleiner also adds, "This article was probably the most rewarding I've ever done, nightmares and all."

How not to commit suicide

Resurrection, the voyage to the land of the dead and back again, is common enough in old legends and in the experiences of people who live through a near-terminal illness or accident. But that journey is also made daily in hospital emergency rooms.

About thirty thousand people kill themselves in the United States each year. An estimated ten to forty times that number try to kill themselves but don't die, either because they don't really want to die or because they don't know how.

I didn't realize the impact of that statistic until I talked to friends and acquaintances while researching this article. Everyone I talked to, whether I interviewed them or casually brought the subject up, knew someone who had attempted suicide.

Some of the stories are tragic. A friend of a friend jumped from a high building and hit a parked car several stories below. She broke most of her bones and punctured several of her inner organs but didn't die. Instead she was wheeled, conscious, to the local emergency room, her most privately conceived act announced to the world by the ambulance siren. She spent the next year in bed, much of it in a hospital ward allocated to critically ill victims of violence, her still-suicidal mind the only functioning part of her body.

This article about what happens to people who attempt to kill themselves started as a brief review of a pair of new publications aimed at the terminally ill. One booklet, the widely-publicized but little-read "death manual", How to Die With Dignity, contains a chart of lethal doses of different types of pills and methods of deliberately ensuring a calm death in a suicide attempt. It was published by Scotlish Exit, the London group that in the past year sought and won more than its share of controversy. Two of the members of the London group are now facing trial on nine charges of aiding people to kill themselves.

The other book, Let Me Die Before I Wake, is a collection of case histories of people who have committed suicide or attempted it and failed, with detailed descriptions of the methods used. It was published this spring by a Los Angeles group called Hemlock, which also counsels terminally ill people on their operations. The book's author, Derek Humphry, is a British journalist who wrote the sentimental Jean's Way, the popular book to describe what Hemlock calls "Self-Deliverance." Humphry's first wife, Jean, discovered she had bone marrow cancer and took a fatal drug overdose as she was on the verge of becoming immobile.

"Perhaps ten percent of our members are terminally ill," Humphry told me. "The great fear of the rest of the members is that they may face a painful, awful death one day. If they can say, 'I have this cache of pills and good advice on how to use them,' they can feel prepared if they eventually do fall ill, and in the meantime can get on with the business of living."

So when I went to emergency room physicians, paramedics, and therapists, I expected to hear of many people who might have needed this information- people who, faced with a grim illness and no alternatives to it, had tried to kill themselves and ended in the emergency room instead. Wrong. People who plan deliberate suicides usually succeed- as Humphrey said, everything in the suicide manuals can also be found in medical textbooks. People in emergency rooms are usually people who attempted suicide on impulse, in temporary despair or anger. Many decide later that it was a mistake.

They are the people whose fate has been thrown into sharper focus by the existence of these new books. The argument between Exit and the British suicide prevention groups played with much commotion in the press and in conversation. The books should not be published, the suicide prevention people said, because temporarily distraught people would use them impulsively and die, where without them they would probably live. Yes, said the voluntary euthanasia groups, but preparing for a rational, planned suicide as the books encourage, and thinking out its ramifications (like who would be affected by it) makes people less likely to kill themselves impulsively. Yes, but the context of the how-to-die information shows suicide as an easy way to solve problems, and doesn't encourage people to look for other options first.

Yes, but the books are only available through the mail, with a three-month waiting period, just to discourage such abuse. Yes, but with easy Xerox access no one can guarantee the books won't find a subterranean following. Yes, but banning the book is equally manipulative- it keeps people from the option of dying easily unless they are lucky enough to find people who will help them. Yes, but they might find people who will help them avoid the pain tomorrow, if they aren't encouraged to end their lives today. Yes, but...

The debate is fascinating to follow because usually talk of suicide is hushed up, for fear it will create more suicides, or someone will be held responsible. Psychologist Davis Gruder worked in a California high school a few years ago when one of the popular seniors killed himself. "In the next two weeks everybody pulled me aside- students, teachers, the principal- to ask me what they could have done, what he meant by it. But nobody said anything out loud to each other. Finally I gave a talk at the library about suicide and suicide prevention, and I had to argue with six levels of school administration to do it. I had to tell them the clinical truth is that talking about suicide often neutralizes it. Ignoring it always paves the way for more attempts."

When a genuine myth rises into consciousness, Ursula LeGuin wrote in "The Language of the Night," the message is always: "You must change your life." Each suicide attempt, I'm convinced, carries that message: to the person who tries it, to the people who are close to that person and to the rest of us as a society. I think what happens after a suicide attempt is a sort of autopsy of what's best and worst about our culture. Here is some of that story.

About suicide

Like the other two hundred suicide prevention telephone hotlines in the U.S., the Marin Suicide Prevention Center holds several eleven-session training classes a year. I sat in one of the introductory sessions. It looked like any suburban adult education class- sixty fidgety people of all ages in chairs too small for them, and two instructors, the Center's Acting Director Noreen Dunnigan and the Program Director David Nolan. After a warning that statistics are misleading, Dunnigan jumped in.

