Psychiatric Hold

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!

Proper Treatment of a Suicidal Patient.

clinical-netflix Netflix 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.