Netflix Suspense Movie Clinical: Treatment of the Suicidal Patient

Proper Treatment of a Suicidal Patient. 

clinical-netflixNetflix recently released a psychological suspense (perhaps some would call it horror) movie called Clinical. It surrounds the story of psychiatrist Dr. Jane Mathis who is an expert in dealing with PTSD. She is recovering from her own traumatic experience, a patient attempting suicide in front of her, and has vowed to not care for these types of patients until her own issues are resolved. However, the work of regular psychiatric problems doesn’t seem fulfilling enough so she takes on the case of a facial transplant patient named Alex.

In one particular scene, Alex calls Jane and states he “took too many pills”. I don’t know how this could be viewed other than a suicide attempt. Instead of calling 911, she goes to his home. Once there, Alex is first scene barely conscious, but is evidently able to stand up and answer the door. From that point on, the conversation goes something like this:

Alex: “Did you call an ambulance?”

Jane: “What did you take? If you don’t tell me, I’m going to have to call 911.”

Alex eventually becomes unconscious. Jane then administers a drug via IM injection. In the next scene, Alex is vomiting.

Jane is holding a prescription bottle in her hand. “How many of these pills did you take?”

Alex: “I just wanted to sleep for a while. What did you give me?”

Jane: “It’s called naloxone. I only use it for emergencies.”

Just. Awesome.

Issue One: I can’t imagine how many ethical and legal lines it crosses that this psychiatrist did not have this patient involuntarily committed to the hospital under an M-1 hold when he clearly tried to commit suicide. I’ve seen M-1 holds placed on patients for far less than an actual attempt.  Clearly, this is a big medical no-no and really doesn’t do the patient any favors. Just because the patient’s worried financially about an ambulance ride doesn’t mean he doesn’t get one.

Issue Two: Let’s discuss the medical drug naloxone or Narcan. This is a reversal medicine for drugs that contain opiates. This would include drugs like morphine and heroine. It’s not clear what drug Alex took— all he says is sleeping pills. To me, sleeping pills would more than likely contain some kind of benzodiazepine, of which there is no reversal a doctor would personally carry, though one is available in the hospital setting.

Issue Three: The scene where the patient is vomiting after the Narcan is administered. I’m not sure if the writers are portraying that the drug induces vomiting so that the patient throws up the pills. If so, that’s not medically accurate. Narcan reverses the effects of opiates at the receptor level. It immediately brings the patient out of their high and they’re usually not very happy about that. Most often, we don’t want to fully reverse the drug as this can put a patient at risk for seizures so we may titrate the dose just to reverse the diminished (or lack of) breathing induced by taking too much of the drug.

I actually think it’s okay the doctor did these things if it would have been pointed out by her mentoring/treating psychiatrist that she acted inappropriately and he was going to report her to the Board of Healing Arts because of her actions.

That would have ramped up the tension/conflict on many levels.

Author Question: Management of Unusual Patients

Amy Asks:


I hope you can address this. Or, if not, point me at a resource that can. I am writing a short horror story in which a patient complains about not being able to get clean. She washes and then within an hour, she’s dirty again. And if she doesn’t wash, the dirt just accumulates. She’s a magnet for dirt. The patient is not complaining of Morgellons and has no history of drug abuse. Neither does she have a history of (or current problems with) OCD behavior.

My assumption is that the doctor would review proper hygiene with herand then find a tactful way to make a referral to a psychiatrist or psychologist. Is that correct?

What questions would the doctor ask? What language would she use when documenting this meeting? And what would she do when more patients start presenting with the same complaint?

In my story, the complaint becomes a pandemic. With this illness, it’s always possible to wash away the dirt, you just can’t keep it away. What are the long-term health consequences of not being able to remain clean? I know that it will increase the possibility of local infections but can you become ill from simply being dirty? (This hypothetical illness would only attract dirt, not pests. But would being dirty make it easier to attract and harbor fleas, ticks and lice?)

Thank you for any help you may be able to provide me!


Jordyn Says:

Wow, Amy. This is a very intriguing question.

I’ll have to take it from an ER nurse’s standpoint. A patient who presents with a complaint of dirt accumulation despite showering definitely raises some eyebrows. If the patient is not expressing wanting to kill themselves or others—then there’s no immediate need to involve psychiatric services. The doctor may say something akin to, “I don’t think this has a medical cause. I think it might be best to follow-up with your regular physician for a referral to a mental health professional.”

Mental health evaluations are rarely done in the ED by an ER physician. These services are likely contracted out or handled by someone else other than the ER physician. You may have heard this phrase about ER docs, “Knowledge of all. Master of none.”—Meaning they have a significant knowledge base but are not specialists. Their job entails identifying a true medical emergency and managing that—so in absence of that, they’ll refer on.

