No Further History

I knocked on Xao’s door. He greeted me in a flat voice, a bespectacled man who looked younger than his 33 years. I tried to picture him as he was in the ER all those years ago: This is a 24-year-old Chinese male University School of Medicine,brought in by the police after he went on a rampage with a meat cleaver.

He is stained in blood and is belligerent and aggressive. . . .

The ER physician had obviously missed his calling as a pulp fiction writer. His note was graphic, the carnage described in vivid detail. It turned out that Xao’s employer sustained deep wounds on his arms and abdomen. He survived, but only after heroic resuscitative efforts—pints of blood, antibiotics, numerous surgeries, and a prolonged hospital stay.

Xao was tried and found NGRI—not guilty by reason of insanity. He then spent 9 years in various psychiatric facilities, before being trans-ferred to this one. In a week, he was to be deported back to China, and it was more out of curiosity than clinical need that I was interviewing him for the first time today.

We talked in a large interview room overlooking the sprawling gar-dens of the facility. He slouched in the manner of a condemned man, shoulders slumped, his straight black hair falling across his eyes. He spoke in accented but reasonably fluent English; from the records, I gathered that he had learned the language entirely during his hospital stay.

His was the typical immigrant story. He came to America, he told me, filled with hope. “I wanted to make money, bring my wife and son here, so we can have better life.” However, things did not go according to plan. He felt isolated and alone, and began feeling depressed.

“Did you have any friends or family here?” I asked.

“I can only talk my language with owner of restaurant, but he shout at me, call me lazy and stupid.” He told me about his first winter in America. “It is dark all time, and my room is cold. I miss home very much. I feel sad, tired. Then, one day, I hear the voices.”

“What were they saying?”

“They say bad things about me, about my boss. They tell me, ‘He give you poison; he do magic to make you weak.’ I hear voices louder, ‘Do something, Xao. Kill him, or he kill you.’ ”

He took off his glasses and rubbed his eyes.

“What happened then?”

“One day, I feel more scared. I think, today he will kill me. So I listen to voices. I take a big knife and when he come to kitchen. . . .”

He trailed off. “I don’t want to talk about this.”

I felt a bit guilty about raking up the past and tried to think of something else to ask him. Maybe he would feel better if we talked about the future.

“How do you feel about going back to China?” I asked.

There was a long pause. “My wife scared; she not talk to me. My son, I not see him since he is 3 years old.” He slumped further in the chair. “I have brought much shame to my family. They not want me to come home.”

I couldn’t think of anything positive to say. I had read his chart, and there was no doubt that he had been depressed and psychotic. I felt bad for him. A serious mental illness is often devastating, but seemed even more so in Xao’s case. He had spent the last 9 years in institutions, and he was now going back home, except it was not home any longer—his son did not know him, his wife did not love him, and in his village, he would always be the crazy man, someone to fear or mock. He had lost his sanity, his family, and his freedom.

Suddenly, I was not so curious anymore. I stood up, signaling the end of the interview. “I hope things get better for you, Xao,” I said feebly and reached out to shake his hand. His grip was light, and I happened to glance down. I hadn’t noticed the scar before. He saw me look at it.

“I try to cut my thumb off,” he said.

“What? When?”

“One night before . . . before I use the knife. . . .”


“The voices tell me, ‘Show you are real man.’ So, one day, I go to my room and chop it.” He held out his thumb. “I tell voices, ‘Only a real man can take so much pain.’ ”

“Did you go to the hospital?” “Yes,” he said. “They stitch it and send me home.”

“Did you tell them you were hearing voices?”

“I told doctor, yes.”

“Are you sure?”


I was shocked. His life had been irrevocably changed when he attacked his employer. Why wasn’t he admitted and treated for his obvious psychosis the previous night?

Xao seemed a bit puzzled at my reaction. It was clear that he did not realize the import of what he had just told me.

“OK, Doctor,” he said. “I will go back to my room and sleep.”

I reviewed the chart again after he left, but there was no mention of a visit to the ER the night before. A delusional memory, perhaps? But his story haunted me the entire day, and so that evening, I went to the hospital to look through the records.

A friendly clerk helped me locate Xao’s records, which were on microfilm. I saw the psychiatrist’s evaluation from the night of the assault. Nothing surprising there— Aggressive, agitated, seems to be actively hallucinating. And then, there it was—an ER note from the night before: A Chinese male, employed as a cook at a local restaurant presents after sustaining a deep laceration to his thumb, nearly severing it at the base.

There were notes from the plastic surgeon who had sewn the thumb back on, and a brief addition: Patient cannot speak English. He speaks only in Chinese. This appears to be a self-inflicted wound, presumably sustained while the patient was using the cleaver to chop vegetables. No further history can be elicited.

I saw Xao one more time before he left the hospital. He gave me a half smile, said hello. I could only look away.

November 24, 2018 | 10:12 am | By Dr Shyam Bhat
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