Since mental health coverage seems headed the direction of women’s health… and actual women in the Trumpcare room… I thought suicidality might be the right next Anxiometer post.

As for chest pain and belly pain, Pre-R shouldn’t be tops on your list of resources to call if you’re feeling suicidal. However, similarly, it’s worth knowing your local resources and what to expect should you take your suicidal thoughts, or your distressed loved ones, to an emergency department.

Frankly, I’ve been avoiding this Anxiometer post because it’s a sensitive topic. We all bring our own baggage, beliefs and histories. Perspectives on suicide itself are all over the map. My aunt with end stage MS killed herself in the early 90s. I can count three doctors who I’ve worked with who have also taken their lives. While shootings get plenty of press in the US, unfortunately, our suicide rates exceed homicide.

Here are the words that push us one way or the other in the ER:

Red Flags:

• Suicidal with a plan
• Access to weapons (guns in particular)
• Access to potentially toxic medications (tricyclics, narcotics…)
• Actual actions taken (like overdose, hanging…)
• Psychiatric comorbidities (mania, depression, schizophrenia…)
• Concrete reasons (terminal illness, isolation, bankruptcy, recent loss…)

Happy Words

• Good social supports at home
• An actual home
• Intoxication
• Numerous previous failed attempts
• Well connected with a psychiatrist and/or case manager
• “I’m not really suicidal, but I’m hungry and it’s cold out.”

For anyone feeling low and seeking help through an emergency department, prepare for a turbulent ride. If you weren’t suicidal on entry, you may be by the time you leave hours later. Frankly, I believe our current approach to the topic may amplify suicidality.

We treat patients with mental health problems like radioactive matter with lawyers. We guard them closely and sometimes we involve “sitters,” who are people who will literally sit in a room for 8 or more hours to make sure patients don’t succeed when we step out. However, I’ll admit that we rarely go deep. Time to reverse what may be causing suicidality is limited in the ER with numerous competing forces, like patients with chest pain, fractures, vomiting, and the like… not to mention complicated EMRs.

We do what we can to deal with medical emergencies. Then when “medically cleared,” suicidal patients are generally sent to people and buildings far away. In 20 years I can count on my fingers the number of psychiatrists I’ve physically seen in ERs. Maybe that’s best for patients, but personally, I’ve always wished for more face time with these docs.

If a patient has overdosed or ingested some poison, we do what we can to limit its effects. Often we ask patients to drink liquid charcoal to absorb the toxin. If patients don’t cooperate then sometimes we’ll insert a tube from nose to stomach to pour charcoal in directly. Most patients cooperate. Sorbital or magnesium citrate may be added to move the charcoal and toxins along.

Urine is collected and blood levels drawn for what are commonly called the “psyche panel.” Sometimes EKGs are done as well. Presence of alcohol or other drugs greatly impacts subsequent care. Surprisingly, drunk or high may mean no future psyche care at all. So we wait until patients are sober to see if they still feel like ending it. If patients wake up saying they are no longer suicidal, they’re often released into the wild. In some hospitals, ongoingly suicidal patients can wait for multiple shifts, or days even, to be transferred to mental health facilities.

Long story short, mental health services are suboptimal even under Obamacare. Improvement under the new team doesn’t feel likely. So if you’re struggling, find out your local suicide prevention hotline line number. The San Luis Obispo mobile crisis team can be reached at 800-838-1381. Incredible people take those calls. For relatives or friends, research what else may be available in your communities.

Another option is: The ER should be a last resort. Of course, you can try Pre-R as well. I can be a good listener. But realize that mental health medications and services aren’t our forte.

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