It was a slow morning in the ED of our small community hospital. I was on shift with an attending fresh out of his residency. I was also fairly new to the ED, having only been there for about a year and a nurse for two. We received a call from the fire department: “42-year-old male, suicidal ideation, history of depression, anxiety, and chronic pain; estimated time of arrival five minutes.”
Emergency medical services (EMS) rolled through the doors with a 6′4", 140-lb., middle-aged man, with long, stringy aqua hair, skin a greenish hue, writhing on the stretcher as if he were crawling out of his skin. Mr. Blue (a pseudonym) was placed in room nine, with the standard suicide precautions. All cords removed, no sharp or blunt objects—just a bed and a patient. While I was taking report from one of the paramedics, the rest of the crew paced around us; usually, as the medic gives report, the crew headed to the EMS lounge to refuel. The medic finished with, “We run on him two to three times a week. This is different. Please do not discharge him home; he will kill himself.” The rest of his crew were likewise adamant that Mr. Blue was a danger to himself. “He said goodbye to his cats through tears,” the last one said. “He's never done that before.”
I followed Dr. R into the patient's room. He took a history, did an assessment, and then bluntly asked the patient if he was suicidal. Confronted with those words, Mr. Blue stammered a no. “I just need a refill on my pain medicine. I've been out for weeks and the pain is too much.” Dr. R left to type up his report and I stayed to do my own assessment. Mr. Blue was avoiding eye contact, evading questions, and randomly bursting into intense sobs. When I stood up to leave and chart my own assessment, he begged me not to leave him alone. So I sat with him in silence, gave his hand a reassuring squeeze, and let him cry.
When I followed up with Dr. R about when the psych consult would assess Mr. Blue, as was standard protocol, Dr. R instead handed me discharge paperwork and said, “He's denying suicidal thoughts. He just wants more narcotics because he's withdrawing.” Replying that he hadn't witnessed the same behavior that I had, I requested that he reassess his patient. This time, Dr. R saw a patient squirming in bed, crying. But he still denied suicidal ideation. Dr. R was firm that since the patient was denying any intent to harm himself, there was nothing he could do.
I depended on my ED docs to always know what to do. Remember, I was still relatively new to nursing; I hadn't yet learned to depend on myself. But I had this sick feeling deep down that I couldn't shake. I figured it must be that “gut feeling” I kept hearing seasoned nurses talk about.
I went back to Dr. R, handed him the discharge papers, and said, “If you're so insistent on this patient being discharged, you're going to have to do it yourself and just know that whatever happens to him is on you.” With that shifting of responsibility, and with the charge nurse standing behind me with her arms crossed, Dr. R reluctantly ordered the consult.
Although the person who evaluated Mr. Blue agreed that he was probably a danger to himself, Mr. Blue continued to deny suicidal intent. State regulations mandated that a patient unwilling to voluntarily go to an inpatient psychiatric facility needed to be petitioned by a family member. While I spent time with Mr. Blue, the charge nurse was able to contact his out-of-state parents, who said that their son had made multiple suicide attempts in the past. They agreed to petition him if necessary.
I asked Mr. Blue if he felt safe to go home, and he said no. He told me he was scared of being alone. I asked him if he would agree to evaluation at a psychiatric facility for a few days. He agreed, but then panicked—he had remembered his cats. I asked if he had any friends he could call to watch them. His cell phone was dead and he didn't have the numbers memorized. At my wit's end, I called up the EMS crew. They were happy to do whatever they could to make sure Mr. Blue got the help he needed. Satisfied by this solution, Mr. Blue left for a facility that same day.
That day taught me a few things. First, that my gut feeling may be more accurate than a respected provider's assessment. Second, that I'm strong enough to advocate for my patient. And lastly, people don't always ask for help, even when they are crying for it.