Occasionally you wish you were wrong, even if you knew you were not.
That is how we felt when, working in a Neurology Residency in a large New York City hospital, we went back to its Psychiatric Inpatient Unit (we are withholding the details for privacy reasons) for a follow-up on a patient that we had diagnosed with Migraines and started treating him, just some days earlier. In our first contact with him, aside from that neurological diagnosis, we noticed that he was in a heightened state of Anxiety/ Depression that seemed not to respond to his medication schedule. Before leaving the ward, we summoned his treating resident to recommend a Suicide Watch.
The pompous “Jersey Boy”—in charge of his clinical care—duly listened to us with a disgusting smirk on his face and then said: “thank you for your concern but you’re wrong. He is well medicated. Do us a favor. You treat his Migraines, and we’ll take care of the Psychiatric end. Agree?” In an utterly condescending gesture, he patted us on the back.
We kept mum as we did not want to engage in a quarrel with another resident that was more senior than we were; but we did observe the golden rule we had learned right at the start of our internship. CWA ( it means “cover your a**) We clearly wrote our fact-based recommendation in our Consultation sheet to comply with that maxim. When we returned to that ward there was a big commotion. As the treating team was duped into believing that this patient “was better off,” he was assigned as a kitchen helper for the next Thanksgiving dinner. And “the inevitable” happened.
When nobody was around, he improvised a noose with linen cloths in a pantry room, quickly threw it around a ceiling’s wood rafter, put it around his neck, got up on a chair and then jumped out, hanging himself. On our way to the ward, everybody was looking at us in total amazement. No, we were not a soothsayer, nor did we engage in crystal ball’s reading. We used our hard-earned medical knowledge and clinical criteria to diagnose “the obvious intentions” of a sick individual. Even if we flatly denied it, some colleagues (especially the ladies) were whispering behind our back that we in fact possessed “a secret gift.” It never hurts to impress the ladies…
Note. This reproduction of a World War II US Navy’s recruiting poster was taken from Wikimedia Commons.
There are 50-65 suicides of hospitalized patients in the USA, usually by hanging and less frequently by the ingestion of toxic substances, which is more common in the rare instance when a female patient is involved; they usually occur in the Psychiatry Units of large public or private hospitals, less frequently in better supervised private clinics or rehabilitation institutions. The Joint Commission has recommended the following Suicide Prevention strategies for clinicians:
- Review the patient’s clinical records and family history for risk factors.
- Screen all patients for suicide ideation using a standardized test.
- Review the patients’ answers before he/she leaves the office or is discharged.
- Engage the family members and other treating physicians for better results.
- Prepare admission and discharge protocols that specifically address this risk.
- Train all the members of the clinical team to look out for signs of this risk.
- Document all the decisions that were made to address this critical risk factor.
However, one of the most common clinical traps we can fall into is what we have described in Emotional Frustration – the Hushed Plague as follows:
“One of the most disseminated fallacies is that someone that attempts suicide must be in a manifest state of anxiety, depression, and despair. A misleading assumption. Many patients are clinically depressed but only a minority has suicidal ideation; similarly, some with suicidal thoughts never have signs of a major depression.
Moreover, when they decide to act, they reach a state of tranquility—akin to a Buddhist peace of mind. Depression is not synonymous with Suicide.”
We, health care providers, have a sacred duty to spot and treat these patients.
Stay distant. Stay safe. Stay beautiful.
What do you think? Please tell us.
Don’t leave me alone.