My head is still spinning. Working ED, when a 25 y/o male is referred (by his friends) for suicidal ideation. I walk pt. back after initial screening. Complaints? As pt. elaborates (over-elaborates) My jaw almost drops! Nothing he's done, but what has happened to him in the past 24/48hrs/week of his life is CRAZY! Feel totally bad for him; want to tell him that he maybe making a mistake - but it's not as though he's reporting himself...others are concerned... Yeah, sometimes it doesn't go unnoticed, but in this particular instance it would be impossible not to notice/to ignore: he's adorable. Male techs enter room and I tell them that they're not needed. Pt. is cooperative; not violent. They leave. Vocabulary is very intelligent; pronunciation (although soft and somewhat monotone) is clean/sheer; very pleasant voice. All the more so making it surreal when it is time to tell pt to disrobe. I actually say "undress." "Everything," I say, "including socks and underwear." Why did that feel so awkward?!?! This is my profession! Why am I even reminding myself of this, I wonder. I'm not being sadistic - it's not even a word in my vocabulary. So why do I feel this way? Why is it the only thing that comes to mind then/now?? Nothing. Did he hear me?? For goodness sakes (all occurring in split seconds') but it was hard enough (awkward, compelling?) for me to say it once already, now I have to repeat myself?!?! Remember: Logic over emotion. I say it again. This time: "I need you to to..." Stressing the "I need" part while staring directly into his eyes. I detached while doing so. Logic over emotion. If this sounds crazy, not two minutes ago, this individual bore his soul to me, and now I'm ordering him to strip naked with all the conviction of a Starbucks employee asking a person for their order... Yeah, it's my job. No, I'm not a psych nurse. And no, either I've not had enough experience to automatically (in my mind) consider this person a threat, or I just don't believe he is, but it's protocol. I begin to assist. I feel power. I feel embarrassed by - not the act- but for the power I'm feeling. Make it quick. Avoid eye contact. Start with non-intimate. Shoes, socks. Wow! Nice feet! Is that a pedicure?? Seriously!?! Anything to take my mind off, I guess... Why?? Because this is so surreal?? The socks must've made a connection to "socks and underwear" that I muttered moments earlier. "Oh...sorry" he said. "What?!?!" Another lightbulb/total realization. I repeat for a third time: "....everything...underwear...it's for your safety...it's our policy..." I explain. I step away, shifting my focus on fetching a gown from the corner basket. Pt. proceeds to undress himself. Male tech enters; looks at pt, then to me, then back to pt. Monumentous moment. I look at pt. Pt. had paused, momentarily, then as if succumbing/accepting the humiliation of it, continued to undress. Safe room. That's what the tech had to say. That pt needed moved to a safe room - as he grappled with his captivation. Again, I turn my attention. Look for gown, grab one, hand to pt in a manner consistent with wanting to end show. Did not notice it was child's size. CRAP!! The three of us walking through ED, down hall to safe room. Feel all eyes on pt; feel eyes on me; don't dare look. Safe room. Finally. Relief. Nothing. Empty room. Sad. Lonely. Isolation. Too small gown. Leave. It's over. Finally. Yeah, right.... Can't get my mind off. Nervous. Shaky. WHAT IS WRONG WITH ME?!?! 15 minutes. A lifetime. Look in on Pt. Why am I staring at his bare soles? Conveyance of something... Feminization?? No, that's the damn gown! Something...something... Vulnerability?? That must be it. "Hi...how are you doing?" Feel stupid. He looks at me like I betrayed him. At least that's what it feels like. "Ok" he says. Leaving room, he stops me. "What's going to happen?" I tell him a professional, evaluation, blah, blah... "Then what?" "I don't know." "Just be honest." Later. F-you eyes with following checks. "You think I'm crazy?" "No." Off duty. Stick around. Girls at desk commenting on pt. A catheter?!?! Can't go. Urine screen. Seriously?? A damn catheter?!?! Yes! Going to facility. Led away. Handcuffs. Barefoot. Open back, too short/tight/small gown. Near naked. Still on my mind. Still thinking of him. Wondering what will happen to him..
So called "Suicide Contracts" should not be relied upon, as they are not evidence based. In fact, evidence points to the opposite- that they are unreliable and result in bad outcomes.
No, that is not our initial intervention. If a child is suicidal it is escalated immediately.
But when the student comes back to school this is part of what we use.
I'm having trouble being coherent here, and hope my points are noted...so much was wrong in this situation! Surely others see this but are being nicer than me.
All this and more was noted but I saw no benefit in going in too hard in this case. The OP is obviously feeling confused, guilty, fragile and mixed-up, I wanted her to feel she could respond and not alienate her.
I agree it's beyond awful that anything like this could happen to an acutely vulnerable person. It crossed my mind to ask how people who have actually committed a crime would be treated in the local area.
There has also been no mention of de-escalation techniques, warning signs or the use of appropriate medication if a patient happened to be dangerous. In this scenario, as painted, a gentle young man who was thinking about taking his life was treated like he was potentially homicidal. Handcuffs? None of his experience was going to make him feel LESS depressed.
I'm kinda hoping the OP might be able to change practice or policy at her workplace if she feels strongly enough about this.
