High Risk Emergency Medicine - The Suicidal Patient Notes

The Suicidal Patient

Assess the patient: A primary step in managing a potentially suicidal patient.
ABCs: Ensure that the patient's Airway, Breathing, and Circulation are stable.
Toxidromes: Identify any potential toxidromes, which are groups of symptoms associated with particular toxins or drugs.
Vital signs are vital: Continuously monitor the patient's vital signs.
Talk to the patient: Engage in a direct conversation to understand the patient's mental state and intentions.

Direct observation is key: Continuous monitoring is crucial.
Find a sitter, 1:1 monitoring: Assign a staff member to observe the patient constantly.
Safe environment: Ensure the patient is in a secure environment.
Place the patient in front of you: Position the patient where they can be easily observed.
Main area of the ED: Keep the patient in the central area of the Emergency Department.
Ligature resistant rooms: If available, use rooms designed to prevent self-harm by hanging.
Remove objects that pose a self-harm risk: Eliminate any items that could be used for self-harm.

Don't Safety Contract: Traditional safety contracts are not effective in preventing suicide and do not decrease liability.
Do involve family members and friends: Engage the patient's support network.
Do consider doing a suicide safety plan with the patient: Develop a detailed plan collaboratively.
Do call the patient for follow-up: Ensure the patient receives ongoing support.
Signing a Safety Contract = Signing an AMA Form: Safety contracts can give a false sense of security.

A 28-year-old female presents from a drug treatment center after being found lethargic and difficult to arouse.
EMS administered Narcan and Zofran.
The patient reports taking 2 oxycodone 30 mg tablets the night before, drinking alcohol, and taking 100mg of methadone that morning.
She denies suicidal ideation and was sober for 1 month prior to relapse.
The physician documents the patient is somnolent but answers questions appropriately while under the influence of an unknown amount of medications.
Neuro exam and labs were normal; UDS was positive for opiates and methadone.
Reassessed prior to discharge, gait was normal, and the patient was medically cleared.
The patient was found dead the next morning; the cause of death was combined effects of methadone and oxycodone.
Allegation: Improper treatment of a drug overdose thus failing to prevent death.

1520: A 50-year-old male with a PMHx of depression and DM presents with police for suicidal ideation.
He had called a crisis center and said he was “going to end my life.”
1545: He was placed on a psychiatric hold, labs drawn, and placed in a room.
1615: He started getting restless about how long things were going to take.
He was told he is on a psychiatric hold and says he has no plans to carry out a plan anytime soon.
1635: Offered nicotine patch, told nurse to leave him alone, advised BG was 327 and doc would like him to have insulin. ETOH 219.
1640: Started yelling out at EP that he did not want to stay, was advised he needed a repeat ETOH in 7 hours.
He states he wasn’t going to take his life “today or tomorrow, not until they come after those DUIs in Georgia.”
1650: RN note: pt sitting on bed, no complaints.
1700: Patient discovered hanging from overhead light. Nurse cut him down and resus efforts started.
1731: Code called.
Reportedly, the ED did not have sitters that day.
Suit filed against doctor and hospital by pt’s mother.
Hospital settled, physician was dismissed.

A 24-year-old female going through a break-up told her boyfriend she wanted to kill herself by jumping in front of a car.
Boyfriend called 911.
Pt arrives with PD and EMS and states she had no plan to commit suicide.
She is crying and tearful.
Crisis intervention evaluates her and gives her a suicide assessment score of 4 based on no organized plan for suicide, good social support system, and rational thinking.
There was concern for likely drug/alcohol use.
Mother, stepfather, and stepbrother thought she was not a danger to herself.
She agreed to a safety contract.
Hours later, she committed suicide by stepping in front of a car.
The EP that saw her in the ED pronounced her on scene and spoke to a biological dad and brother who questioned mom’s judgement.
Mom affirmed pt was safe but received a text from boyfriend after discharge that likely prompted suicide.
Suit brought against PD, EMS, the hospital, doc and psychiatrist. Settled for $36,000.

Words associated with suicidal feelings include: DULL, AWFUL, RETARDED, PITONTIC, FOUL, LINE, TENT, UNFORGIVABLE, HOPELESS, SICKENING, PATHETIC, EVIL, STUPID, CARELESS, DESPICABLE, HIDEOUS, SELFISH, IRRELEVANT, LOATHSOME, INFERIOR, POWERLESS, HOPELESS, UNWANTED, SHAMEFUL, BROKEN, UGLY, UNLOVABLE, WORTHLESS, RELENTLESS, RECIPEINT, LESS, DEPLORABLE, INFERIOR, LOST, WEAK, IDIOTIC, EVIL, UNFIT, STUPID, WIMP, UNWANTED, SHAMEFUL, TYIL, YOUL, DISAPPOINTING, ROTTEN, THOUGHTLESS, WEAK, DIRTY, USELESS, INEXCUSABLE, BAD, DISGUSTING, INADEQUATE, HELPLESS, UGLE, LOSIT, ALONE, DEFECTIVE