Annals of B Pod: Social EM Corner- Suicide Related Behaviors
/PATIENT PRESENTATION
A young woman with a past medical history of major depressive disorder presented to the emergency room via EMS for a report of intentional ingestion of an unknown substance. EMS reported that she was vomiting profusely on their arrival to the scene but during transport became increasingly lethargic. She was given intranasal Narcan with no improvement in clinical condition. On arrival to the ED, she was unresponsive and had oral cyanosis. Her intial oxygen saturation was in the mid-eighties, therefore she was placed on supplemental oxygen.
Social work contacted her family who stated that she has had several prior suicide attempts by ingestion. They were concerned when they found her vomiting and suspected she drank an unknown substance. Her sister provided collateral history that the patient had been drinking heavily over the last several days. The patient was notably uninsured due to losing her job six months ago, which prevented her from accessing psychiatric care during that time frame.
Despite supplemental oxygen, she remained hypoxic. Her venous blood gas demonstrated metabolic acidosis, hyperoxemia, and elevated levels of methemoglobin. In conjunction with the Drug and Poison Information Center (DPIC), intravenous methylene blue was initiated for suspected methemoglobinemia with moderate improvement of her symptoms over the next hour, including return of baseline mental status and resolution of hypoxia.
DISCUSSION
Suicide, the act of intentionally taking one’s life, is the fifteenth most common cause of death and accounts for 1.4% of deaths worldwide.[1] In addition, for every completed suicide there are approximately twenty attempts.[2] Prevention of suicide and adequate recognition of those at risk remains a national and international priority, with recent statements from committees including the World Health Organization and Joint Commission.[1,2] Patients at risk for suicide often interact with emergency medical care. Suicide-related behavior (SRB) accounts for 1% of all Emergency Department (ED) visits; additionally, greater than 8% of patients visiting emergency departments are likely experiencing suicidal ideation at the time of the encounter.[3-5] Nearly a quarter of patients presenting after a self-harm attempt will go on to have ED visits related to repeat attempts, often with increasingly dangerous means.[6] Each individual who commits suicide is bereaved by an average of six persons, all of whom are at increased risk for suicide in their lifetime, further compounding the burden of suicide on the healthcare system.[7] SRB also creates a financial burden; in the United States, the annual financial cost of suicidality is estimated to be greater than 40 billion dollars.[8]
While there is no standardized screening tool for SRB, there are well established trends that emergency medical providers may use to identify patients at risk.[9] Adolescents and patients in their early twenties are at increased risk.[10] Additionally, nearly 60% of patients evaluated for SRB in the ED are female.[11] With respect to gender and orientation, patients who identify as sexual and gender minorities present with SRB at a higher frequency, though the true prevalence remains unknown given that patients may not be asked and/or disclose their gender identity or sexual orientation at time of the visit.[12] Unsurprisingly, social and economic factors also have a significant impact on a person's risk of suicidal ideation and attempt. Patients who are single, experiencing unemployment, or have limited formal education are at the highest risk.[11] A nationwide study conducted in 2013 found that the rate of presentation to emergency departments for suicidal ideation was nearly double for economically disadvantaged persons compared to their wealthier peers.[11,13] Furthermore, patients who are uninsured or receive Medicaid made up approximately 53% of ED visits for SRB.[11] Finally, many patients who present to the ED with SRB have a history of mental health and/or substance use disorders. Mood disorders, such as depression, are the most common psychiatric comorbidity, followed by anxiety disorders and schizophrenia.[10] Persons with substance use disorders have similarly increased risk. The risk of suicide for persons with alcohol use disorder is ten times that of the general population; for those who inject drugs, there is a fourteen time greater risk of suicide.[14,15] It is vital that ED providers recognize these risk factors to identify and intervene for patients at highest risk for SRB.
After providers identify patients at high risk for SRB, including patients who present to the ED following suicide attempt or self-harm, they should perform a risk assessment to determine appropriate disposition. While many tools for such assessment exist, the American College of Emergency Physicians recommends against the utilization of risk assessment tools alone in the determination of appropriateness for discharge. Rather, they favor an approach that weighs risk factors, protective factors, and risk reduction.[16] Commonly cited risk factors include recent stressors (including bereavement, job loss, divorce, etc.), prior suicide attempts, access to lethal means, and concomitant substance use. Protective factors include familial support, connection to community, religious beliefs, and established care for mental health. Finally, risk reduction includes strategies such as lethal means counseling and establishment of a safety plan with involvement from loved ones.[16] This combination assessment can help providers understand who can be safely discharged and who would benefit from further psychiatric care.
If a patient is safe for discharge, especially in cases where care is likely to be limited by socioeconomic factors, they should be provided local mental health resources including psychiatric emergency services, nonprofit organizations, and contact information for crisis hotlines. In cases where patients are already connected to outpatient or group resources, attempts should be made to contact their provider to relay the reason for their ED visit and establish follow-up care, as this has been proven to reduce a patient’s risk. In Cincinnati, resources include the Psychiatric Emergency Services ED and community partners such as Talbert House and Greater Cincinnati Behavioral Health. The National Suicide Prevention Hotline is also an excellent resource and can be reached 24/7 at 988.
If providers are unsure about or concerned for the patient’s suitability for safe discharge, attempts should be made to engage hospital specific psychiatric resources. Examples include personnel with additional psychiatric training such as social workers or direct psychiatry consultation. When these services are not available on site, they may be available electronically though telephone or video services. Given the frequency of patients who present to emergency departments for SRB, providers should be aware of institutional policies and local laws regarding the care of this patient population.
CASE CONCLUSION
Upon recommendation of the DPIC, the patient was observed for approximately 8 hours following her ingestion, at which time methemoglobin levels were undetectable. The remainder of her medical work up was unremarkable. The patient disclosed that she ingested several tablespoons of sodium nitrite powder she purchased online. The patient was placed on a psychiatric hold and the family was notified. The patient was amenable to this plan. She was transferred from the emergency department to psychiatric care for further evaluation.
AUTHORED BY ALESSANDRA DELLA PORTA, MD
Dr. Della Porta is a PGY-2 in Emergency Medicine at the University of Cincinnati
EDITING BY THE ANNALS OF B POD EDITORS
REFERENCES
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14. Substance Abuse and Mental Health Services. Published 2010. Accessed March 6, 2023.
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