A beautiful holiday evening was shattered by the phone and a challenge to evaluate suicide risk, decide about hospitalization, and assess risk despite the patient's denial. As a Clinical Nurse Specialist and psychotherapist in group practice, I was "on-call" for emergencies and was covering a suicidal patient named John. His girlfriend called saying she was worried but John, an attorney, calmly said all was well. He sounded confident and self-assured but I doubted him but I did not know him. I suspected he had overdosed despite his denials.
It was the late-1980s and a perfect holiday eve before the phone rang. I was reading a captivating mystery and enjoying a glass of Cote du Rhone as the crackling, hypnotic fire licked the pine logs. The blazing fire’s red and gold flames flickered on the Christmas ornaments. As the mulled wine aroma wafted from the kitchen, I tasted the clove, orange and cinnamon scents perfuming the room. After working at the Suicide Prevention Center, I was a clinical nurse specialist and nurse psychotherapist in group practice. I was “on-call” for emergencies this holiday for a senior colleague’s patients. A fortnight before her vacation, my smiling colleague gave me a brief overview, saying, “My patients have been well but John has a routine check-in call at 7 p.m. and will call you. You have not seen his chart but I wrote two sentences about him in these notes.” When John subsequently walked through our office foyer one morning, I had a momentary glimpse of a tall, handsome, charming attorney who struggled with bereavement and had contemplated suicide according to the notes. I expected his call in an hour at 7 p.m. The “on-call” coverage sounded routine.
The jangling phone startled me when it rang before 7 p.m. A high, dreamy, unfocused voice said “Hiya there, um, I’m John’s friend, uh his girlfriend; I’m worried he might do …. um…something. He’s depressed.” Her fast-paced words and shaky voice intensified. Then I slowly asked, what did he say?” I paused between questions. “What might he do? or ….Does he have any dangerous medications or weapons.” She replied as she stifled a giggle, “Uh, I dunno. He didn’t say or do anything.” Nervous, I needed specifics to assess risk but I questioned her credibility. It was almost 7 p.m.; my shoulders tensed as I waited five minutes for the answering service to forward John’s call. When he didn’t call by 7, I was annoyed but dialed him. No answer. I redialed and it rang endlessly while my fingers drummed irritation as I paced. When he answered with a calm, melodic, and steady voice, I sighed and said,
“Hi John, Dr. V, calling; you missed your 7 pm call, “How are you? Your girlfriend seems very worried.” I paused for his reply.
In a strong and reassuring baritone, he replied, “I have no idea why she called; I’m fine … at home making dinner just lost track of time. She’s a worrywart.” I continued, “Well, why was she was so upset and thought you were depressed?” I paused. “Are you feeling depressed? Have you had any medications or alcohol?” I asked to determine risk. He asserted, ”No, nothing is wrong. I’m making pasta with pesto. Let me tell you this recipe.”
The girl’s angst which contrasted with his equanimity distressed me and made no sense. I imagined an overdose but he sounded fine. Still, doubt nagged. If I were overreacting, colleagues would laugh. Often, attorneys are stoic and compartmentalize feelings. Was he telling the truth? Was he high risk or was I exaggerating? I needed to know how he looked, acted, and if he seemed impaired, but we didn’t have Facetime. My colleague’s notes identified his neighbor, Fred, who gave permission for contact. I called and asked him to dash over and report his observations. As my distress grew, I stared, willing the phone to ring. I was holding my breath. I texted my psychiatrist about a potential overdose and asked him to call immediately but he didn’t. I was on my own and doubting my clinical intuition.
After a half-hour, Fred called whispering, “Dr. V. Something’s wrong. John has tiny pupils, slurred speech, and a giddy mood but says he’s fine.” My concern grew, my mouth was dry. John was not supposed to have over 1-2 weeks of psych meds but what if he had more? I directed the neighbor to gather pill bottles, wrap John in a jacket or blanket and take him immediately to the University Emergency for evaluation and call me. My heart was in my throat as I waited for an update. Had he overdosed or had I jumped to a conclusion? My heart jumped to my throat as I paced and could not focus. I thought about the hospital.
On holidays, emergency units are deluged so they triage people and send home those who appear functional. John’s cogent arguments could convince staff that he was low risk. I phoned the emergency unit. Dr. V calling, I said, “I’m sending John, a potential overdose -- please have the psychiatrist on duty evaluate him for hospitalization; this high-risk suicidal patient with serious past attempts is charming, convincing, and denies everything. He denied overdose and acted stoic on the phone.” I suspected a lethal overdose with alcohol. The staff listened but I could hear the unit’s loud yelling and pandemonium that echoed like a blaring bass drum in the background.