"For every 100,000 people in the United States," she said, "an average of 12.5 attempt suicide each year. At this center we get 1200 calls a month, from 250 clients. Most people call more than once. Wednesday is our busiest day. ("It's the day most therapists take off," Nolan interrupted.) Eighty percent of the people call about themselves; the rest are clergy, friends, family- calling because they're worried about someone. The later the hour, the higher the number of calls. Thirty-four percent of the callers are male, sixty-six percent female. Can anybody guess why?"

"Men aren't as used to reaching out for help," said a man, the only black person in the room.

Dunnigan nodded and went on: "Fifty-four percent of the callers are not in a suicide crisis. Forty-six percent have problems with alcohol or drugs. Thirty-five percent live alone. Once every fifty hours, in what we call active intervention, we send someone in- an ambulance or friends, or clergy, or someone else goes over to their house because we ask them to."

"What do you mean by suicidal crisis?" asked a studious-looking woman. "You don't mean forty-six percent are actually trying suicide?"

David Nolan replied. "No, the fifty-four percent are people who don't mention suicide at all. They have some other problem- loneliness, maybe- and they want someone to talk to. Twenty-six percent have suicidal ideation. They're thinking about it. Thirteen percent are threatening suicide. Six percent are attempting as we talk to them. The rest, we don't know about; the calls are too short or we don't find out."

Noreen Dunnigan gave some statistics from the Marin coroner's office about people who did kill themselves. "The highest rate of suicide is in May. We'll talk about what happens to people in the spring. The second highest is in January, just after the holidays. the older the person the higher the suicide rate. The average age for males is forty-one. The average for females is forty-five."

"That doesn't mean anyone was actually at those specific ages," Nolan said. "There were forty-seven known suicides in Marin in 1980. (There are others we don't know about.) Thirty-four were male. Thirteen were female. Fourteen people shot themselves. All but one of them were male. Six people died from car exhaust. Four jumped off the Golden Gate Bridge. The rest were drug overdoses."

Dunnigan described the established theories about why people commit suicide. Frued, for instance, thought most people have two instinctual drives- the wish to live (Eros) and the wish to die (Thanatos). Karl Menninger said a suicidal person acts out a wish to be killed ("I don't deserve to live"), a wish to kill someone else, or a wish to die. Old people usually fall into the latter category ("I can't go on."). Young people usually wish to die or be killed.

"There is also a need for attention," she said. "A lot of people have worn out their families and friends. The coroner's office tells us that they can usually tell most people don't really want to die. According to their suicide notes, they wanted to be rescued. Anyone here can be suicidal given the right circumstances or the proper amount of stress.

"When someone calls, we assume they are ambivalent, no matter how suicidal they say they are. Otherwise they wouldn't call. For myself I want the right to choose to live or die- for example if I were terminally ill I don't know how I'd choose- but anyone who calls here will have a heck of a battle.

"They let us know there's a glimmer of hope and that's the side we work with. We feel them out- we ask if they are thinking of killing themselves. We try to find alternatives- not giving them our alternatives, but asking them what they did last time they felt this way, getting them to remember when they DIDN'T feel this way."

About half the people in the room were taking notes. A woman in her twenties asked, "What do you say after you ask 'Are you thinking of killing yourself?' and they say 'Yes'?

"Well, often the simplest response is that we don't want them to die. It's not easy. Dealing with suicidal people is usually unrewarding. They're the toughest for therapists, and in fact dealing with them makes some therapists become suicidal." The bearded man in his thirties nodded his head.

A teenage girl with glasses and short-cropped brown hair said, "You say to the person, 'I don't want you to die' and the person says 'Why?' What's your answer?"

"You say, 'I don't want you to die because I care about you.'"

"They go for that?"

"Yes, they do, if you're sincere." She paused. Nobody said anything. The girl looked dubious. "Have you ever cared about anyone who wanted to die and NOT been able to come up with a reason why they should go on living? Usually by the time I' awhile I have a rapport going, and by that time I usually do have a reason that I care about them. A very intimate relationship builds up very quickly on the phone. Some of you may not be able to dredge up any feeling for some of your callers and in that case you shouldn't lie to them. They can spot a phony right away."

The girl still looked unconvinced, but nodded. Someone else asked, "What do you do with your emotions?"

"You talk to fellow counselors, you talk to staff," Noreen Dunnigan said. "You don't let any individual callers get into a personal relationship with you. In fact, any counselor who meets a caller outside of the Center is automatically suspended- not suspended- what's the other word for final?" "Expelled," someone called out.

"Expelled. We don't use the word terminated here."

Laughter. More talk about what to say to people on the phone. "We want to explore their death fantasies and deglamorize them. How do you know there's a life hereafter? Have you known anyone who came back? You won't be able to see your own funeral, and show everyone you were serious. If you overdose you'll probably choke on your own. Your bowels will go. Who's going to find you?

"Get used to saying, 'I want you to flush the pills away now,' instead of saying, 'Would you mind putting the pills away for us?' We want to assert ourselves. We ask, what will your children think when they find you? What kind of example would this be for your children as a way to solve problems? We use all the things we can think of and sometimes they sound manipulative. The ARE manipulative. We want to get the person through the crisis. We want them to take the gun away and put it on a shelf where they can't see it. Or put it out of the house, better yet.

"We find out what has given meaning to their lives. Has it always been this way? What was it like when it was not this way? Sometimes people say they've always felt this way. You say, 'Lets count back and see if that's true.'"

