Do Others Say Patient Is Dangerous?
Do Others Say Patient Is Dangerous?
Take it seriously and track down witnesses
A 25-year-old male patient is brought to an ED because of suicidal statements made to his ex-wife. The patient arrives via police escort and is placed in a room. The ED nurse assesses the patient, who denies suicidal ideation or intent. Although the man admits to drinking alcohol, he does not appear to be overtly intoxicated and is coherent. The ED is extremely busy, and the physician assistant (PA) picks up the chart.
After the police officers leave, the patient tells the PA there was a "misunderstanding" and assures the PA that he is not suicidal. The PA briefly mentions the patient to the ED physician and orders a basic medical screening evaluation. The intent is to request a formal psychiatric assessment of the patient once he is "medically cleared."
Two hours later, the physician goes into the room to examine the patient, but the patient is gone. The PA and nurse inform the physician that the patient denied suicidal thoughts, and the physician dictates a note that the patient "did not appear to be actively suicidal and eloped from the department against medical advice."
Several hours later, toward the end of his shift, the ED receives a call from the paramedics who inform him that the patient, who had been in the department the same evening, shot and killed himself in the front lawn of his ex-wife's house. The patient's parents successfully sue the emergency department and hospital.
Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS and codirector of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH, says that the main lesson learned from this case is that it behooves the emergency physician to take the time to "track down" witnesses to the behaviors and statements made by the potentially suicidal patient prior to the ED presentation.
"Police officers and paramedics could be a valuable resource, either through personal observation, or as a lead to others who witnessed the patient's suicidal remarks or gestures," says Garlisi.
Garlisi acknowledges that this can be a time-consuming and often frustrating exercise for the ED physician. However, he says that these efforts often will yield the "evidence" necessary to justify forced detention of the patient. This eliminates the risk of elopement, and allows for medical and psychiatric evaluation and safe, appropriate disposition of the patient.
"Physician failure to perform this 'due diligence' in the assessment of a potentially suicidal patient leaves the door open for adverse clinical outcomes and medical-legal complications," warns Garlisi.
Mariann Cosby, RN, principal of MFC Consulting, a Sacramento, CA-based legal nurse consulting firm, was an expert witness on a case involving a patient transferred from an ED to an inpatient psychiatric facility. Although the patient was a suicidal risk and on a 5150 hold, he was cooperative in the ED and didn't appear to be acting out or volatile.
When he was placed in the ambulance for transfer to the inpatient mental health facility, the ambulance attendants did not restrain the patient's arms or legs. "The patient ended up escaping out the back of the ambulance while it was at a signal. The patient fled and ended up killing himself," says Cosby. "The lesson learned, of course, is that the ambulance staff should have restrained him."
ED staff should be sure to clearly convey and document the patient's statusa 5150 hold due to suicidal threatsto the transport staff.
Include Family Members
Andrew Slutkin, an attorney with Silverman Thompson Slutkin & White in Baltimore, MD, says that he has seen several "failure to prevent suicide" cases involving the ED. "In my cases, interviews with the family members who brought the patient into the ED would have revealed information that the patient did not disclose to the ED. This would have prevented the ED from discharging the patient," says Slutkin.
In one case, a young man had no history or mental illness, yet over a few days he became psychotic. He complained of people who were coming after him and trying to kill him, to the point where he said he wanted to kill himself. On admission to an ED, a psychiatrist evaluated him and recommended admission because of the suicidal and paranoid thoughts. Lorazepam, a short-acting anti-anxiety drug, was prescribed.
After the patient calmed down, a psychologist interviewed him and recommended discharge because the boy told him that everything was fine and that he just wanted to go home.
"He killed himself the next afternoon by jumping off of a bridge. Our experts said he never should have been discharged," says Slutkin.
The experts stated that the medication calmed the patient down enough to tell the psychologist exactly what he wanted to hearthat everything was finewhen in fact nothing had changed since admission. Their position was that once the lorazepam wore off, the boy was going to be in exactly the same position as when admitted to the ED.
The failure of the psychologist to consider that the short-acting lorazepam was not going to change things and cure a psychosis was a very important factor in the case.
"Also, the psychologist effectively overruled the psychiatrist, which we said should not occur," says Slutkin. "If the psychologist had talked to the family members present, he would have learned that they had watched him severely deteriorate into paranoid delusions over a few days, such that no reasonable person would have sent this kid home."
Slutkin adds that he isn't sure that an ED's documentation stating that the patient is not a suicide threat really matters, if in fact the patient really is a continuing threat. "In this case, they said he wasn't a threat, but the facts and circumstances indicated otherwise," he says.
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