Removing out of concern of privacy although details had been significantly changed.
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Sending clients to the ER
- Thread starter psychma
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1) You did the right thing and you know it.
2) No one wants to go to the hospital. It's unpleasant. But there is a difference between getting better and feeling better.
3) For treatment, the prerequisite is having a living human being. So... you know... you should probably first keep your patients alive.
4) You had two choices:
a. Hospitalize them. If this turns out to be a bad choice, the consequences are some extra medical bills
b. Don't hospitalize them. If this turns out to be a bad choice, the consequences are a dead person.
That's an easy choice.
5) I don’t know what medications you are referring to, but things like lithium and depakote build up in "your system", resulting in neurological signs, kidney failure, etc. The half lives of some of these approach 30hrs. That means that this wasn't going to get better on its own. Plus she was going to be out of medication soon, which is another problem. The former is a life threatening emergency, the latter is likely to lead to decompensation resulting in hospitalization anyway.
2) No one wants to go to the hospital. It's unpleasant. But there is a difference between getting better and feeling better.
3) For treatment, the prerequisite is having a living human being. So... you know... you should probably first keep your patients alive.
4) You had two choices:
a. Hospitalize them. If this turns out to be a bad choice, the consequences are some extra medical bills
b. Don't hospitalize them. If this turns out to be a bad choice, the consequences are a dead person.
That's an easy choice.
5) I don’t know what medications you are referring to, but things like lithium and depakote build up in "your system", resulting in neurological signs, kidney failure, etc. The half lives of some of these approach 30hrs. That means that this wasn't going to get better on its own. Plus she was going to be out of medication soon, which is another problem. The former is a life threatening emergency, the latter is likely to lead to decompensation resulting in hospitalization anyway.
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Probably, and at minimum, clearly defensible and understandable. Trust your gut that you trusted in that moment. You say she had "signs of a concussion" - based on her reporting there should have been a reason to believe she could have already been in the middle of an acute life threatening emergency, perhaps had taken something that day and lied to you. The fact that other professionals then evaluated her and felt she met the criteria for an involuntary hold should serve as further evidence that you made the right call. I also often believe that when patients engage in certain types of behavior (e.g.: coming into the ER and saying they don't want hospitalization, then coming back; or lying to you and then eventually sharing it with you) they are doing this because some part of them really does realize that they need to be hospitalized and are in a dire emergency, but for a variety of reasons cannot fully accept that.
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This one is a bit more complicated because of the potential medical concerns so agree with calling in the troops. When I have been in similar situations, the need goes from assessing suicide risk to evaluating medical risk which is outside our scope and necessitates further action.
Sanman
O.G.
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She is not actively endorsing suicidal ideation, but has already developed a plan, engaged in high risk prepatory behaviors resulting in significant self-harm, and seems to lack insight into the severity of her concerns. You took the right steps. Once she is released, getting her switched to an alternative medication that cannot be overdosed on (if possible) and creating a safety plan to address recurrence of such behavior would be a good thing. On the chance that she does not show up to therapy any longer following release, breathe easy knowing you made the correct call and are covered. At the end of the day, the goal is to reduce self-harm. Beyond that, we hope for the best.
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Sounds like even if you're having some doubts now, you would've had more (and more significant) doubts if you'd done the alternative. When in doubt, do what's in the best interest of your patient and their safety, which is what you did. You've built a therapeutic relationship with this person; if you didn't believe that she would be safe, there's probably something to that.
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It sounds like you just sent her the ED rather than admitting her, right? If the ED didn't think she needed hospitalization, they would have released her (at least, that's happened with patients in the past).
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You did the right thing. It's never fun to make such a call but, you showed some real competence here.
Kind of reminds me of something that happened a few weeks back.
I recently saw a minor patient (age 8) - referred for an evaluation to see if the kiddo has ADHD in addition to ASD. The first time I saw the patient they showed up about 20 minutes late and ended up ransacking my office. I couldn't finish the intake so we scheduled a follow up. Of course their parent is a last-appointment-on-fridays type parent. They again show up late. The kid will not transfer to my office and proceeds to begin throwing chairs in our waiting area. Kid then accesses mothers car keys from her purse (why mother allowed this, I will never know) and elopes to the parking lot. Thankfully the parking lot was dead and myself, interpreter, and head nurse were able to beat the kid out.
At this point, I'm pretty concerned, and suggest that mother take kid to nearby kid hospital for inpatient evaluation - given the dangerous behavior and that interpreter heard a suicidal threat. I also suggest a med consult at our facility because we have some rad prescribers. Mother says "Kid is already prescribed a med but we haven't given it because we're concerned about side effects." Either way, kid is likely not stable enough to test at this juncture and I'm not sure if delineating an ADHD dx is valuable right now.
Personally, I think it's probably more likely ODD and maybe autism. But who knows? I think some vitamin Abilify will help the kid engage in some behavior that is more conductive to learning.
