#SimBlog: Will you just hurry up!
"35-year-old male attending ED admitting to taking an overdose of amitriptyline."
He has ongoing suicidal ideation and previous mental health attendances. Not currently in contact with the Community Psychiatric Nurse (CPN).
Observations
A – Patent
B – RR 18, Sats 100% on air, No respiratory difficulty
C – HR 86, BP 120/80, Heart sounds normal
D – GCS 15, PEARL size 3, BM 6.2
E – No injuries, Mild RUQ tenderness
Clinical Findings
No injuries
Very reluctant to talk
When he does answer, very obnoxious and keen to leave
Why We Simulated?
This simulation was designed to highlight the need to take a very careful history. The patient reluctantly agreed to do some bloods and when they come back his paracetamol level is high. However despite this, the patient had decided to get up and leave as he was fed up of waiting.
There were many challenges with this simulated patient, all of which have happened to me in real life. The patient is reluctant to give any specific details and his hidden the full truth. The other issue is he absconds. This was a surprise twist to the simulation.
Up to 10% of all admissions to an Emergency Department (ED) have a psychiatric component to their presentation. This includes self-harm, depression, psychosis and other less common psychiatric conditions. These patients may present in a range of ways from a suicide attempt or overdose (OD), either deliberate or accidental, and from a florid first presentation of illness to a known ‘frequent attender’ with a chronic condition. Psychiatric patients can often be seen as challenging because of their complex histories and needs. Of all the psychiatric presentations to an ED, the most common reason for attendance is Self-Harm (SH). SH includes a wide range of activities, such as an intentional OD, cutting, poisoning using any substance or route of self-administration, etc.
In 2010/11 and 2011/12 there were more than 114,000 inpatient hospital admissions each year in England for intentional self-harm (SH), a 7% increase compared to 2009/2010, when there were just over 107,000 admissions. This mirrors the overall increase in suicide rate in the UK from 11.1 to 11.8 deaths per 100,000 of the population. The highest suicide rate was in males aged 30 to 44 (23.5 deaths per 100,000 of the population). Worldwide, suicide is the tenth leading cause of death, with an annual mortality of 14.5 per 100,000 of the population. This equates to 1 death every 40 seconds globally.
People who SH are more likely than the general population to kill themselves. Associated with this, there is a general increase in morbidity and mortality. It is estimated that approximately 15-30% of patients who present with an episode of SH will SH again in that year. Of those who present to ED with an act of SH, 8-10% will successfully commit suicide in the same year. Also these patients often don’t disclose the full truth and that might be for a variety of reasons.
What to do if a patient tries to abscond?
RCEM says: “Security staff can only be asked to restrain or forcibly bring a patient back to the ED if they lack capacity or if it is felt the patient is mentally ill and requires a mental health act assessment. In an emergency where there has been no chance to assess the patient’s capacity but there is a significant risk of harm, a patient may be restrained or brought back by force effectively under common law (see separate MCA guidance). If a patient who lacks capacity requires ongoing restraint to prevent him/her from leaving or, in order to provide emergency treatment deemed to be in their best interests, rapid tranquilisation may be an option if all other efforts have failed. Emergency Departments should have a protocol for rapid tranquilisation.”
What to do if a patient has absconded?
RCEM says: “If a patient absconds who is felt not to have capacity, and is at risk either of SH or deterioration of their condition, then departments should activate a search of hospital premises Departments should have a policy for when to call security and what it is expected security will do to search for the patient. ED staff should try to contact the patient and relatives by phone.”
Further Reading:
- RCEM: The Patient Who Absconds (PDF)
- #EM3: Capacity & Absconded Teenager
- RCEM Learning: Psychiatric Emergencies for the Adult Patient (module)
Learning Outcomes
These patients can be very difficult to manage. But careful history, use the ambulance sheets and collateral history are all crucial.
Consider testing paracetamol and salicylate levels in patients where there is doubt to the medication they have taken.
Get help, with patients if they want to abscond.
Positive Feedback
- Great teamwork
- Good communication
- Great use of the TOXBASE® guidance on managing amitriptyline OD