My nervousness grew. About two hours later, the ER nurse called saying, “Dr. V. John overdosed on 200 sedatives and alcohol and was involuntarily hospitalized on a 5150. I gulped at the lethal dose and asked for his condition which was stable. As my heart calmed, I was relieved I had listened to my clinical hunch. He was safe, being observed, and having his stomach pumped. I could relax; he wasn’t out of the woods yet from a lethal overdose but the hospital was in charge.
My husband grumbled and was impatient to serve a late veal-piccata dinner with latkes and an almond tart which I adore and must have eaten, but I don’t remember. Relieved but exhausted, I fell into bed and tried to calm my thoughts before falling into a deep sleep.
Two days later I was shocked when the ER called to say, “Dr. V, you need to come and discharge John.” I was shocked, bit my lip and took a deep breath. This was highly irregular. I asserted, “The psychiatrist on duty should handle discharges.” Although I had bluffed earlier to get John hospitalized, nurses did not have hospital privileges at that time. Furthermore, I had never met John and he hid his overdose so I was not the right person to evaluate him. I said, “No, I’m on-call for emergencies only. Have staff discharge him or call his therapist tomorrow.” Neither my colleague nor I had hospital privileges; our consulting psychiatrist managed this. It would take years before masters or doctorally-prepared nurses had hospital privileges. Startled, I realized our psychiatrist had not called. I left a new message to update him and request a call. The ER psychiatrist discharged John who had recovered from the overdose; he bullied staff and threatened to sue unless discharged.
When my colleague returned from vacation, I briefed her saying, “Although John had overdosed with more than 200 sedative/hypnotic pills, he denied it. He was on a 5150. He did not relate to me so I will not be on call for him again. His overdose during your vacation is worrisome and suggests he may need a more secure holding environment and inpatient treatment.”
I wondered if she heeded my caution. She said, “John was doing well but he had also overdosed during her vacation last year.” My mouth fell open as I noted, “I needed to know that. Why didn’t you tell me that before you left?” I was furious she had not alerted me to that critical event. Her face seemed surprised at my annoyance, and she went to see her next patient. I vowed to ask more precise questions about warning signs before I agreed to be on call. Despite self-doubt and his (John's) glib denials, I followed my clinical hunches and took action at every decision point. I was relieved he survived.
Sharon Valente, APRN, PhD, FAAN is a Clinical Nurse Specialist with expertise in suicidology and thanatology and over 40 years experience. She served on UCLA and USC Schools of Nursing faculties, conducted research on suicide in high risk groups and was a Chief Nurse at West Los Angeles Veterans Administration.
Specializes in ED, Tele, MedSurg, ADN, Outpatient, LTC, Peds.
Beautifully written! Thank you for being persistent and saving his life! That clinical judgment was spot on!
You were indeed the right person to be on call at the right time!
It was the late-1980s and a perfect holiday eve before the phone rang. I was reading a captivating mystery and enjoying a glass of Cote du Rhone as the crackling, hypnotic fire licked the pine logs. The blazing fire’s red and gold flames flickered on the Christmas ornaments. As the mulled wine aroma wafted from the kitchen, I tasted the clove, orange and cinnamon scents perfuming the room. After working at the Suicide Prevention Center, I was a clinical nurse specialist and nurse psychotherapist in group practice. I was “on-call” for emergencies this holiday for a senior colleague’s patients. A fortnight before her vacation, my smiling colleague gave me a brief overview, saying, “My patients have been well but John has a routine check-in call at 7 p.m. and will call you. You have not seen his chart but I wrote two sentences about him in these notes.” When John subsequently walked through our office foyer one morning, I had a momentary glimpse of a tall, handsome, charming attorney who struggled with bereavement and had contemplated suicide according to the notes. I expected his call in an hour at 7 p.m. The “on-call” coverage sounded routine.
The jangling phone startled me when it rang before 7 p.m. A high, dreamy, unfocused voice said “Hiya there, um, I’m John’s friend, uh his girlfriend; I’m worried he might do …. um…something. He’s depressed.” Her fast-paced words and shaky voice intensified. Then I slowly asked, what did he say?” I paused between questions. “What might he do? or ….Does he have any dangerous medications or weapons.” She replied as she stifled a giggle, “Uh, I dunno. He didn’t say or do anything.” Nervous, I needed specifics to assess risk but I questioned her credibility. It was almost 7 p.m.; my shoulders tensed as I waited five minutes for the answering service to forward John’s call. When he didn’t call by 7, I was annoyed but dialed him. No answer. I redialed and it rang endlessly while my fingers drummed irritation as I paced. When he answered with a calm, melodic, and steady voice, I sighed and said,
“Hi John, Dr. V, calling; you missed your 7 pm call, “How are you? Your girlfriend seems very worried.” I paused for his reply.
In a strong and reassuring baritone, he replied, “I have no idea why she called; I’m fine … at home making dinner just lost track of time. She’s a worrywart.” I continued, “Well, why was she was so upset and thought you were depressed?” I paused. “Are you feeling depressed? Have you had any medications or alcohol?” I asked to determine risk. He asserted, ”No, nothing is wrong. I’m making pasta with pesto. Let me tell you this recipe.”