"But isn't that denying what they just said?" someone asked.

"No, you acknowledge their feeling but you want to do a reality test with them. 'It sounds like you've always felt this way but let's talk more about it.'"

"It sounds like you're trying to instill guilt."

"We don't want them to feel any worse than they already do. But often they haven't thought about everything. It's like tunnel vision. Usually it hasn't dawned on them who it will effect or what the long-range effects of their act will be. Once they realize it they often don't want the suicide to happen. They don't want to die; they want the pain to stop. People who are sure about killing themselves rarely call the suicide hotline."

The view from those who help

Telephone crisis hotlines didn't exist until 1958, when two Los Angeles psychologists stumbled across a bulging file of suicide notes in the coroner's office. Intrigued by the lack of research on rescuing or preventing suicides, they made themselves available for emergency consultation to suicide patients. Soon it seemed like daytime hours weren't enough, so they set up a phone where patients could call day and night, and manned it with seven staff members. This was the first telephone crisis hotline of any kind, ever. After a few months, the paid staff couldn't handle the number of calls so the doctors trained volunteers.

By trial and error they worked out the principles that most suicide prevention work is based on now. Find out first how lethal a person's intentions are and defuse their plans as quickly as possible. Don't talk about how much there is to live for; ask callers what their options are. Encourage callers to talk to a different counselor each time they call, so one doesn't get overloaded. Assume that because they called they are asking for help and you have a mandate to save their lives however you can, including tracing the call and sending the police.

Personally, I feel suicide prevention volunteers, like volunteer firemen, are among the most altruistic community heroes we have. Telephone hotlines are probably the readiest and least manipulative valves available for the lonely or depressed. A lot of their value comes from the quality of the people who put in time on them. Most work six to eight hours a week, and the people I've talked to or heard about say they volunteer mainly because they like the other people who work there.

Some volunteers got their start with the drug-trip hotlines of the sixties, and drug and suicide hotlines co-evolved, taking methods, enthusiasm, and staff people from each other. Other hotlines like poison control or sex information developed later from these.

The upper-echelon professional suicidology scene is more like an academic industry. Edward Shneidman and Norman Farberow, those two Los Angeles psychologists who started it all, have thirteen books in print on the subject between them. Most are collections of essays by respectable social scientists. Farberow's latest, "The Many Faces of Suicide" (1980 McGraw-Hill Book Co.), says that sky-diving, intervening in violent crimes, drunk driving, prostitution, gambling and taking risks in general are all suicidal and implies they can be treated psychiatrically.

In suicide prevention much of the training is learning to listen and react to people. You have to ask direct questions, like "What happened next?" instead of trying to smooth over bad feelings. You have to learn to keep someone who sounds apathetic about everything on the phone and dredge up something they can get excited about. You have to find out what's going on on the other end- are the callers drinking? Have they abused a child? Are they calling so they can masturbate while they talk to you?- and you have to without making judgment about any of these things.

The end of the call is supposed to involve a contract. The caller agrees they will call again before they try suicide, or they will set a small goal for themselves, like writing a letter, and do it. Or they'll go for therapy. The exception is the six percent of people who commit suicide before or during the telephone call. They get the police and ambulance sent to their door.

"Someone calls up and says, 'I just took all these pills, and now I don't want to die'- that's easy," David Nolan said. "They're willing to give you their address. One counselor stays on the phone with them, the other calls for the emergency vehicles. It's a code 3- lights and sirens- but we like them to turn them off when they get near the house.

"Other times a caller says, 'I just took fifty Valiums and I'm drinking a quart of vodka and I want to talk to you while I die.' We don't do that. If we think a life is in danger, we take over. Getting them to tell us where they are depends on the skill of the counselor. 'I need to know where you are and I need to know right now. You are dying.' It's extremely eerie when a person is told he is dying.

"If we have to we will hold them on the line and trace the call. In Marin, tracing takes thirty minutes to two hours, so we usually don't do it. Other places, we hear, are faster. Once it's traced, we tell the people that we are sending over an ambulance. (Not every suicide prevention center tells them but it's our policy.) 'You called suicide prevention, we'd say, 'and you're dying, and I'm sending you some help. ' We ask them to turn on the lights and unlock the door. We don't break contact over the phone until the emergency people get there."

Marc Rubin, a paramedic with the San Francisco Department of Public Health, heard I was doing this article and suggested I interview him. Until then it never occurred to me to interview any of the emergency people who are sent to the scene of a suicide. I didn't realize that they are probably more involved with the suicidal person than anyone else. They're the first people who comfort them, the only people who see where they live and what they did to themselves, and they seem to get a more vivid idea of the person's personality than anyone else, until they drop them off at the hospital and never see them again. Rubin talked like he had been storing up feelings for some time. He made me wonder if working in emergencies by nature makes people impassioned and articulate.

"Half my ambulance calls just involve going to a person's house, calming them down, recommending they go to a doctor in the morning. It's a "give me strokes" kind of call. People just want to talk to somebody. If they call emergency and say they're contemplating suicide they are sent the ambulance and the police. If there's violence the police go first- they're paid to risk their lives. Then we take the people to the hospital.

