In the Trauma intensive care unit, tragedy abounds. People wind up here after shooting each other in trivial disputes; they get drunk and smash  their cars and bodies; heart attacks make old men plow Cadillacs into trees; feckless pedestrians get broken by careless cell phone talkers.  We see elite riders trampled by their horses and athletic young acrobats with devastating brain injuries.

The near-suicides are the worst, though. That's Jesse's story.

Jesse is only 24, but he's been in treatment for psychosis for 14 years. This time, for reasons we will not understand, he walked onto a highway hoping to get hit and killed. He did get hit. When he reached the Trauma ICU, there was automobile glass in his lungs. After an urgent bronchoscopy, the respiratory therapist quipped,"His lungs look like a diamond mine!" That much foreign material in the lungs practically mandates a rip-roaring case of pneumonia, so Jesse has a tracheostomy tube and a ventilator pushing air into his beat-up lungs. 

Jesse also broke his foot, bled into his brain, smashed his face and fractured a few ribs. His lip piercing was torn out, leaving a ragged necrotic crater. He stinks. He coughs up foul creamy mucus like rancid  pudding. It drips from his tracheostomy, soiling his cervical collar and skin. He has diarrhea. He flails around in bed, exposing himself. It is impossible to keep Jesse clean, comfortable and modest, but the nurses do our best. Cruelest of all, Jesse is aware of what's happening in spite of the psychosis and the sedatives. Sometimes, a nurse almost wishes there were a hopeless brain injury.

Jesse's older brother came to visit, smelling of alcohol. A pack of cigarettes poked through a hole in the pocket of his grimy flannel shirt.  Fear occupied his face as he silently acknowledged me and his mother. He stood well away from the bed and us, wary of this foreign ICU social protocol. Cautiously, he approached and touched his brother's hand. One of Jesse's wildly waving limbs landed firmly on his torso, and he hurried to leave the room. 

Some of my less senior colleagues blame Jesse's unsophisticated family for his state, certain his sincere mother's cheerful attempts at conversation must signify ignorance. They assume someone's got to be at fault - an explanation that does wrap things up neatly. But I know the story cannot be so pat. I've observed in my 26 years in the ICU that family tragedy can rarely be reduced to a single bad actor.  In the saddest of cases, the tangled chain of causation seems to lead back to one strikingly consistent source: underequipped people doing their best in very bad circumstances. These are families who tread a precarious ledge where their stability is always under threat - then someone makes one accidental misstep, and they all fall down. 

I talk with Jesse's mother as she labors to keep the mood light in spite of this weary cycle: Jesse gets sick - Jesse gets hurt - Jesse winds up in the hospital.  I do not subject her to another telling of this family's history of tribulations. I express my sympathy and point out the good signs: stable blood pressure, normal heart rhythm, normal oxygenation. She smiles.