I would say localized infection from open wounds is the biggest risk. As far as attracting other pests—what kind of environment do they live in? Just because you have extra dirt on you doesn’t mean you’ll have lice, etc.


I also ran you question by friend, author and ER physician Braxton DeGarmo.

Braxton says:

I cannot think of a single scientific way that someone could become a dirt “magnet.” As such, the idea of a pandemic in which people can’t keep clean would very much require some sort of fringe science explanation and to pull the plot off you’d have to build that idea in bits and pieces to make it believable—much like Crichton did for re-building ancient DNA from amber to clone dinosaurs.

Now, as a psychiatric condition, this is very plausible. I’ve taken care of people who thought they were shrinking and that snakes were under their skin. All of these were manifestations of a psychotic break. So, yes, a tactful referral to psych would be warranted. It would be easier to come up with something that causes such a psych pandemic than one where people keep attracting dirt and grime.

The problem, though, is that everyone’s psychotic break would be different. So, again, you’d have to build some case where they all share OCD or the opposite, an attraction to dirt to where they purposefully seek to get dirty. Both scenarios will require some work to build scientifically plausible causes.

Perhaps, there could be an illness that leads to a specific deficiency and the dirt they instinctively “collect” somehow fills this need and is absorbed through the skin. To the casual observer, they just look dirty, but a closer look finds common mineral “X” or whatever, within everyone’s grime. And it’s the only common factor, thus leading the protagonist or someone to figure it out.


Most folks have heard of people with certain deficiencies sharing a common trait, such as pica to fill an iron deficiency. So, this might be an easier way to build plausibility.
 


As for the specific questions, yes, local skin infections might become more of a problem, but not necessarily any systemic issues. Likewise, with fleas and such. Degree of skin cleanliness has nothing really to do with such infestations. 

Best of luck with this novel! Very intriguing idea. 


Pediatric Psychiatric Issues: The M-1 Hold

As many readers of this blog know, I’m a pediatric ER nurse. What that means is that I just don’t take care of newborns and toddlers but also teens and young adults up to the age of twenty-one.

Particularly, in the last five years or so, I’ve helped care for an increasing number of patients that have been placed on M-1 holds. An M-1 hold (it may go by other names in your area) is essentially a mental health hold or involuntary placement into the hospital for a mental health evaluation.

In our hospital system, there’s not a required length of stay but it does mean that, essentially, we take over custody of your child until this evaluation takes place. That means that you as the parent cannot take your kid from our facility and we can transfer them where they need to go without your consent.

Your child can be placed on an M-1 hold by two parties– either law enforcement or a physician. Sometimes kids come in via police already on an M-1 hold.

A patient is usually placed on a hold for expressing thoughts of wanting to hurt themselves or others by making these statements to either a parent, school counselor, mental health counselor, physician or law enforcement officer.

When a patient makes these statements or requires medical treatment for self-harming (cutting too deep that the cut requires sutures) or outright suicide attempt (like drug overdoses) then they’re placed on an M-1 Hold. Emergent or stabilizing medical treatment is always handled first.

When a patient is placed on an M-1 hold, the medical staff must provide for the patient’s safety.

We have them change into scrubs of a particular color and confiscate all their clothes. This means everything but their underwear (excluding bras– yes, they must remove those as well) and perhaps socks. Part of the reason for this is to keep them from fleeing (by taking their shoes) and also as a security measure so staff know that a person leaving the facility in those scrubs needs to be stopped. They also cannot wear hair bands, necklaces, or bracelets. All piercings need to be removed.

They are placed in a “safe room” which, at our hospital, is not the “rubber room” you might imagine but it is devoid of basically everything but the bed and a chair. No cords. No monitor. No alcohol hand gel.

The patient is asked to provide a urine sample. Girls are tested for pregnancy above the age of twelve. All are tested for drugs. If they give a concerning history for possible ingestion– blood tests may be added to test for aspirin and acetaminophen which can be deadly overdoses.

The patient is then scanned for metal using a wand-type device that you see at airports.

At all times, the patient is under one-on-one observation by someone on our staff even if they have a parent present.

After that, the physician will have a talk with the patient alone, the parents alone and then both parties together if the patient agrees. After that, the physician touches base with the mental health staff to determine the best course of action for the patient.

With the advent of telehealth, some of these mental health evaluations can take place with face-to-face interaction over the computer. This has helped decrease the need for transfers but is a very lengthy process. Each interview mentioned above also takes place by the mental health counselor. Each interview can take 30-60 minutes.

If a patient is transferred, it must be by ambulance. Parents are not allowed to ride in the ambulance for this type of transfer. Again, this is a safety measure. It may be surprising but sometimes parents can complicate matters and for the safety of the EMS team– they take only the patient.

I hope this provides insight into what will happen if your child is placed on an M-1 hold or you need it for a scene in your novel.