tips for dealing with suicide threats?

[bearstanley]

EM intern. common occurrence at my shop: pt presents with SI / seeking dual diagnosis bed. psych evaluates the patient and calls me to say they're clear to go to regular detox. when i communicate this to the sleeping patient, they acutely deteriorate and start yelling that they're going to kill themselves, why don't you believe me, i'm going to overdose and you'll be liable, how do you live with yourself- all peppered with expletives, etc.

i always have security present, but i just don't know what to say to this cohort of patients. i have a very chill bedside manner and am generally very well liked by patients (even typically challenging DCs), but i have not found an effective strategy for these folks.

my go to line has been basically "psych determined that you are stable enough to go to detox. i would strongly encourage you not to kill yourself." but that seems pretty weak.... right?

any tips?

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[slurpy15]

EM intern. common occurrence at my shop: pt presents with SI / seeking dual diagnosis bed. psych evaluates the patient and calls me to say they're clear to go to regular detox. when i communicate this to the sleeping patient, they acutely deteriorate and start yelling that they're going to kill themselves, why don't you believe me, i'm going to overdose and you'll be liable, how do you live with yourself- all peppered with expletives, etc.

i always have security present, but i just don't know what to say to this cohort of patients. i have a very chill bedside manner and am generally very well liked by patients (even typically challenging DCs), but i have not found an effective strategy for these folks.

my go to line has been basically "psych determined that you are stable enough to go to detox. i would strongly encourage you not to kill yourself." but that seems pretty weak.... right?

any tips?

You are taking this too much to heart. As long as they aren't threatening YOU, then don't worry, have security present, and document. Is detox monitored and are they reassessed for SI when they are sober? If so, don't worry, move on. Be glad you have detox! We keep these patients in the ED until they are sober enough for a psych consult. Now THAT'S a headache. Usually they are very remorseful for any indiscretion when sober. It's the substance talking, not them. Grab another chart and move along.

 

[emergentmd]

As you have noted. They are unreasonable.

Many times, I just put the discharge up and they disappear. If I have to talk to them, its from a far distance. State it one sentence and walk away

 

[Siggy]

You are taking this too much to heart. As long as they aren't threatening YOU, then don't worry, have security present, and document. Is detox monitored and are they reassessed for SI when they are sober? If so, don't worry, move on. Be glad you have detox! We keep these patients in the ED until they are sober enough for a psych consult. Now THAT'S a headache. Usually they are very remorseful for any indiscretion when sober. It's the substance talking, not them. Grab another chart and move along.

Not nearly as much of a headache as admitting these patients to medicine. ;-)

 

[GeneralVeers]

If I really think they are malingering I just ignore it and discharge them. If no one documents suicidality then it's not a problem. Typically I can get the nurses on board to not document any suicidal threats if that isn't the chief complaint they came in for.

 

[Rendar5]

1. At my shop there is a large detox population, and they will Threaten suicide if they find out that they cannot go voluntarily to detox. In these cases I always document Lack of SI so that if they try to change their mind I just say that I’m sorry but you already denied suicidality and it’s too late to change your mind.

2. If you work someplace where you consult psych all the time I don’t see what the issue is other than you taking it to heart.

“Psychiatry has seen them and determined they are low risk of suicide completion. Patient was informed of this and had to be escorted out by security after becoming belligerent on finding out they didn’t meet admission criteria”

If they scream at me, I just tell them to have a good day. If they threaten to kill themselves I tell them that if they do, I’ll be happy to see hem again. I spend no more than 15 seconds interacting with this type of patient at time of discharge, and I’m someone that usually takes the time out to chat with patients and family.

 

[RoyBasch]

As you have noted. They are unreasonable.

Many times, I just put the discharge up and they disappear. If I have to talk to them, its from a far distance. State it one sentence and walk away

This is it. These people are very manipulative. They have been cleared by a qualified mental health professional. Liability is served and they are processed. I don't spend very much time having irrational conversations with irrational people.

Just pull the pin, throw the grenade over your shoulder, put your sunglasses on and walk away. Cool guys don't look at explosions.

 

[The White Coat Investor]

Be glad you have psych. All I get is a crisis worker then it's on me to decide if they get admitted or not. So if I'm in doubt, I send them to the psych unit. If the psychiatrist thinks they're malingering, they can discharge them.

So yea, I'd use a line like you're using. "The psychiatrist disagrees and thinks you won't kill yourself. There's nothing I can do but I hope you don't and that you find meaning and happiness in your life." Then escorted out the door by security if necessary.

When you go choose your big boy/girl job, choose someplace in the suburbs with a better payor mix and you'll deal with this sort of stuff a lot less. Don't assume all patient populations are like those in ivory towers, trauma centers, county hospitals, inner cities, and residency programs (which are often all of the above). There actually are ED patients who haves homes, jobs, and insurance out there.

