Suicide prevention or detention? You tell me.

I'm working through an emergency call I participated in the other night that is kind of bothering me.

We got a call for a psych transport.  It seems that the patient was on the phone with her therapist and something she said (I don't know exactly what) alarmed the therapist, who called 911, who dispatched the rescue squad and the police.  There was some sort of concern that she was a suicide risk, and protocol dictates that suicide risks MUST be taken in for a psychiatric evaluation.  (I should note that there was an unrelated suicide in town the day before, so maybe everyone was a bit extra on edge.)

Long story short...this particular patient did not strike me as terribly suicidal (but I am not qualified to judge), and emphatically did NOT want to be evaluated.  However, under threat of arrest she allowed herself to be taken to the ER.  Which she wished to leave, immediately, because she felt she was fine, and she had committed no crime.  Except that once at the ER, they have to take a suicide risk seriously, and have to lock her up until they determine that she's actually not a suicide risk.  My discomfort comes from my participation in requiring her to follow this process, against her will.  I should also note that this patient was pretty close to my age, so perhaps the incident hits a little closer to home than I might like to think.

When we got to her home, the patient was sitting in a chair, part irate, part frustrated, part tearful, being lectured/cajoled by a state cop.  (I'm not sure why state cops were called in, instead of local...might be because there was a lot of other cop activity in town earlier...it was a crazy night.)  It transpired that the cop was calm but firm that if the patient did not get in the ambulance of her own accord, she would be taken in, in handcuffs.  She insisted that there was nothing wrong with her, she did not need to go to the Emergency Room, she did not wish to leave her home (and her dog), she was fine.  The cop was adamant about those handcuffs.  So she came with us.  She was clearly a bit alcohol-impaired, as she stumbled a lot getting out of the house.  However, her conversation was perfectly clear and coherent.  In the ambulance she claimed that she had only had 2 glasses of wine and nothing else, including no medications, which I don't know if I should believe, given her lack of coordination.  The whole time she was cogent and more or less cooperative with us, if a bit whiny (as I would probably have been in a similar situation). She was clearly not happy about being forced to go to the hospital.  She talked to her friend and her brother on the ride, and insisted that as soon as she got to the hospital she would be returning to her home.

I am very grateful for the presence of my crewmate.  He was kind but very firm in reiterating several times that (1) we were just the messengers and (2) she HAD to go to the ER.  I am not certain that I could have been so assured.  I tried to reassure her that we were there to support her and make sure that she is safe and well and that at the ER they would probably send her home immediately.

Upon arriving in the ER, our protocol is to (1) provide details about the patient to the intake nurse; (2) obtain a bed for the patient from the ER supervisory nurse; (3) accompany the patient to the bed and help them into it; and (4) officially transfer care by making a report on the patient to their assigned nurse. A patient is the rescue squad's responsibility until we complete step 4.

While we were waiting for step 1 (the intake nurse was MIA for a couple of minutes) the patient made motions to climb off the stretcher and leave the ER.  This made me nervous for several reasons, including (a) the stretcher hadn't been lowered, so that in her slightly inebriated state she might have fallen off and hurt herself, and (b) if she runs off without our check-in, it raises all sorts of questions, especially for a suicide risk.  So, again, with a little discomfort on my part, we talked to her and calmed her down and encouraged her to sit still and allow herself to get evaluated.  Another crew member got a wheelchair and we helped her into that, with the hopes that it would make her feel a little less like a seriously ill person.  The intake nurse tried to get her to sign the paperwork that gives consent for treatment (which of course she refused to sign), and tried to put the hospital bracelet on her, which at first she refused, but eventually allowed.  The ER staff, at this point, recognized that we had a serious "elopement risk" on our hands (yes, that is the technical term), and they whisked us into the psych wing of the ER (step 2 accelerated), to wait for steps 3 and 4.

The psych wing of the ER is a very special place.  Unlike the rest of the ER (where there's pretty free access to everything and patients and family wander at will), you can't get in there without a special badge.

You also can't get out without a special badge.

And there's no working patient bathroom in there.

You want to pee?  You WILL be accompanied by a security guard.

When we got her into her assigned room, the patient was, of course, still planning to make her exit.  She asked for water (which we are not allowed to provide) and a bathroom (see previous paragraph).  She got up and walked to the door of the psych wing.  Which, of course, didn't work for her.  I think that's when it really hit her.  At least that's when it truly hit me.

She asked me to be let out so she could go to the bathroom.  Presumably with the intention of sneaking out from there.  I could not have helped her with this, even if I felt it right to do so.  So a security guard was summoned. 

That was the last I saw of her. 

Even before we left her home, I was reflecting on how I would wish to be treated in a similar situation.  And throughout I felt obligated to do what I would not wish done to me.  I am reminded of the very short story by William Carlos Williams, The Use of Force (an excellent read if you haven't already).  I am very comfortable that IF she was actually a suicide risk, we did everything right and acted as compassionately and respectfully and helpfully as anyone could wish.  I would not want it on my conscience that I didn't bring someone in, who I could have, and then have that person end up committing suicide.  What I am NOT so comfortable about is whether our response was more helpful than harmful to a person who was NOT a suicide risk.  It felt to me like the standard definition of a tragedy:  everyone does what they are SUPPOSED to do, and yet we get a bad outcome.

I can easily see myself venting about a crappy day to someone.  Maybe that person hears something I did not intend.  Maybe that person doesn't know me so well.  Maybe that person is a little overly sensitive because they've experienced a suicide in their family.  Maybe that person is a mental health professional who has liability insurance to consider.  Maybe that person is a close friend who doesn't want to take ANY chances with my well-being.  But once they make that call, and the police get involved, I am essentially guilty of suicidal thoughts until proven innocent, and will suffer a corresponding loss of autonomy until I can clear myself.  Frankly, in the patient's position, I think I'd have been far more enraged and probably far more verbally abusive to anyone within earshot.

I have to wonder whether these kind of considerations deter a lot of people who might want and benefit from mental health treatment from getting it.  I suspect that people know that once you get flagged for mental health issues, you are at risk for having parts of your autonomy taken away in various low-risk situations, so why allow yourself to get flagged in the first place?   And wouldn't having part of your autonomy taken away further undermine your mental health, leading to a downward spiral?

I wish the best for this patient.  I fervently hope that she has no suicidal tendencies, and that this incident will be speedily forgotten, and that whatever bad day she was having that triggered these events will not repeat.  I hope that she will continue to receive whatever mental health services she needs, from a therapist who will be therapeutic for her.

And mostly I want to know better how to do right for patients in this sort of situation.  Which is probably impossible.  Without being able to look directly into another person's heart, I don't know that we can ever really know what is the best and safest course of action, even when we have the best intentions.  In the absence of perfect knowledge I believe we did the right thing.  I just wish I felt more convinced.