"If you talk to the police and paramedics you find they feel many of these people should be allowed to die. We're bound by our jobs to make them live, but there's a lot of distaste for it. You never know if the suicidal person was distraught or made a rational decision. It's real hard to put a value judgment on it.

"We see a lot of alcoholics, gays, recently divorced or separated people, lonely people. People that I would characterize as emotionally vulnerable. We see them at the height of their vulnerability. We see people who cut their wrists gingerly, knowing that it won't kill them, just to try it and see what it feels like. We see others who are serious about it, actively seeking it out but not sure if they're going to do it until the moment comes. Those are the ones we have to talk to as they're about to jump off a building.

"My last call of the shift last night was a man who shot himself. I got there and saw this girl cool in the doorway: 'I think my father's shot himself. Check downstairs.' His wife said, 'I didn't want him around anymore and he shot himself.' He was a Chilean. In some cultures in a situation like this they don't think the man's a jerk if he takes his life. It's the courageous thing to do.

"I like working on the street. People in emergency rooms get patients for a length of time, but I do my medical things and get them there and then I'm done. My role is medical intervention. I make sure they don't compromise their vital functions. That means checking their airway- listening for the movement of air through the nose and mouth- and their breathing rhythm- are their lungs expanding? And checking the heartbeat- is it fast enough? Is it stopped? If it's off you have to do cardio-pulmonary resuscitation, which involves pressing on the sternum and spine to get the heart going again. A lot of times if someone's lost fluid or if they're in shock we have to replace the fluid or blood intravenously.

"If their suicidal we are always required to take them to the emergency room, If they're conscious, say if we just bandaged their arm, then as a courtesy I'll ask if they'll come to the hospital with us. If they're upset or say no, they'll still have to come, though.

"There are so many scenarios. Most of the time, police, medical people, and firemen are very compassionate, but it's still scary. There are six or eight people in uniforms looking at this scared, vulnerable person. If everything goes well, they might even like giving up responsibility for themselves to the people in uniform. But otherwise, all it might take for them to go off the handle is for someone to make a wisecrack- say if the patient's in drag. Or sometimes people get angry just because you're in a uniform. Then you have to talk them down.

"I stay professional a lot of the time- not cold, but impersonal. Then I move up or down from there to more or less professional in tone. Sometimes I'll talk to the person about why they did it, what their alternatives are. If they're hysterical I try to get them to talk about something they like to do. I'll talk about my own problems, real or contrived.

Society doesn't support its losers. A theme I get repeatedly from suicides is, 'Look at me, I've failed and I don't want to seek help.' There's a lot of embarrassment. I tell them everybody needs help. A lot of people go to psychiatrists- doctors, police, politicians. I try to get them laughing. I don't myself, but I try to get them to.

"I kind of enjoy it. As you know there are realms of thought under a psychedelic that you can't enter any other way. Psychosis is like that and that's why I appreciate it. I've sung things like quasi-Indian chants with people. I find that some policemen do the same. There's often a lesson that a psychotic person is offering me. Not to get too dependent on something- habits, jobs, people, money, family- that has let someone down. Or not to take myself too seriously. I think you have to be somewhat egocentric to attempt suicide. I ask the egocentric ones if the world is really going to care that much.

"There's a lot of voyeurism in it. I find that with a lot of medical people. They'll hear a hot call- a knifing, maybe- and really want to see it. Anytime you have a collection of fire and ambulance equipment, people gather on the street.

"A lot of people don't want to take the responsibility. A friend of mine had a call downtown- a man on a roof twenty stories high. She stayed up there talking to that man. Can you imagine how you'd feel if he said, 'No, no, you're wrong' and jumped off?

"That guy who shot himself in the head last night- I wouldn't feel comfortable trying to resuscitate him. He was warm, but the chances of living were too low. If he had any other signs of life- blood pressure, pulse, respiration- I would have had to do something. It's hard to do heroics to bring someone back to life for a day or two. I had a man a couple of months ago who had been shot in the head and I did resuscitate him. I felt bad that he had the trauma of being slapped in an ambulance. Things like that you have to try to do. You have to try.

"The whole idea of trauma centers is to take people who would die otherwise and bring them back to life. Whether their life is meaningful or not doesn't matter. We go for everybody. You're usually naked when you go in. I can't put it down, but in a way it's barbaric. I wouldn't want to go through it. If I'm that close I'd just as soon let it go."

The medical aftermath of suicide

Until recently, emergency room doctors were people who'd rather be elsewhere. Even now, a lot of emergency room doctors are moonlighting residents or specialists forced by their hospitals' rotating assignments to do occasional "trauma duty." But emergency medicine is becoming a specialty of its own, perhaps because four times as many people per capita visit emergency rooms as did twenty years ago. If someone you know is in danger of dying, call emergency services, not your family doctor, because that's what the emergency room does- keeps people from dying.

The basic principle for keeping suicides from dying is to do as little as possible. Most drug overdosers are left unconscious in a place where they can heal. The more the hospital has to do, the more chance of infection or accident. Drugs, including psychiatric drugs, are avoided, because they might react with drugs the patient already took. Before the 1940s, when Swedish doctors discovered this, about forty-five percent of the barbiturate overdose patients in emergency rooms died from attempts to wake them up with drugs.

