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.

Author Beware: Don’t Make Medical People Look Like Uncaring Idiots 2/3

Today, I’m continuing my discussion of an uber popular book that didn’t paint medical people in a good light— like at all.

You can find the first post here. I’m not mentioning the author or the novel here to protect the author from angry medical people everywhere (okay, perhaps it’s just me.)

What follows is the same encounter, different section. As a quick reminder, this fourteen-year-old girl believes she’s been raped and is looking for guidance from a female physician.

What follows in italics is an exert from the book.

doctor-563428_1920-1There had been a question burning in my throat for the last ten minutes, but it was her reaching for the handle of the door that forced me to say it. “Is it rape if you can’t remember what happened?”

 The doctor opened her mouth as if she were about to gasp ‘oh no’. Instead, she said so quietly I almost didn’t hear it, “I’m not qualified to answer that question.” She slipped out of the room soundlessly.

 Problem: There are so many problems with this response from this doctor to her patient that I am flabbergasted as to even know where to start. First, how about starting with a doctor who cares enough to simply ask a few follow-up questions?

Such as, “Please, tell me what happened.”

What is shocking is just the amount of information that has been disseminated to the population about getting mutual consent before a sexual encounter. In fact, in just the last couple of years was the infamous “Tea Consent” video which you can view below.

In fact, the video states, “And if they’re unconscious, then don’t make them tea. Unconscious people don’t want tea and can’t answer the question, ‘Do you want tea?’ because they’re unconscious.” So it seems the issue of whether or not this was consensual would be fairly easy to determine.

No consent, then a crime has occurred.

The first signal to this physician is her patient’s memory problems. This is very concerning for her getting slipped a drug so that she could be raped. If the physician feels this is something she can’t explore, especially considering the patient’s age, then she should seek outside guidance. This could rise to the level of needing to be reported to the police.

Never just stop and not say anything more. This young girl is clearly in crisis. A doctor is qualified to help this patient, particularly one in this setting, who should be clearly educated in circumstances just like this.

Who else can this girl turn to for answers if not a trusted physician?

Treatment for Amnesia

Marissa Asks:

How do doctors proceed if they suspect amnesia? In my novel, the patient was brought to emergency after being found on the side of the road (in the snow.) The patient shows signs of physical torture: multiple rapes, bruises, lacerations, glass embedded mainly in his hands, hypothermia, and a cold (because obviously my character needs to be ill on top of everything).

burnout-384086_1920The patient has just woken up and had a panic attack. Been settled down. You asked for his name and he seemed uncertain as he gave his first name. You asked for his last name and the patient shook his head. What next? I mean obviously the glass would have been removed from his hands and a drip put in for painkillers but what next? Who does the nurse call? Or what does she ask now? And if memory loss is confirmed, how do they find out it’s amnesia like which SPECIFIC tests do they do? Who is contacted and brought in to liase?

I just sort of need a timeline rundown because my character is going to be going through that.

Jordyn Says:

Thanks so much for sending me your question. First of all, it sounds like this patient has a period of time where he is unconscious in the ER. You make it sound like he wakes up on his own and not in response to an exam by a doctor.

So an unconscious patient found with these injuries would have a CT scan of his head. Hypothermia could be determined simply by taking the patient’s temperature and warming him up with something as simple as warm blankets to more complex as heated IV fluids. Regarding the IV drip for pain— this is actually unlikely in the ER. This is referred to as a PCA pump (patient controlled analgesia) and I’ve never seen them used in any ER setting. Would we treat the patient’s pain? Yes. But, you might be surprised that we may choose not to use a narcotic (for many reasons) and instead try something like Toradol which is an IV form of an NSAID (which is in the same drug class as Ibuprofen.)

The glass embedded in his hands would be removed. The wounds irrigated and stitched closed if necessary. The lacerations would be treated the same way. Keep in mind, not all lacerations can be stitched closed if they’ve been open too long due to the risk of infection.This patient would also receive a tetanus booster if he hasn’t had one in the last five years (even if he can’t remember the last time he had a shot.) If anything looks infected, he would receive IV antibiotics.

If the patient wakes up and doesn’t know who he is (and doesn’t have any form of identification on him) then we would involve the police. Likely, they are probably already involved considering the circumstances— that he was found unconscious and beaten. Plus, you mention that the character has been raped several times so a sexual assault kit should be collected, but the patient’s consent is required, so we’d ask him if he wants this when he’s awake. Yet another reason the police would be involved.

If the doctors think the amnesia is related to a brain injury from the beating, they may just see if it improves with time.

I think it’s reasonable to admit this patient to the hospital and I speak a lot here about how it is actually rare to admit a patient with concussion, but considering the amnesia (it sounds like you want it to persist), the beating, the rapes, the wounds to his hands (as well as additional lacerations), and the hypothermia then some watchful observation is warranted. The doctors could consider a neurological and/or some type of psychological evaluation considering the circumstances of the case to see if his memory loss has a non-medical cause. Neuro might request an MRI of his brain to look for additional injuries not as easily discerned via CT scan.

In the end, if he never remembers, there’s little treatment to “correct” amnesia. This is good for the writer because you have a lot of leeway in what you want to happen to the character. Your time frame can be what you wish.

I think if he were stable in the hospital for a few days and the neurological/psychological evaluation didn’t warrant anything that required further inpatient treatment, he could be discharged home even if the amnesia persists with outpatient neurological follow-up and perhaps outpatient therapy if he consents.

Obviously the police would be very involved with this case.