 

[slurpy15]

Be glad you have psych. All I get is a crisis worker then it's on me to decide if they get admitted or not. So if I'm in doubt, I send them to the psych unit. If the psychiatrist thinks they're malingering, they can discharge them.

So yea, I'd use a line like you're using. "The psychiatrist disagrees and thinks you won't kill yourself. There's nothing I can do but I hope you don't and that you find meaning and happiness in your life." Then escorted out the door by security if necessary.

When you go choose your big boy/girl job, choose someplace in the suburbs with a better payor mix and you'll deal with this sort of stuff a lot less. Don't assume all patient populations are like those in ivory towers, trauma centers, county hospitals, inner cities, and residency programs (which are often all of the above). There actually are ED patients who haves homes, jobs, and insurance out there.

I have to say I find psych and drug/alcohol problems to be a much bigger issue in the extremely affluent (one of the wealthiest counties in the US), non-diverse community in which I live and practice. The wealthy have just as many, perhaps more, psych and alcohol problems as the poor, and unlike the poor they can negotiate their way out of everything. So many "functional" alcoholics, suicidal teens, noncompliant bipolar executives, rich axis 2 spouses, teen cutters and cocaine users, alcoholic, dysfunctional scions of families whose names you would recognize. I agree that certain areas have less of this, but I can't, IME, correlate it with payor mix, but with work. Those who need to work, and do work, seem to have many fewer of these problems than others. Some of these workers are poor, some are rich. I would say that immigrant communities seem to have much less of this than middle America.

YMMV. But the rich can be just as screwed up as the poor, and they are way more entitled about what they want. And they have lawyers.

 

[emergentmd]

Psychs are the easiest patients. I rarely even touch them, history from EMS, pan psych labs, telepsych, and either discharge/admit. Most the time I don't even come back to talk to them.

 

[RustedFox]

I have to say I find psych and drug/alcohol problems to be a much bigger issue in the extremely affluent (one of the wealthiest counties in the US), non-diverse community in which I live and practice. The wealthy have just as many, perhaps more, psych and alcohol problems as the poor, and unlike the poor they can negotiate their way out of everything. So many "functional" alcoholics, suicidal teens, noncompliant bipolar executives, rich axis 2 spouses, teen cutters and cocaine users, alcoholic, dysfunctional scions of families whose names you would recognize. I agree that certain areas have less of this, but I can't, IME, correlate it with payor mix, but with work. Those who need to work, and do work, seem to have many fewer of these problems than others. Some of these workers are poor, some are rich. I would say that immigrant communities seem to have much less of this than middle America.

YMMV. But the rich can be just as screwed up as the poor, and they are way more entitled about what they want. And they have lawyers.

My "home base" hospital is in a very wealthy suburb. You hit the nail right on the head.

My wife didn't believe it (in terms of pattern recognition) until there was a seizure issue with a family member, and I said [coldly]:

"This is a benzo-withdrawal seizure. [Family member] is fine. She simply ran out of [sic] Zannie-Bars (Xanax) because she broke up with her boyfriend."

The rebuttal came: "How can you say something as cold and and heartless as that?! What do YOU know about how [family member] is living?!"

Yep. Love you. Just wait.

Surprise; a neuro consult, a normal MRI, and a (confession) later...I'm right.

"How did you know?!"

"Every Sunday/Monday morning at the hospital is the *wealthy rehab club*... Either they ran out of drugs, pissed off their dealer, or just couldn't hang/needed an excuse to not show up at the country club on Monday afternoon. They're always looking for some overarching tragedy or obscure medical condition to cover their tracks."

I got stunned silence from the wife.

...

"Spend just one shift with me, sweetheart."

 

[slurpy15]

My "home base" hospital is in a very wealthy suburb. You hit the nail right on the head.

My wife didn't believe it (in terms of pattern recognition) until there was a seizure issue with a family member, and I said [coldly]:

"This is a benzo-withdrawal seizure. [Family member] is fine. She simply ran out of [sic] Zannie-Bars (Xanax) because she broke up with her boyfriend."

The rebuttal came: "How can you say something as cold and and heartless as that?! What do YOU know about how [family member] is living?!"

Yep. Love you. Just wait.

Surprise; a neuro consult, a normal MRI, and a (confession) later...I'm right.

"How did you know?!"

"Every Sunday/Monday morning at the hospital is the *wealthy rehab club*... Either they ran out of drugs, pissed off their dealer, or just couldn't hang/needed an excuse to not show up at the country club on Monday afternoon. They're always looking for some overarching tragedy or obscure medical condition to cover their tracks."

I got stunned silence from the wife.

...

"Spend just one shift with me, sweetheart."

Preach it, RF. I don't know where WCI works, but I'm assuming it's not an overly affluent area.