Now more than ninety-five percent of people who come into the emergency room on a drug overdose live. Many suffer no more than a day or a week of discomfort in a hospital bed, like a teenager I heard about who tried to kill himself with 100 vitamin tablets. Others compound their problems with severe medical damage that may be permanent or take years to go away.

My information on the medical aftermath of suicide comes from half a dozen interviews with emergency staff people, but two were especially helpful- Larry Bedard, M.D., a former psychiatric resident who now manages the emergency room at Marin General Hospital, San Raphael, and Howard McKinney, Pharm. D., a pharmacologist with the San Francisco Poison Control Center. Like other emergency room staff people I talked to about this article, both these men are among the most thoughtful, direct people I have met.

This is NOT an exhaustive survey; anything less than a medical textbook is bound to be sketchy, misleading in places and oversimplified.

Suicide by drug overdose

Most suicides are drug overdoses, and many drug overdose patients reach the hospital in a coma. The danger in all drug overdoses is that the brain may not get enough oxygen. The airway to the lungs may get blocked off by the patient's vomit, or by the tongue falling back into the throat, or by drug-induced slowdown on the part of the deep brain that controls the rate and depth of breathing. Or the heart may seize and fibrillate- all the heart muscle fibers quiver, but none in rhythm to each other. The blood doesn't move, so it doesn't take oxygen to the brain or carry away waste.

It only takes three to five minutes without oxygen to do permanent damage to the brain, starting at its most sophisticated sections. The memory is destroyed; the ability to read or speak is cut back. The longer it goes on, the more severe the retardation. So any poisoned patient is constantly monitored to make sure they can breathe and their heart is beating. If they can't breathe, they are intubated. A physician slides a tube down their mouth or nose, into their lungs for air to pass through.

Drug overdose patients are usually given sugar (in case they have low blood sugar), thiamine (which might have been depleted from the blood by alcohol) and Narcan, an antidote for opiates. They're given because the deficiencies or drug effects they correct are hard to spot right away and can be quickly lethal. Compared to the very few other antidotes that exist, these are considered low-risk. Patients are often given Ipecac, which makes them vomit. Then they are given activated charcoal, which looks like gruel and soaks up some of the poison in the intestines before coming out in diarrhea induced by a cathartic, magnesium citrate. The cathartic also increases the rapidity with which the poison goes through the intestines, thus cutting down the amount absorbed by the body.

If the patient is in a coma a tube may be run through the nose or mouth and passed bit by bit down the esophagus into the stomach. A saline solution flows through it into the stomach, and then is sucked back through the tube with some of the poison. Emergency room staff call this "lavage"; on the street it's known as getting your stomach pumped.

"If you come in awake and alert you should not have your insides washed out," Bedard said. "But some doctors and nurses don't like to take care of overdoses. They feel like suicidal people should be punished, so they stick a tube down. It's not pleasant- the tube is about the size of your thumb. Most people feel like they're choking to death."

The two most common types of drugs in suicides, McKinney said, are those found around the house and those used in psychotherapy. Seemingly innocent aspirin is "one of the messiest, most complicated overdoses you ever hope to see," he said. People who swallow lots of aspirin react first by getting sick to their stomachs. Beyond that it affects nearly every system in the body unpredictably, and two different people who took 100 aspirins could get sick in completely different ways. Aspirin is an acid. It burns the gastrointestinal tract from the inside. It changes the blood's pH level, which is normally 7.4 (close to neutral). It sometimes makes the blood acidic, but it also accelerates the brain's breathing control center, which puffs out carbon dioxide twice as fast as it normally would, and thus makes the blood alkaline. EIther way, it throws off the metabolic balance among kidney, lung and blood. "It produces fever," McKinney said. "The fever, in turn, if it goes on long enough to overheat the brain, can cause seizures. You can burn out parts of your nervous system." Aspirin also carries a high risk of gastric hemorrhage. Occasionally people on aspirin overdoses become deaf or develop a ringing in their ears that doesn't go away.

The pain reliever Acetaminophen, sold as Tylenol, also makes people sick to their stomachs at first, but then it gets more deadly. The drug changes into toxic particles that are usually neutralized by glutathione, one type of coenzyme found in the liver. In overdose, if it isn't pumped out in time, the toxic particles deplete all the glutathione, causing the painful death of an hepatic coma. Even relatively late in the process surrogate glutathione can save the liver, but if the organ does become diseased the results can be similar to those of hepatitis: jaundice, itchy skin, depression, long-term listlessness, inability to eat much.

"The liver detoxifies poisons that build up in the body," McKinney said. "If you destroy the liver it's like never taking the garbage out. Specifically the most common buildup is ammonia in the blood, which you know if it goes too far will put you in a very deep coma, and then kill you."

Both McKinney and Bedard told me about people who took Tylenol or phosphorus, which also destroys the liver (and incidentally produces phosphorus vomit). In both cases, they slept off the initial sickness, and recovered for five days- during which time they decided suicide was a mistake after all, and they wanted to live. But the liver had been destroyed, and after five days each of them started to feel very sick, passed into deep coma and died. "He knew it would happen, and there was nothing we could do about it," Bedard said, "and his friends and family knew it, and for five days they sat in the hospital together waiting for it."

