Author Question: Emergency Care of the Suicidal Patient

Riannon Asks:

I’d really appreciate your help in answering some questions. I’ve Googled as much as possible, and I just can’t seem to find answers for some things.

At one point in a play I’m writing, a character attempts suicide. His goal is not actually to die, but he does go through the process. What happens is that he’s very drunk and it’s a combination of probably alcohol poisoning and a lot of pills, something relatively accessible lying around the house, but potentially lethal in a high dose and then he calls 911 right afterwards.

So my questions are:
1. Would he be allowed to have visitors the next day? Essential for plot reasons.
2. Would visitors have to be family members or something or would friends/acquaintances be able to fudge their way in?
3. Before someone visits a patient, is the patient told that they’re coming and who they are? (I have very little knowledge of how hospitals work.)
4. How screwed up would he be physically?
5. Would he have to be committed to psych, and if so, when?
6. What could he have overdosed on?

Jordyn Says:

Hi Riannon!

Thanks so much for sending me your questions.

1. Would he be allowed visitors the next day? Depends on where he is at in the process. I’ll give you the process a patient goes through at our hospital, but you might need to adapt it if your play is located in a specific town, state, etc.

When a patient comes in with a suicide attempt, they are placed on 1:1 observation. The patient must be “medically cleared” before they can participate in a mental health evaluation. What that means is that they are no longer in danger medically from what they ingested AND that they are clear mentally to participate in the process. For instance, our patients would have to be below the legal limit for alcohol in order to participate. During the time of medical clearance and during the mental health evaluation (as for pediatrics parents are involved in the process) the patient is allowed to have visitors. A limited number. We try to keep it to two at a time and generally only immediate family.

If the patient is deemed to be a danger to themselves and does not voluntarily consent to treatment, then they are placed on an M1-Hold. This will have different names in different areas, but it is a legal document where the patient is involuntarily committed to a mental health institution for stabilization for about three days. Most mental health facilities will strictly limit visitors and may not let anyone visit during the initial 24-48 hours. Depends on the facility.

2. Could family/friends fudge their way in? I think I’ve mostly answered this above. If the patient is at a mental health hospital probably not without inside help. These are generally locked facilities that will keep a close eye on who is coming and going.

3. Is the patient notified of visitors? I can give you the ER answer and that is it depends. If the patient is unconscious then probably not. If the patient is conscious then we do want to inform the patient of who is there, but we would likely keep it to immediate family. We don’t want to inflame an already volatile situation so if the patient would become harmful to themselves or others then visitors are restricted. Pediatric patients will sometimes try and not have their parents visit, but parents are part of the process, so we encourage them to be at the bedside as long as the patient can be safe.

4. How screwed up would he be physically? Depends on a lot of factors. What he took. How much he took. And how long before he sought medical care.

5. Would he be committed to psych? If so, when? Yes, in this instance, he would be committed involuntarily if he did not agree to a voluntary admission. This would happen once he’s medically stable and after his mental health evaluation. Sometimes, patients may not be medically cleared for 12-24 hours (sometimes longer depending on the drug’s half life). Then we have to wait for an available mental health counselor which can take an additional 3-6 hours. Then waiting for placement could be another 3-24 hours. It can be a very lengthy process. Mental health beds are not that easy to find at times. Patients are held in the ER until they have a bed placement. It is also a requirement of our hospital that patients be transported by ambulance to their mental health facility and generally family members are not allowed to ride in the ambulance with them. This is a safety concern for the EMS crew.

6. What could he have overdosed on? This is really up to you as the author. Any drug can be toxic given in enough quantities and alcohol ingestion on top of that can make things much worse. Some of the more common medications most people have at home that can become easily toxic, in my opinion, would be acetaminophen (Tylenol), aspirin, and diphenhydramine (Benadryl).

Hope this helps and best of luck with your novel!

The Movie Unsane is Insane in its Portrayal of Mental Health Care

A recently released movie, Unsane, starring the remarkable Claire Foy, highlights the plight of Sawyer Valentini after she’s been involuntarily committed into an inpatient psychiatric hospital.

This post does contain spoilers to the movie so stop reading if you don’t want to know more about the film.

The crux of the story is that Sawyer believes her stalker has made his way into the psychiatric unit where she is a patient— whether or not that is the case is the mystery.

Unfortunately, the way that psychiatric care is highlighted in the film is disturbing at best. At worst, I hope it doesn’t deter anyone from seeking mental health treatment if they need it.

Problem One: Not disclosing to a patient why she’s being admitted. The genesis of Sawyer’s admission into the psychiatric unit stems from a visit with a counselor where she discloses at times she thinks about hurting herself. She’s left unattended (a no-no if you think someone is suicidal) and the next scene is a nurse escorting her into an intake room. The nurse never fully explains to the patient the reason for the admission and leaving it out doesn’t really increase the drama of the scene— it just makes the nurse look mean and uncaring. Simply, a nurse could say, “Your mental health provider has placed you on an involuntary hold because she’s concerned you’re going to hurt yourself. ” Then the heroine can argue with her about why she feels the admission is unnecessary.

Problem Two: Having the patient undress but allowing her to keep her bra. A bra is considered a ligature risk and patients can’t have anything on their person that they might use to hurt themselves. Hair ties, piercings, and other jewelry are all removed.