Teens overdosing left and right (I think we had two deaths last year in our smallish town), unsupervised while their parents are in Paris or St. Bart. Also love the benzo withdrawal patients on Keppra, the "family history of liver disease" cirrhotics, the middle-aged ladies who come in for the weird combo of benzo and Adderall refills, the panic attacks among the affluent teen girls, the DV cases where the husband is a high-powered Wall Streeter, the folks on the phone to their attorneys after I sign commitment papers, the family disputes where three lawyer relatives disagree, oh, and figuring out the private plane to rehab. The look of shock on parents' faces when I explain that yes, there is a big drug problem here among teens and that no, living in a rich, privileged, exclusive, monochromatic area did not protect their children but in fact exposed them to drugs.

 

[hamstergang]

psych evaluates the patient and calls me to say they're clear to go to regular detox. when i communicate this to the sleeping patient,

I'm confused -- psych evals the patient but then has you tell the patient what they determined? As a psychiatrist myself, this sounds like psych's job.

 

[engineeredout]

We have no in house psych, crisis person, whatever you'd like to call it. Just an inner city ed. Nothing infuriates me more when someone comes in and just says "I want detox". They have stable vs, not clinically withdrawing, and I tell them that I will provide a list of rehab facilities they can contact. They start getting angry saying I am required to transfer them to a facility for detox. I respond with No, I'm not required and even if I wanted to, there are virtually no inpatient psych beds I can just push you in to Fromm the emergency department. They're all full in the city and nobody is around to sort out your insurance issues (or lack thereof).

Then it comes with the "OKAY WELL I WANT TO KILL MYSELF". I sigh and go "no you don't". Her response is "YES I DO I WANT TO KILL MYSELF AND YOU CANT PROVE THAT I DONT".

Most frustrating **** I have to deal with. Every word gets documented. Patient ends up getting their wish and patient is sent to a CRC (which will usually give them their overnight stay and food)

This kind of **** is why I drink

 

[turkeyjerky]

We have no in house psych, crisis person, whatever you'd like to call it. Just an inner city ed. Nothing infuriates me more when someone comes in and just says "I want detox". They have stable vs, not clinically withdrawing, and I tell them that I will provide a list of rehab facilities they can contact. They start getting angry saying I am required to transfer them to a facility for detox. I respond with No, I'm not required and even if I wanted to, there are virtually no inpatient psych beds I can just push you in to Fromm the emergency department. They're all full in the city and nobody is around to sort out your insurance issues (or lack thereof).

Then it comes with the "OKAY WELL I WANT TO KILL MYSELF". I sigh and go "no you don't". Her response is "YES I DO I WANT TO KILL MYSELF AND YOU CANT PROVE THAT I DONT".

Most frustrating **** I have to deal with. Every word gets documented. Patient ends up getting their wish and patient is sent to a CRC (which will usually give them their overnight stay and food)

This kind of **** is why I drink

Maybe we should institute some sort of suicidiality stress test. Hand the patient a bottle of Tylenol and see what happens.

 

[The White Coat Investor]

Preach it, RF. I don't know where WCI works, but I'm assuming it's not an overly affluent area.

Teens overdosing left and right (I think we had two deaths last year in our smallish town), unsupervised while their parents are in Paris or St. Bart. Also love the benzo withdrawal patients on Keppra, the "family history of liver disease" cirrhotics, the middle-aged ladies who come in for the weird combo of benzo and Adderall refills, the panic attacks among the affluent teen girls, the DV cases where the husband is a high-powered Wall Streeter, the folks on the phone to their attorneys after I sign commitment papers, the family disputes where three lawyer relatives disagree, oh, and figuring out the private plane to rehab. The look of shock on parents' faces when I explain that yes, there is a big drug problem here among teens and that no, living in a rich, privileged, exclusive, monochromatic area did not protect their children but in fact exposed them to drugs.

No, it's a middle class people have jobs and insurance kind of place. Don't get me wrong, there's plenty of SI and psych. But there's a whole lot less "I am too suicidal" sandwich-seeking than I've had in other jobs. Maybe it's Utah. Either way, yay me!

 

[slurpy15]

No, it's a middle class people have jobs and insurance kind of place. Don't get me wrong, there's plenty of SI and psych. But there's a whole lot less "I am too suicidal" sandwich-seeking than I've had in other jobs. Maybe it's Utah. Either way, yay me!

Interesting. Thought Utah had a huge rate of substance abuse. But maybe less need for sandwiches.

 

[TooMuchResearch]

No, it's a middle class people have jobs and insurance kind of place. Don't get me wrong, there's plenty of SI and psych. But there's a whole lot less "I am too suicidal" sandwich-seeking than I've had in other jobs. Maybe it's Utah. Either way, yay me!

You know what makes me happy? SI I can fix with a sandwich. Better than drugs and years of outpatient therapy!

 

[turkeyjerky]

You know what makes me happy? SI I can fix with a sandwich. Better than drugs and years of outpatient therapy!

I wish it were that easy...we give out sandwiches to people in the waiting room if requested, and never kick people out (unless rowdy or threatening), and yet we're still swamped with them.