Probably the most painful form of suicide attempt, whether or not it ends in death, is swallowing lye, Drano, oven cleaner, and other household caustics. Most of us know how painful these are because scare stories have been passed down on household lore from 100 years ago, when caustics were the preferred suicide method. Unlike suicides today, who visualize themselves slipping into oblivion, people who killed themselves in the nineteenth century expected to suffer along the way.

"Very few people that ingest caustics die," McKinney said. "If they do die, it's days, weeks or even months later, of infection. I'm pretty immune to most gore but I draw the line at the burn unit." Caustics scar the mouth and tongue, puncture holes in the esophagus, burn the chest from the inside and block the gastrointestinal tract with scar tissue. Even the process of treating the inner burns is painful; surgeons drop an endoscope, or fiber-optic camera, down the person's throat, unavoidably scraping against the raw nerves there, to see what the damage is. Repairing an inner burn can take fifteen to twenty years worth of surgical operations plus fluid therapy and antibiotics to keep infections from growing. Swallowing can be painful for the rest of the person's life, and survivors of such attempts have to be fed intravenously for years afterwards.

Psychiatric drugs- phenothiazines like Thorazine or Haldol, tricyclic antidepressants like Elavil- cause what are probably the most morally offensive overdose cases. "It's a built-in irony," McKinney said. "The very population of patients currently under therapy to supposedly avoid suicide are often handed enormous quantities of medication. You might as well give the guy a gun. Except for child abuse, nothing outrages the emergency room staff as much as when someone comes in with an overdose on Thorazine and you go through their pockets and see the same doctor has prescribed three or four hundred tablets in a two-week period. Those are the doctors who get a phone call at three am saying, "You better get down here now and see your patient." (Hardly ever does the psychiatrist show up, McKinney and other doctors told me; it's more common for the answering service to find out who's calling and why and then say the psychiatrist is out of town.)

Tricyclic antidepressants patients are in a particular high-risk situation," McKinney said. "Typically a person is depressed over a long time; he goes to a psychiatrist and after some psych workshop procedures it's decided he needs an antidepressant. Classically, Elavil is prescribed. Elavil takes three to eight weeks to work and an average of four weeks. The person may not be told clearly enough or may not want to hear that the drug takes a long time. Two weeks later he bolts upright and says, "This is the biggest crock of shit,' and swallows the rest of them."

The phenothiazines, or major tranquilizers. are used to calm down psychosis or extreme anxiety. The tricyclic antidepressants are chemical mood elevators. Both work by somehow altering the minute bursts of chemicals which neurons send across the synapses, or gaps between nerves, to carry impulses from one nerve to another.

Because they affect the nervous system which in turn reacts with every other system in the body, psychiatric drugs have lots of side-effects- dilated pupils, dry mouth, feverishness, speeded-up heartrate, slowed-down digestive muscles, breakdowns in coordination, rolling eyes. Overdose can accelerate these in any part of the body. I once met a man whose hand muscles had contracted violently after a phenothiazine overdose, leaving his fingers permanently warped. Tardive dyskinesia, a Parkinson's Disease-like condition caused in some patients by long-term use of the drugs, can be accelerated by an overdose. Probably the most common permanent damage from overdose is brain damage, caused by seizures and fibrillation.

The exotic drugs of mystery novels, strychnine and cyanide, are painful and deadly but rarely show up in emergency rooms. What shows up all the time are sleeping pills and mood pills- the sedative hypnotics- barbiturates like Seconal, mild tranquilizer like Valium. Typically, a sedative overdose will do nothing more than put you to sleep for a day or two and leave you with a bad hangover and a case of the slows when you wake up. But like many other overdoses, sedatives are often taken with alcohol, which makes people nauseous. Anyone who vomits when they're passed out risks sucking some of the vomit into their lungs, which is called aspiration.

It's as dangerous as it sounds disgusting. Vomit contains enzymes from the stomach that destroy tissue, and those go to work on the lung walls. It also contains a rich broth of food, perfect for pneumonia bugs to grow in. People can also drown in vomit; which keeps air from getting to the brain, which once again causes brain damage. An aspirating patient goes into intensive care; a device called a bronchoscope is used to look into their lungs and pull out whatever pieces of vomit it can.

Drug overdoses are always unpredictable. The drugs react with other drugs people take at the time, with alcohol, with odd allergies, and drugs lying around the bloodstream from years before. "One fellow took four cold tablets," McKinney said, "and went to an emergency room complaining of a headache. He blew the blood vessels behind one of his eyes out."

Violent suicide

Violent death is so often portrayed as sudden and painless, but the human body is harder to kill than it seems. For instance, people rarely die from slashing their wrists. "Most people who try it aren't really suicidal." Bedard said. "Usually it's a cry for help. A few want to see what it feels like to cut themselves. We just sew them up and call a psychiatrist." Even if you cut your artery, which most people don't, it's hard to bleed to death because the bleeding stops on its own unless the cut is extremely severe. Popular wisdom says sitting in hot water makes you bleed faster, but Bedard said he's known people who tried it, passed out, and woke up in a bathtub full of cold, bloody water.

"But it's an easy way to hurt yourself," he said. "You can damage the tendons and median nerve which control the muscles of your hand. People end up with claw hands. Lots of times, with microsurgery, that can be repaired, but it means six to twelve months of your life, and you still end up with a weak or deformed hand."

