Case Presentation

Gunshot Wound to Abdomen—Depression/Suicide Attempt

Mary is found to have a Gunshot wound to the right abdomen with suspected liver
laceration. She has used a 22 caliber handgun owned by her husband. A large bore IV is
started, a Foley catheter inserted, NGT inserted, and an initial dose of Azactam I Gm
started. She is then transported to the Operating Room for repair.
Surgical repair is accomplished to the right lobe of the liver. A destructive injury
is noted in the Hepatic Flexure of the colon necessitating a right hemicolectomy with
ileotransverse colostomy.
Hospital course is tenuous with enteral feeding via jejunostomy begun the day
after surgery being tolerated poorly. TPN is started at 50 ml per hour via a right
subclavian triple lumen catheter. Antibiotics are continued. Bowel function returned the
fourth postoperative day. Wound care is being accomplished with sterile wet-dry
dressings for the partially open abdominal wound. Yellow drainage is noted from the
upper border.

Assessment includes the following:

Neuro—Awake and complaining of abdominal pain. States her pain is a 8 on a scale of
1-10.
CV—BP 102/82, HR 110. No S3, S4, gallop, or murmur. Sinus rhythm. Extremities
cool to touch.
Resp—Rate 30/min.
GI—Jejunostomy Tube Feeding at 20 ml per hour. Ileostomy pouch intact. Jackson-
Pratt drains to right lower edge of surgical wound.
GU—Foley draining clear, dark amber urine. Output 30-35 ml/hr. S.G. 1.040, urine
osmolality 1400.
Skin—Abdominal wound covered by a large dressing of abdominal pads over 4 by 4’s
with Montgomery strap lacings.
Psych/Soc—Third hospitalization for suicide attempts. Mother was depressed during her
life. Father buried self in work. Views neither parent as loving and caring. Both are
deceased. Two daughters and one son.
The oldest daughter lives about 200 miles away and has two small children. She
is very supportive but feels like there is little she can do to help her mother (the patient).
The youngest daughter, who had been very close to her mother and lived within a few
blocks of her parents, was recently murdered. The daughter was divorced and raising a 7
year old son. The son came home from school one afternoon and found his mother dead
of strangulation. The murderer was never caught. The father of the child now has
custody and lives out of state.
The son is married to a woman who had two small children by another marriage
and is considerable older than the son. The son and his wife met in a graduate program
and are practicing counselors. Mary and her husband have had to help the son financially
on many occasions.
Mary describes her marriage as “needy.” Her husband works long hours, leaves
the house very early in the morning and when he gets home late in the evening he is tired
and uninterested in her life. She and her husband are members of a church and have been
active in varying amounts from time to time. Her husband sings in the choir and that
makes up most of his social life outside of work.
Mary met and married her husband in college and she never had aspirations for
anything else. She never worked outside the home and had little social life. She felt that
her family came first and devoted all her time to them. She says she doesn’t have
hobbies because she has never been good at anything. She likes to cook but doesn’t do
much of that now that her children are grown and grandchildren seldom visit.
At present, she does not want to live. She believes that she can’t go on without
her daughter. She says her husband will be better off without her. She feels like she is a
burden to him and always has been. She believes God is punishing her because He took
her daughter away. She believes the world is evil and her daughter is better off now that
she is in heaven.
The husband doesn’t understand the wife’s negative feelings. He grieves over the
daughter but says he has “come to grips” with it and is “moving on”. He describes his
wife as the average housewife. He says she was a good mother but always moody. He
saw his wife’s decline after the death of the daughter and got her back in counseling. He
did not realize she was serious about wanting to die even though she has had two major
attempts in the past. He had her hospitalized for 30 days after the death of the daughter
because she was so distraught. She had been suicidal at the time but the treatment team
believed she was not suicidal at the present. She had responded well to treatment and she
wanted to be discharged. She gradually began to loose interest in activities, loose sleep,
and stayed in bed most of the time until she took the gun her husband carried in the car
with him and shot herself in the abdomen. When she did not die right away she called
her husband and told him what she had done. He sent an ambulance and met them at the
hospital.