Author Question: Treatment of Teen Suicide Victim (2/2)

Today, we’re continuing our discussion of the medical treatment of a fifteen-year-old male suicide victim who slit his wrists at school. You can find Part I of the discussion here. In this post, we’ll focus on more of the mental health aspects over the medical treatment.

Pink Asks:

Upon examining a patient, and if sexual abuse is suspected, what is the hospital protocol? How do the hospital staff work with police and the victim’s family?

Jordyn Says:

If outward physical exam of the skin shows injuries concerning for sexual abuse, this can be handled several ways. In order to answer this best, I’d need to know what kind of hospital your patient/character is at in order to give advice as to how that community would likely respond but I’ll give thoughts as to how my institution would handle it—which is a large, urban pediatric medical center. A rural hospital would likely handle it much differently.

One thing I want to say is that no sexual assault exam would be done without the patient’s consent (or parental consent—a court can order if needed)—so this would not be done on an unconscious person. What you can see from the outside would be the limit. For instance, in girls and women no internal vaginal exam.

There might be an extreme outlying caveat to an internal exam if the patient were near death, concern for loss of evidence, or other victims were at risk, but it would have to be VERY PRESSING circumstance and likely the courts/law enforcement would be involved in order to move forward.

Regarding the suicide attempt, the next thing to keep in mind is that the patient’s medical needs are always addressed first. In fact, the patient must be “medically cleared” by a physician before they can participate in a mental health evaluation.

If there is a concern for sexual abuse, we would first contact social work through our hospital to develop a game plan. If a sexual assault exam needs to be done, we have health care professionals that are very experienced in doing these with kids/teens and we want the most experienced professional to do the exam and collect any evidence. Social work will do a couple of things if they think the concerns are valid. One, report it to the state (Department of Children and Family Services—something along those lines depending on the state) and second, report it to the police if they believe a crime has occurred. The incident is reported to the police jurisdiction where the crime took place and not the location of the hospital where the patient is receiving care.

As an example, if a woman is raped in Anchorage, AK, flies to Seattle and seeks treatment there, the hospital in Seattle is going to have to call Anchorage, AK police to report the crime. Local police can help determine the appropriate jurisdiction if it’s not clear.

The timing of the sexual assault is important in collecting evidence. If a person was just raped, we’d be very anxious to encourage the person to have a sexual assault exam done ASAP. If they are reporting something that happened more than three days prior (it’s 72 hr for us)—it’s not as pressing that an exam should be done immediately but plans can be made with the patient and family for follow-up exam and care.

Larger police departments typically have victim advocates that can help families through processes like this, but it is up to them to call that person in. Contrast this with a more rural hospital that may “hotline” the concern for abuse to the state, call the police, and depend on state social workers to determine the course of action.

Pink:

Are patients who attempt suicide always sent to a mental health facility for treatment? I know patients speak with a crisis counselor, but what if the attempt wasn’t caused by being under the influence of drugs, or a mental illness, but due to a desperate situation (domestic violence)?

Jordyn:

The most important determination about whether or not someone will receive psychiatric care is whether or not they are a current danger to themselves (and/or others) and how likely are they to act on it. This is determined by a mental health professional and not the medical staff. The reason for the attempt doesn’t necessarily differentiate potential lethality—it’s what the patient is thinking about in their mind and how at risk they are to act on it.

I think you’re trying to make a distinction that a desperate situation caused by domestic violence leading to a person’s suicide attempt would be seen as less lethal and it wouldn’t. If a person is trying to kill themselves because their home situation is driving them to do that—that is very significant and taken as seriously as someone who swallows pills, or slits their writs, or is having a psychiatric break. Someone attempting suicide due to domestic violence will likely have other co-existing mental health issues like anxiety and depression.

This is a very serious topic and definitely worthy of fiction to help foster discussion of suicide. Good luck with this novel.

Criminal Minds: Can a Patient be Admitted for Psychological Distress?

In a recent episode of Criminal Minds, a woman was nearly shot and killed by a madman operating a drone. She is saved and uninjured, but is admitted to the hospital just in case she begins to suffer some psychological distress.

Can this really happen?

The situation as portrayed on television— no.

When admitting someone emergently for a psychiatric problem, one of two things needs to be a concern. Either the person is a threat to themselves, to another, or both. You might hear a provider ask, “Is the person expressing HI or SI?” which stands for suicidal ideation or homicidal ideation.

If a person is expressing either or both of these concerns then a couple of things happen. The patient first must be medically cleared by a physician to ensure that there are not any coinciding medical concerns. Once this takes place, they then are put through a mental health evaluation.

Once a mental health evaluation is complete, it is decided what type of psychiatric services the patient may require. Sometimes, it is admission under an involuntary hold. Other times, the patient may be connected with outpatient services.

Think about the many events that have happened just in the US where people will be suffering psychological distress, but are not expressing suicidal or homicidal thoughts. The  devastating hurricaines. The mass shooting in Las Vegas. Put simply, if we admitted every patient that we were concerned for the potential of psychological distress outside of expressing HI or SI— we’d quickly run out of hospital beds. Plus, patients expressing these concerns should not be placed on a medical floor unless they also have co-existing medical problems that they need treatment for. Also, in that case, they require one on one observation.

Although a nice thought, you do have to have a mental concern other than psychological distress from surviving a potentially life-ending event to be admitted into the hospital.

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.

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.