The few people who cut their throats also rarely die. "They often cut the recurrent laryngeal nerve," Bedard said, "the nerve that goes up to the voicebox and larynx, and lose their voices. Or they cut themselves and bleed beneath the surface until they choke on a buildup of blood inside the trachea."

Bedard said most suicide shootings he's seen were hostile, done while someone else was around to react to it. Interestingly, you can shoot yourself in the head and miss the brain but merely blow out an eye or part of your jaw. If you die, the death is usually drawn-out and painful.

"People can live eight hours with a hole in their head the size of a half dollar," Bedard said. "If you shoot yourself in the temple, the primitive parts of your brain that control breathing will go on for a long time, from minutes to hours. Or they may not be shut off at all. One man I treated was partially paralyzed on his left side, and can't speak, walk, or feed himself. It's as if he had a major stroke. He hit the part of the brain that controls motor function."

Jumps and hanging, again from Bedard: "I'm amazed at how far you can fall after a jump and not kill yourself. Some people have fallen 150 feet and lived. They'll break many of their bones, or rupture an organ like the spleen. Many people who try to hang themselves don't fall far enough to jerk their neck back and snap their airway. They strangle themselves instead, and don't always die; they get brain damage from lack of oxygen." People who try to poison themselves with gas or carbon dioxide may also get brain damage for the same reason.

And finally, just falling into a coma can lead to permanent damage. "If you're slumped on a table, leaning on your arm for a day and a half," Bedard said, "you put pressure other armpit. You can permanently damage the nerve there and make it hard to use your arm. Or your muscle might start to dissolve into your bloodstream and clog up your kidneys. The muscle damage probably eventually returns to normal."

The psychiological aftermath of a suicide attempt

These clinical generalizations make suicidal people seem like statistical cyphers who made a mistake and suffered the immediate, appropriate retribution. But it doesn't feel like that at the time. Whether or not you're glad you were rescued, recovering from a suicide attempt is like being in the emergency room for another reason. The flash that brought you there was over in a moment.. The waiting, being embarrassed, wondering what will happen next, and bearing sharp or dull pain go on for hours.

How, according to people who work with them, do suicide attempters feel when they wake up in the hospital? Glad they were saved. Convinced that suicide was a mistake. Angry they were saved. Angry at the friend or neighbor who betrayed them by calling emergency. Eager to get out of the hospital so they can try it again. Embarassed. Relieved. Happy to be taken care of. Eager to start taking care of themselves again. Unwilling to think about it. Wondering what everyone else they know thinks about it. Wondering if the person they were trying to reach will finally pay attention to them.

"A lot of what I hear in the emergency room is hostility toward a specific person," Dr. Bedard said. :"Once they know they're not going to die, they go out of their way to talk to me about it. 'I'll show that son of a bitch. He didn't think I had the guts to do it.' A lot of these people fantasize about seeing themselves at the funeral. 'The whole world's going to be upset.'"

There are people who get ignored repeatedly until they attempt suicide. One woman I heard about tried to kill herself six times in one year. "My husband says he's too busy if I ask him to take me to dinner," she told the emergency room staff. "But for this he makes time."

If it isn't the attention of a particular person, it might be the emergency room staff. Sadly, many people can only get a lot of paid professional people to notice them by threatening their own life. "A lot of people we see are repeaters," Bedard said. "They might come in twenty times in five years. To them it's a game. 'Either you take Ipecac and vomit or we'll have to do gastric lavage,' well say. 'You know and I know it'll hurt, so why don't you take the Ipecac?' Sometimes you see the same person so often it's like visiting an old friend."

Other people take a pill overdose not to risk their lives, but to find a place where they can be taken care of and forget their problems for a little while. "People want time out," said Temple University psychiatry professor Michael Simpson, who ran the emergency psychiatric service at Guy's Hospital in London.

"That's why sometimes they'll see psychiatric support but leave in a day or two. They used to be able to do it more freely in the drug culture by finding a crashpad. Now the medical model is one of the few excuses for going away and lying around and having people take care of you that is seen as a valid reason to leave work. Maybe we need other ways to legitimize that."

People who attempt suicide are almost never arrested, but they lose their right to decide what happens to them. In every state, being a possible danger to yourself, in the opinion of the psychiatrist who interviews you, is cause for being held for psychiatric care for a limited period of time. In California, the period of time is three days; it can be followed, with an application to the judge, by a fourteen-day period and after that another fourteen-day period. Beyond that, the regular rules for entering a mental hospital voluntarily or being committed apply. Clearly, how you act at the initial interview with a psychiatrist has a lot to do with how long you stay under psychiatric care. So does the attitude of the psychiatrist who examines you and the availability of good or bad psychiatric facilities in your area.

Rarely are patients held longer than three days for psychiatric reasons. In fact, some hospitals send more than half of the suicidal patients home as soon as they can go. Some patients are routed to state or private psychiatric hospitals; some go to local board-and-care homes or halfway houses or outpatient clinics or nowhere at all. "The only generalization you can make," said Ed Hamell, a senior psychiatric specialist at a private psychiatric hospital in Washington D.C., "is that people who find themselves in hospitals following suicide attempts will be treated as not able to be responsible for their own safety."

