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ER Goddess

Don't Make Monumental Changes Before You SWIM

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000578580.32486.9a
ER Goddess

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Suicide is a permanent solution to a temporary problem. It happens when pain exceeds the resources for coping. And you may be at risk when you suffer a life stressor.

The Centers for Disease Control and Prevention reported last year that only half of people who died by suicide had known mental health issues; the other half had been stressed by job, legal, money, housing, physical health, and substance abuse issues. (Vital Signs, June 7, 2018; http://bit.ly/31JU2Zl.) These problems and the pain they cause are very real, but the belief that there's no other answer is generally not. Unfortunately, your emotions might tell you otherwise if you're in a crisis. A mindset that might be reactionary, transient, or situational can become tragically lethal if you don't have strategies to see past current circumstances.

If your circumstances have pushed you to thoughts of death, you might feel less isolated by understanding that our profession has the highest suicide rate. Our toxic culture of bravado, our feeling that we can't show weakness or fragility, and our fear of mental health questions on licensing forms lead to denial and ignorance. Yet, many of us reach that point, and you are not alone if it's happened to you. National Physician Suicide Awareness Day is Sept. 17 because people do care about our mental health and want you to get help if you need it.

Loice Swisher, MD, and Ramin Tabatabai, MD, published potentially life-saving advice for anyone with thoughts of self-harm. (http://bit.ly/2WAYVVv; see box for more articles by them.) Read it. I've taken their suggestions and devised a Nemo-inspired mnemonic (we docs love mnemonics) that hopefully will help you or someone you know who is drowning in suicidal ideation: SWIM—Sleep, Wait, Interact, and Metabolize. Basically, don't make monumental and life-altering (or life-ending) decisions when you're tired, overly emotional, lonely, or under the influence.

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Sleep

Sleep deprivation destroys your coping ability to the point that something that would normally bother you a little may deeply enrage or hurt you. It impairs your judgment as much as being drunk. After 17 hours without sleep, your performance will be the equivalent of or worse than if you had a BAC of 0.05%. After a longer period without sleep, your performance reaches levels equivalent to a BAC of 0.1%. (Occup Environ Med. 2000;57[10]:649; http://bit.ly/2KHx3rK.) Moreover, disturbed sleep heightens suicidal ideation, so getting a few nights' rest may help you feel better.

Physicians and schedulers must have more respect for the deleterious effects of sleep deprivation and circadian disruption. Sadly, powering through without rest is often worn like a badge of honor in medicine, and needing rest is seen as a sign of weakness. In fact, the opposite is true. The less sleep you get, the more susceptible your mind is to negative and even suicidal thought, so instead of jumping on that train, sleep on it. Get at least eight consecutive hours of sleep before making any serious decisions.

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Wait

Half of all people who attempt suicide go from thought to attempt in 10 minutes or less, and the phase of acute suicidal crisis usually fades in hours, said Drs. Swisher and Tabatabai. When you're on the cliff's edge, do whatever you have to do to distract yourself and buy some time. Take a cold shower, do push-ups, go for a walk. Feelings and actions are two different things, so get some distance between your suicidal feeling and potential suicidal action.

Try to delay at least three days. Your circumstance may not change in that time, but your frame of mind might. You might have a flash of hope, like a text from a friend or a meaningful song on the radio. Remember, change is the one constant in life, and time is the great healer. Big decisions deserve time, so wait several days before you act.

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Interact

Isolation is devastating. Physicians are notorious for not reaching out for help. We go to work and leave our personal issues at the door because we're not supposed to be sad. Have you ever told a suicidal patient he needs a better coping strategy than trying to hurt himself, and then drowned your sorrows in alcohol or even thought about your own death? If so, let me give you some stern advice that a lot of us need to hear: You need support. You have to let someone in. You can't do everything alone.

Suicidal ideation comes from loneliness. You may have developed tunnel vision and be fixating on suicide as your one viable option when better alternatives exist. You might just need someone else to help you see them. Talking about how you got to where you are releases a lot of pressure and could help you cope. Reach out to that person you can trust and confide in—a friend, a family member, a minister. Don't just leave a social media message, text, or voicemail; have an actual phone conversation or, even better, a face-to-face interaction. The last thing you should do when things get tough is isolate yourself.

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Metabolize

We all know substance amplifies underlying mental health issues. How many times have you said, “Metabolize to freedom” about a patient, indicating he can be discharged from your ED when he is safe from the harmful effects of whatever alcohol or drug he used? You must also allow yourself to metabolize until your mind is free of the sinister effects of drugs and alcohol before you make an irreversible decision. As Drs. Swisher and Tabatabai said, “There is no safety without sobriety.” Never make a suicidal decision while intoxicated by any substance.

We're all prone to making snap judgments when we've depleted our ability to cope. Do what you can now to help yourself stay safe if you are ever in crisis. If you have a gun, keep it locked up and keep the bullets far away from it. Put a note to yourself on the lock and bullets. Have a list of friends and the national suicide hotlines to call: 800/273-TALK and 800/SUICIDE. Make a list of what you love to look at when you need to put the brakes on a negative-thought train. Voicemails and pictures of loved ones on your phone can be clutch when you've reached the end of your rope.

Please, if you find yourself having suicidal ideation, remember to SWIM first. Do anything you can to give yourself a chance. You are worth it.

Read firsthand accounts of their experiences with suicide in a Special Report by Loice Swisher, MD; Ramin Tabatabai, MD; and Christopher Doty, MD, at http://bit.ly/SuicideSpecialReport.

Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.

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