The girl’s angst which contrasted with his equanimity distressed me and made no sense. I imagined an overdose but he sounded fine. Still, doubt nagged. If I were overreacting, colleagues would laugh. Often, attorneys are stoic and compartmentalize feelings. Was he telling the truth? Was he high risk or was I exaggerating? I needed to know how he looked, acted, and if he seemed impaired, but we didn’t have Facetime. My colleague’s notes identified his neighbor, Fred, who gave permission for contact. I called and asked him to dash over and report his observations. As my distress grew, I stared, willing the phone to ring. I was holding my breath. I texted my psychiatrist about a potential overdose and asked him to call immediately but he didn’t. I was on my own and doubting my clinical intuition.
After a half-hour, Fred called whispering, “Dr. V. Something’s wrong. John has tiny pupils, slurred speech, and a giddy mood but says he’s fine.” My concern grew, my mouth was dry. John was not supposed to have over 1-2 weeks of psych meds but what if he had more? I directed the neighbor to gather pill bottles, wrap John in a jacket or blanket and take him immediately to the University Emergency for evaluation and call me. My heart was in my throat as I waited for an update. Had he overdosed or had I jumped to a conclusion? My heart jumped to my throat as I paced and could not focus. I thought about the hospital.
On holidays, emergency units are deluged so they triage people and send home those who appear functional. John’s cogent arguments could convince staff that he was low risk. I phoned the emergency unit. Dr. V calling, I said, “I’m sending John, a potential overdose -- please have the psychiatrist on duty evaluate him for hospitalization; this high-risk suicidal patient with serious past attempts is charming, convincing, and denies everything. He denied overdose and acted stoic on the phone.” I suspected a lethal overdose with alcohol. The staff listened but I could hear the unit’s loud yelling and pandemonium that echoed like a blaring bass drum in the background.
My nervousness grew. About two hours later, the ER nurse called saying, “Dr. V. John overdosed on 200 sedatives and alcohol and was involuntarily hospitalized on a 5150. I gulped at the lethal dose and asked for his condition which was stable. As my heart calmed, I was relieved I had listened to my clinical hunch. He was safe, being observed, and having his stomach pumped. I could relax; he wasn’t out of the woods yet from a lethal overdose but the hospital was in charge.
My husband grumbled and was impatient to serve a late veal-piccata dinner with latkes and an almond tart which I adore and must have eaten, but I don’t remember. Relieved but exhausted, I fell into bed and tried to calm my thoughts before falling into a deep sleep.
Two days later I was shocked when the ER called to say, “Dr. V, you need to come and discharge John.” I was shocked, bit my lip and took a deep breath. This was highly irregular. I asserted, “The psychiatrist on duty should handle discharges.” Although I had bluffed earlier to get John hospitalized, nurses did not have hospital privileges at that time. Furthermore, I had never met John and he hid his overdose so I was not the right person to evaluate him. I said, “No, I’m on-call for emergencies only. Have staff discharge him or call his therapist tomorrow.” Neither my colleague nor I had hospital privileges; our consulting psychiatrist managed this. It would take years before masters or doctorally-prepared nurses had hospital privileges. Startled, I realized our psychiatrist had not called. I left a new message to update him and request a call. The ER psychiatrist discharged John who had recovered from the overdose; he bullied staff and threatened to sue unless discharged.
When my colleague returned from vacation, I briefed her saying, “Although John had overdosed with more than 200 sedative/hypnotic pills, he denied it. He was on a 5150. He did not relate to me so I will not be on call for him again. His overdose during your vacation is worrisome and suggests he may need a more secure holding environment and inpatient treatment.”
I wondered if she heeded my caution. She said, “John was doing well but he had also overdosed during her vacation last year.” My mouth fell open as I noted, “I needed to know that. Why didn’t you tell me that before you left?” I was furious she had not alerted me to that critical event. Her face seemed surprised at my annoyance, and she went to see her next patient. I vowed to ask more precise questions about warning signs before I agreed to be on call. Despite self-doubt and his (John's) glib denials, I followed my clinical hunches and took action at every decision point. I was relieved he survived.
References
Coping and suicide risk In high risk psychiatric patients
Clinical Practice Guideline: Suicide Risk Assessment
Concordant Actions in Suicide Assessment Model
How Clinicians Incorporate Suicide Risk Factors Into Suicide Risk Assessment
About Svalente
Sharon Valente, APRN, PhD, FAAN is a Clinical Nurse Specialist with expertise in suicidology and thanatology and over 40 years experience. She served on UCLA and USC Schools of Nursing faculties, conducted research on suicide in high risk groups and was a Chief Nurse at West Los Angeles Veterans Administration.
Share this post
Share on other sites