Howard Blackstone, the clinical director of the Marin County mental health crisis unit, told me some of the things that happen in the initial psychiatric interview. "We're trying to find out what happened. Was it well thought out or was it impulsive? What kinds of problems led up to that point? What state were they in when they tried to do it? How likely are they to try it again? Oftentimes someone will come in upset, but after a day or two hold they will they wake and say, 'Why the hell did I do that?' If we believe that someone is still perturbed and still ruminating about how to kill themselves, we are required to hold onto them. We evaluate reasons less than state of mind. The purpose of what we're doing is to help someone out of a state of mind where they may do something not in their best interest."

Beyond that, I can't generalize about the psychiatric consequences of suicide. There are too many possibilities, they differ too much from place to place, and the patient has too little control over where he or she ends up. In many psychiatric institutions (and other social welfare institutions, like nursing homes) suicide is a sensitive issue, because a funding agency may investigate an institution if a suicide happens within its walls. Or a psychiatrist may be held responsible for a suicide if it can be proved he knew about it beforehand and didn't act reasonably to prevent it. Here as elsewhere, the main priority is keeping the person alive.

That may be changing. "There are a growing number of people in the psychiatric community, " David Grudrt said, "who feel privately that their patients, regardless of the law, have the right to decide whether or not to take their own life. Under certain circumstances, there are psychiatrists who won't prevent some of their patients from killing themselves. But you can't talk about this out loud too often, because it's illegal and could also be grounds for disbarment." He said an influential book on this subject is "Back to One" by Sheldon Kopp.

The ethics of suicide

If you believe, as I did starting this article, that each of us has a right to commit suicide and potentially valid reasons for doing so which should be respected, you might think there's something gruesome about a system which automatically acts to preserve life, whether the person wants it or not. There's an apocryphal story told in every emergency room: someone comes in for the thirtieth or fortieth time on a suicide attempt and a doctor finally explodes and says, "Look, why don't you try it THIS way," and the patient does next time and dies. Every professional I talked to- doctor, paramedic, suicide prevention counselor, therapist, pharmacologist, nurse- said there have been people who made them think, 'you're right. You have nothing to live for.' But the attempt to save someone's life is always made. As Dr. Richard Fein, who directs outpatient services at San Francisco General Hospital, said, to decide when someone's life is worth living in an emergency is gross arrogance.

There are people who think suicide can be a method of natural selection in an overcrowded world. Suicides in prison are not often saved, I was told by several people; the same is true sometimes in cities, for the indigent suicide, the alcoholic suicide, the aged or non-white suicide. Nobody wants them; they finally succumb to the obvious. Aren't there people who ought to be killing themselves but are not?

Brr. I'm on the side of saving lives automatically. I liked what Stuart Bair, who counsels many of the desperate and penniless suicide attempters at San Francisco General Hospital, said: "I believe in miracles. I think there's always a reason to hope someone's life will improve." And I like what psychiatrist Michael Simpson said about the terminally ill that groups like Exit and Hemlock are trying to reach: "Those who work with terminal patients, like people in hospices, say there are very few requests for suicide. People want to be relived of pain, which we could do for nearly everyone if we were given good hospice and palliative care. We need to be sure we've guaranteed mercy living before we get around to mercy killing."

Anyway, I suspect suicidal people are automatically rescued not for their own sakes, but for the rest of us. A suicide death, unless it is rationally prepared for, devastates. The message of a suicide attempt is often: Death is better than the pain you've caused me. And the message doesn't have to come from someone you know. David Gruder, who directed crisis hotlines, told me about a woman who called up and raved, "I've had it. I'm pissed off. I'm killing myself and damned if I'm not going to take someone else with me and you, you bastard, are coming." BANG! She shot herself. And, as it happened, it was the hotline worker's first call. She went right into a nervous breakdown.

But I believe the main reason a suicide attempt devastates and fascinates us is it reminds us how fragile our hold on life is. "Here I am struggling with my own problems," Michael Simpson said, "and here's this guy who's given up. Is it possible I'm wrong in bothering so hard to try to live? Once you start discussing suicide you're asking what the grounds are for killing ourselves. The other side of that question is, 'What am I living for?" That's an ugly question for most of us because we don't usually know."

How to prevent a suicide

If someone you know is thinking suicide, or you think they are, and you don't want them to die, tell them, "Please call me or call suicide prevention before you try anything because I care about you and I don't want you to die." Don't argue with them about why life is worth living, because you can't win that one in a rational argument. Tell them how you and other people will feel when they're gone. If there are mental health services you trust in your neighborhood, you may want to suggest them.

If you are scared you may commit suicide, and sometimes you want to, there may be more options than you realize. A good guide to whatever mental health services are around and how to find them is "You Are Not Alone". It's worth looking around to see if there's a friend, family member, or neighbor that you can talk to about it. Even if, like me, you distrust mental health services, it's probably worth calling suicide prevention. They're listed under that name in the phone book white pages.

If you want to make someone pay attention to you through a suicide attempt, you might consider leaving a note for that person and checking into an emergency room and telling them you're suicidal. You'll go through the same psychiatric hold. but without the damage to your body. Choose your emergency room carefully. Some, like Herrick Hospital in Berkeley, often have eight- or ten-hour waits for noncritical patients, in dismal surroundings that will probably make you feel worse.

Or, have you considered changing your life?

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