Dealing with chronic suicidal pts in the ED

dansamy · Sep 19, 2013

Are these uninsured patients? Maybe they lack access to mental health care. Or the meds that work for them are too expensive & they aren't getting any assistance with affordability.

Even with "good" insurance, mental health care in my area is hit or miss. Add an unstable patient with poor/no family support and you have disaster.

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Sassy5d · Sep 19, 2013

My 1, schizophrenic, pleasant, cooperative pt put it to me best.. If you're not suicidal/homicidal, you get no help.

So when he comes in, he wants to make sure I 'put it all down' that he's a threat to himself and others, he wants to kill xyz, he has command voices for violence. And an ice water, lunch, remote, pillow and blanket.

I feel for you, and I know what you're saying. I find it no different than the frequent flyer drug seekers, who scream, cuss, throw fits and act like toddlers who don't get their way and they keep coming back because the odds are good that the doc on will give them dilaudid iv every 1 hour with a negative work up.

I can't imagine what these repeat, rude, suicidal pts lives are like outside the ER walls. But they know they have to play the part or else they won't get 'help'. Maybe your coworkers will take one for the team and alternate when they return.

JustKeepDriving · Sep 20, 2013

I'm not an ER nurse, I'm a relatively new psych nurse (in a state run forensic facility), I get patients that threaten to harm themselves or others quite frequently. Sometimes it's because they are in serious emotional pain (Maybe with a Axis I disorder like Major depression), or psycho-socially they lived an extremely traumatic life, or maybe they don't really want to kill themselves but it's the only way they can get the positive reinforcement they need (maybe they have an Axis II disorder like borderline personality).

Many times these behaviors are chronic and reoccurring. It's frustrating because in mental health, sometimes we have to measure progress differently. We might never make this person "better", we might never stop them from wanting to hurt themselves, take their own lives or use maladaptive coping mechanisms. Instead we have to measure progress in baby steps. Small victories like "It's been two weeks since this person has been admitted for attempting to self/other harm", "Today, this person rated himself as a 4/10 on thoughts of suicide, yesterday he was at a 6/10".

It's all about dealing with the immediate threat of self-harm and trying our best to provide for that person's long term safety.

In the end, I say my absolute best piece of advice comes from a quote from Psychologist Carl Rogers,

"In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth".

thelema13 · Sep 20, 2013

We usually use a dose of B52 or geodon shot:)

The ED is no place for a psych patient because they almost always do not get the help they truly deserve. During the acute overdose or self-inflicted injury, of course come to the ED.

With that being said, I have had a few psych patients that made me question why the government ever shut down mental asylums.

Guest219794 · Sep 20, 2013

First off, I try and distinguish between suicide attempts and gestures. Taking 10 tylenol and posting it On Facebook is different from sticking a shotgun in your mouth. Of course there is a huge grey area in between, and suicide gestures often precede suicide.

Regarding your guy with over 20 serious suicide attempts? I am not sure I buy it. Unless this guy is extremely low intelligence if he wants to die, he can figure it out in under 20 tries.

But- as an ER nurse, none of this affects how I treat the patient.

"Why are you here?"

"I want to die."

"Oh boy, did you come to the wrong place."

Like any other patient, they are medically stabilized.

Regarding rude, demanding jerks: It makes no difference whether they are suicidal, making gestures, or have a sprained ankle. The behavior is unacceptable.

For a variety of reasons, we have a system that rewards frequent fliers- psych and medical. While I have a problem with the system it is silly to blame the people who use it. I would rather deal with a polite frequent flyer than a jerk with a legitimate problem any day.

Want three hots and a cot, a tv, and people who will treat you respectfully and professionally? Many people know the magic words to get it. Imagine how crappy your life must be if a day in an ER or psych unit is an improvement over your regular life.

As an ER nurse, it's not my job to assess their motivation, just to keep them safe. I treat recurring psych patients the same as medical- according to their behavior. For example if somebody, in a civil manner, tells me they are hungry, I will order them a tray. If you demand food immediately because you are a diabetic, or have low blood sugar, or whatever, I will do a fsbs, which takes me longer than ordering a meal. If your sugar is OK, and it always is, Nothing. Maybe a saltine.

Bottom line, is these patients are no different to me than any other broad category of patient. Somebody being rude or abusive doesn't affect me. It's annoying, but so are mosquitos and humidity. Just a fact of life.

Anna Flaxis, BSN, RN · Sep 23, 2013

The way I see it, people who want to harm themselves are in pain. They are hurting from whatever horrible thing or multiple things that have happened in their lives, and they don't know how to cope with it all. If you are fortunate enough to have never been abused or to have never experienced a tragic loss or to have had a functional family environment while growing up, particularly in early childhood, then it may be hard to understand the type of pain this person is experiencing. It might be helpful if, just as you can empathize with the guy who has the femur fracture, you could try to imagine what it must be like to live in emotional hell every single day of your life.

EDNurse74 · Oct 2, 2013

We used to get the influx of Suicidal Ideation pts when the weather got crappy. After a few days of rain the homeless pts that did not want to necessarily go thru CT scans, lab draws, etc would claim SI instead of vague abdominal complaints. Then they at least could boss the psych tech around, get a few warm meals and maybe even and shower if they proved that they could walk with a steady gait and not acting like a total A hole. One guy used to come in monthly claiming SI and got to the point that if we told him to wait in the waiting room because it really was busy he would run out to the street and lay down in the street which would send security out there dragging him into the ED and a bed in the hall for his suicide attempt which I personally saw as him having a control issue, lack of patience, and chronic abuser of the system. I honestly doubt he would have flung himself in the street if he actually saw the bus coming down the street.