I give mom two options, I can either call an abulance or mom can take kid if she thinks she can safely do it. Mother agrees to take kid in and I have our social worker coordinating care with the ED.
Monday rolls around, and my amazing social worker calls mom who didn't take the kiddo in because "she calmed down in the car" and "dad talked to her about her behavior."
I'm super annoyed - because it's obvious that this parent is the "I'm just gonna do what ever the frick I want and not listen to treatment team." I still suggest that they take the kid in because of the suicidal threat. Thankfully, they were already established at another community healthcare center. I also suggest they look into intensive outpatient treatment and offer to make the referral.
Either way, I simply can't have that level of explosive behavior in our lobby. We deal with medically complex and fragile kiddos. We just cannot provide the level of care this kid needs.
But, it's just super frus when this stuff happens. Even worse is on a Friday, last patient. I bet you thought about it a lot this weekend. I'm sorry dude.
Kind of reminds me of something that happened a few weeks back.
I recently saw a minor patient (age 8) - referred for an evaluation to see if the kiddo has ADHD in addition to ASD. The first time I saw the patient they showed up about 20 minutes late and ended up ransacking my office. I couldn't finish the intake so we scheduled a follow up. Of course their parent is a last-appointment-on-fridays type parent. They again show up late. The kid will not transfer to my office and proceeds to begin throwing chairs in our waiting area. Kid then accesses mothers car keys from her purse (why mother allowed this, I will never know) and elopes to the parking lot. Thankfully the parking lot was dead and myself, interpreter, and head nurse were able to beat the kid out.
At this point, I'm pretty concerned, and suggest that mother take kid to nearby kid hospital for inpatient evaluation - given the dangerous behavior and that interpreter heard a suicidal threat. I also suggest a med consult at our facility because we have some rad prescribers. Mother says "Kid is already prescribed a med but we haven't given it because we're concerned about side effects." Either way, kid is likely not stable enough to test at this juncture and I'm not sure if delineating an ADHD dx is valuable right now.
Personally, I think it's probably more likely ODD and maybe autism. But who knows? I think some vitamin Abilify will help the kid engage in some behavior that is more conductive to learning.
I give mom two options, I can either call an abulance or mom can take kid if she thinks she can safely do it. Mother agrees to take kid in and I have our social worker coordinating care with the ED.
Monday rolls around, and my amazing social worker calls mom who didn't take the kiddo in because "she calmed down in the car" and "dad talked to her about her behavior."
I'm super annoyed - because it's obvious that this parent is the "I'm just gonna do what ever the frick I want and not listen to treatment team." I still suggest that they take the kid in because of the suicidal threat. Thankfully, they were already established at another community healthcare center. I also suggest they look into intensive outpatient treatment and offer to make the referral.
Either way, I simply can't have that level of explosive behavior in our lobby. We deal with medically complex and fragile kiddos. We just cannot provide the level of care this kid needs.
But, it's just super frus when this stuff happens. Even worse is on a Friday, last patient. I bet you thought about it a lot this weekend. I'm sorry dude.
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Agree with others. Safety first, concern about the relationship comes second here. It seems like the person may have needed medical care as well as a psychiatric evaluation.
Also, hindsight is 20/20. It might also help to think about the litigation possibility had you done nothing and the unthinkable happened. Having a current client who had been actively suicidal and engaging in extremely dangerous behaviors near the time of an appointment would’ve given the person’s family a decent case against you should anything have happened and you just went with the person’s word in the current moment, which seems like it could’ve changed quickly given the recency of the dangerous behaviors. Also, taking toxically high levels of medication for like a few weeks or so shows planning and intent over time on top of that. Intent was very high here, even though the person claims to be safe at this moment.
You did the right thing, in my opinion.
Also, hindsight is 20/20. It might also help to think about the litigation possibility had you done nothing and the unthinkable happened. Having a current client who had been actively suicidal and engaging in extremely dangerous behaviors near the time of an appointment would’ve given the person’s family a decent case against you should anything have happened and you just went with the person’s word in the current moment, which seems like it could’ve changed quickly given the recency of the dangerous behaviors. Also, taking toxically high levels of medication for like a few weeks or so shows planning and intent over time on top of that. Intent was very high here, even though the person claims to be safe at this moment.
You did the right thing, in my opinion.
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I almost always go with the most conservative approach, which in the OP case would be the ED and let them evaluate the patient. Make sure to have solid documentation too.
You did the right thing by sending them.
I'm thinking you did the wrong thing by posting this though, as it seems detailed enough it would be over my line for comfort describing in a public forum? Will defer to @AcronymAllergy and @futureapppsy2 .
I'm thinking you did the wrong thing by posting this though, as it seems detailed enough it would be over my line for comfort describing in a public forum? Will defer to @AcronymAllergy and @futureapppsy2 .
Details were changed to make this unrecognizable, but I will delete.
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