Again, it's not clear that an indwelling catheter has been placed. Time has been compressed by the narrative. We only have a sequence of events. The sequence of events occurred over a nonspecific period of time. In the real world, the urine results have to be back before the inpatient facility will accept the patient, so it's clear to me that at the very least, an hour has passed between the time of the catheterization and the time the patient left the ED (because it will take about 30 minutes for urine results to be posted, then another stretch of time for the physician to communicate, for the transportation arrangements to be made, and for secure transport to arrive - most likely more than 30 minutes, meaning that the period of time between the catheterization and the patient leaving the ED had to have been at the very least an hour). This completely ignores the fact that the qualified mental health professional who will assess the patient to determine the level of threat they pose to their own safety and whether this warrants inpatient admission may not assess the patient until after the urine results are back, so we could be talking a much longer period of time than one hour.
Since the original poster is clearly taking dramatic license and compressing time, we cannot reliably know that a foley catheter was placed. This is an assumption on the reader's part; an assumption that serves the writer well in her effort to paint the picture of inhumane treatment of a sympathetic individual at the hands of the medical establishment.
Thank you, especially for the part I have bolded.
The patient was poorly handled from the beginning --
Not being directed to an appropriate room, creating the situation that he needed to walk from point A to point B clad in only a hospital gown
Being given an inappropriately sized gown -- if you grab the wrong gown by mistake, how much effort does it take to say, "oops - hang on - let me get another one"? And why no second gown to cover the back ... or scrub/pajama pants?
Why no socks? Since when do we allow any hospital patient to walk around barefoot? Still too busy admiring the patient's feet?
Yes, a urine specimen is required for a UDS, as well as either a breathalyzer or blood ETOH level. But this could have been handled so much better. And BTW - OP has provided no evidence that any catheterization was performed -- only that she perceives that "girls at the desk" were talking about it.
When it was time for the patient to be transported to the inpatient facility, supposedly he was handcuffed. This would be a violation of health department regulations and most EMS agency policies. I have treated and admitted many psych patients -- none have been restrained except temporarily during an episode of violent behavior. In short ... I'm not buying it.
The only thing I am convinced of from the OP -- is that her own practice with the patient was poor to say the least. If the OP was written as some kind of catharsis -- it would be nice to see some recognition of this, and some resolve to improve.
I respectfully disagree. safety is the end all be all. The lowest level of intervention required to ensure the safe care of the patient is always the goal, as it also preserves the dignity as much as possible. However, in the hierarchy of needs safety is a more basic need than esteem.
Not all suicidal persons have the same level of risk to self harm. Unless the person is in severe psychosis, there is always ambivalence at play. Especially with someone who recognize their own feelings, determine that they need help and set about to seek that help. And that assessment ( of the risks to self harm) is done by simply talking with the person.
This cookie cutter approach used here implies that every person who thinks about suicide is a time-ticking bomb waiting to explode. Not so. A majority of depressed people are in fact non violent.
To insist on striping someone of his or her dignity, under the guise of safety, might precipitate a peaceful situation into possible violent acts. All this when said person only wanted to explore their own feelings with a professional therapist.
I will say it again, safety is not the end all be all. Comon sense must be applied.
I respectfully disagree. safety is the end all be all
Hello wolf9653,
I recognize that safety is important. As I have mentioned in one of my previous post, I can see - and certainly agree with - to some safety measures when the person is obviously a danger to themselves or others. But I do not equate suicide ideation with obvious danger. It is not that simple. That is only one of the factors to consider before implementing any measures.
Again, a careful assessment has to be done to evaluate those risks.
I have thought about this scenario and wonder how I would have handled this if the roles were reversed. My friend brings me to the ER because I have confided to him that I'm suicidal. Suppose The nurse is a male and he asks me to remove my clothing just like the previous story and then has to cath me because I can't pee ( in front of him and with handcuffs on ), watches me constantly to make sure I am not a threat. Then the final insult is a gown that is too small and is open in the back as I tread through the ER to the van that is to take me to the Psych Unit with a male driver no less. I might get a little hostile !
I respectfully disagree. safety is the end all be all. The lowest level of intervention required to ensure the safe care of the patient is always the goal, as it also preserves the dignity as much as possible. However, in the hierarchy of needs safety is a more basic need than esteem.
I have thought about this scenario and wonder how I would have handled this if the roles were reversed. My friend brings me to the ER because I have confided to him that I'm suicidal. Suppose The nurse is a male and he asks me to remove my clothing just like the previous story and then has to cath me because I can't pee ( in front of him and with handcuffs on ), watches me constantly to make sure I am not a threat. Then the final insult is a gown that is too small and is open in the back as I tread through the ER to the van that is to take me to the Psych Unit with a male driver no less. I might get a little hostile !
That is one of the reasons why I do not believe using the baseline every-suicidal-person-is-high-risk nonsense actually work. Don't get me wrong; it's safe (if that's all you care about) but it isn't very effective in helping a suicidal person. In a situation where a person readily recognize he or she needs help, and sets about to get that help, it causes undue embarrassment, humiliation, and can certainly lead to hostile situation when there is absolutely no need for it. Who, in their right mind would accept to be treated that way?
Although to be fair, if I read OP's post correctly, the handcuffs only went on when they were ready to transport the guy from the ED to the psych clinic.
I disagree with you, Farawyn. So-called "high-risk" kicks in once the specific situation of the person has been assessed. Until then, it is just guess work. If that.
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Farawyn
12,646 Posts
No, that is not our initial intervention. If a child is suicidal it is escalated immediately.
But when the student comes back to school this is part of what we use.