Problem Three: Drug injection sites. Emergency drugs for agitated patients are usually given IM (intramuscular) and not IV (intravenous) to the neck or arm. Can you imagine trying to start an IV on an agitated patient? It’s much easier to land a needle in a large muscle group then to try and finesse a tiny IV catheter into a moving target.

Problem Four: Leaving a patient alone in restraints all night. There are very specific regulations around restraints and significant documentation that goes along with it. Patients in restraints are continuously observed by a staff member and circulation to their extremities is checked often. Also, the patient must be offered bathroom breaks at a minimum of every two hours and you can’t deny them food as punishment. The goal is always to get patients out of restraints as soon as they can be safe— and that doesn’t always imply that they are calm.

Problem Five: A mixed gender open unit. Need I say more?

Problem Six: That psychiatric care is an insurance scheme for money and that patients are intentionally kept until their insurance money is exhausted. This is a large crux of the movie to the point that one of the patients is actually an undercover police officer trying to uncover the scam. This is the most disappointing aspect of the film. There are so few mental health beds around the country right now that it is not difficult to fill them. Here’s a news article here, here, here, and here— which all posted within one week. Trust me, mental health facilities can keep their beds full without perpetuating insurance schemes.

Overall, an interesting movie, but portraying the current state of mental health care in this country would have only increased the tension and drama for this film.

Physical Restraint of a Mentally Ill Person

Physical Restraint of a Mentally Ill Person

Isn’t a medical scene more dramatic when you get to restrain someone? However, to ensure your scene is medically accurate, an understanding of the law and the limitations on using restraints is important. Of course, evil characters can do away with the law. That’s your latitude as a writer. Just remember the reader needs to know that you know this medical person is doing something improper.

I’m pleased to host Patti Shene as she shares her expertise from working as a psychiatric nurse. You can learn more about Patti by visiting her website.

Welcome, Patti!

man-921004_1920For a long time, restraint was used as a means to control the unpredictable and sometimes violent behavior of mentally ill patients. However, over time, the courts have recognized that these persons have an inherent right to freedom from inappropriate use of physical or chemical restraint.

The Supreme Court acknowledged, in the 1982 case of Youngberg vs Romeo, that the use of restraint severely inhibits personal liberty. They concluded the use of restraint should reflect “the exercise of professional judgment.” However, this statement encompassed a broad range of views that resulted in a nebulous interpretation.

Over the past decade, it has become clear that restraint and seclusion can legally be used only as a method of last resort when the patient is an imminent danger to himself or others.

Suppose you have a character who meets this criteria for “imminent danger to himself or others”. First, this information pertains to leather restraints.

Physical restraint consists of four leather cuffs placed around the wrists and ankles of the patient. The cuff has adjustable sizes and is fastened with a leather belt that passes through a metal loop on the cuff. The belt is then secured to the frame of the bed and locked in place. The belt can only be released, or opened, with a key.

The use of restraint should be considered a psychiatric emergency, and not used for convenience of staff or as a form of “punishment” for inappropriate or unacceptable behavior. There are many safety issues to consider when a patient is placed into physical restraints.

A nurse must always be present to assess the need for restraints. A patient can be physically contained by staff members prior to the arrival of the nurse, but only if there is an imminent danger to the patient or others.

Physical restraint without the use of an external device should adhere to strict guidelines. Cornell is one such method, a procedure that incorporates three staff members and greatly reduces the risk of injury.

The patient should always be physically contained face up to prevent asphyxiation or choking.

No cloth, clothing, or other restrictive material should ever be placed over the face during a restraint procedure.

Once the patient is placed into physical restraint, is imperative that circulation be maintained. If the caregiver’s finger does not fit comfortably between the cuff and the patient’s skin, the cuff is too tight.

A caregiver must check the patient at a maximum of fifteen (15) minute intervals.

The emotional needs of the patient must be met at all times.

Hydration and toileting needs must be met every two (2) hours.

A patient should never be left alone in a room with a door open after restraints have been applied. This would expose the patient to possible assault or injury by another patient.

The nurse must notify the physician and obtain a telephone order for restraint not later than one hour after the restraint has been initiated.

The dignity and privacy of the patient must be maintained at all times during the restraint procedure. Never is the patient to be teased, taunted, screamed at, intimidated, or in any way physically or verbally abused during the application or confinement of restraints.

If a personal issue exists between the patient and a particular staff member that could result in the violation of these basic rights, that staff member should immediately be removed from the situation.

In the case of child restraint in a residential child care facility, the parent/guardian must be notified as soon as possible that the intervention has taken place and the behaviors that led up to it.

Reevaluation of the patient in restraints, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is 4 hours for adults ages 18 and older, 2 hours for children ages 9-17, and 1 hour for children under age 9.

The patient must be released from restraint as soon as he/she is calm, cooperative, and able to maintain control. He/she must be able to commit to display safe behavior toward himself and others.

Several incidents across the country in recent years resulting in serous physical or psychological injury or even death have brought national attention to the issue of physical restraint. Do your mentally ill character justice by knowing the legality of how they should be treated when restraint is warranted.

Source material found at here and here.

***This is a repost from 12/3/2010***


patti-shenePatti is a 1969 graduate of a state nursing school in Long Island, New York. Her exposure to state hospital surroundings led her to choose a career in psychiatric nursing. She is a Veterans Administration Hospital retiree and also worked at Colorado Boys Ranch, a psychiatric residential treatment center for several years. Retirement allows her to pursue her interest in writing. She currently fills the position of Executive Editor for Starsongs Magazine, a publication of Written World Communications for kids by kids.