As an emergency medical technician working in the emergency department, I had the privilege of taking care of an array of patients with varying medical conditions. Even though the first thought of someone walking in through the emergency department revolved around tending to the emergent complaints, the chief complaints related to mental health were often overlooked. And although they are not prioritized, it has become more apparent in today’s world of tumultuous political climate and the global pandemic that we can no longer push our mental health or the mental health of our patients aside. While in the emergency department there was a particular patient that remains embedded in my memory, where her physical health became priority only because her mental health was not addressed at the appropriate time. 

My first encounter with this patient was in triage where she came in expressing suicidal ideation after having “naughty thoughts” relating to sexual fantasies involving herself and another man (other than her husband). Feelings of guilt and hopelessness rushed out of the patient’s mouth, she mentioned her and her husband had just found out weeks prior that he was diagnosed with terminal prostate cancer. This 83 year old patient confessed keeping all of these ideas, emotions, and stressors to herself so as to not worry her husband any more. She explained having trouble sleeping since finding out her husband’s diagnoses and it was only then she began to have these delusions and a new onset of ideas of suicide. She had a plan of overdosing on OTC aspirin that she kept in her bathroom cabinet but no intent to follow through with the plan right at the moment. She clearly had insight into her illness and that is why she sought treatment and help at the ED that day. 

Other than her SI and delusions, the patient was exhibiting no physiological deficits or symptoms. Her vitals signs were relatively stable, with a slightly elevated blood pressure possibly attributed to the stress she had been feeling. Nonetheless, after triggering our health institution’s Columbia Suicide Scale, I was instructed by the triage nurse to establish suicide safety precautions and accompany the patient to her room where another ED tech would observe and ensure the pt’s safety as a 1:1 sitter. At that moment in time, I turned over the patient and went home as it was the end of my shift. The next morning, to my surprise they had discharged the patient and encouraged her to follow up with outpatient services. I did not think much of it until about two weeks later, when the same patient showed up via EMS, this time with a chief complaint of intentional overdose. My gut wrenched when I found out it was the same patient. After several diagnostic tests, the patient had indeed acted on her thoughts of suicide. She ingested enough salicylate pills to induce a gastrointestinal bleed, the patient was now in critical condition. 

Now seeing the patient in her new condition, pale, vomiting blood, and a bottoming out blood pressure, I tried to understand where we went wrong since we had seen her. I thought back to that day I met her and tried to recall the social history she had mentioned to us. She had been retired for a few years, none of her kids lived within the state (decreased protective factors), and increased stress of finding out her husband had just been recently diagnosed with cancer. Initially, the patient expressed she was involved in her community by attending Sunday mass regularly but had stopped since having the “naughty thoughts.” I was not present for the overall psychosocial assessment the primary RN or the on-call psychiatrist performed but would have anticipated them assessing further for any protective factors, as well as assessing any chronic factors, such as past suicide attempts or psychiatric hospitalizations. 

I believe it would have been beneficial to do a thorough SAFE-T 5 assessment during her first visit to dive further into her whole life. The SAFE-T 5 would have been useful in identifying any risk factors, such as the exacerbation and stress of her husband’s terminal diagnosis. She is possibly feeling socially isolated and hopeless knowing she lives in a city without her family members and what her future might look like if her husband passes away. We could have identified the fact that she is more vulnerable knowing that she is female and that females attempt suicide more often than men. This patient was also of caucasian descent checking off another risk factor. We already established that she did not have too many protective factors living in close proximity but reaching out to those in other states would be beneficial. The obvious suicide ideation should have led us to assess her suicide inquiry in its entirety. We understand she came into the ED discussing SI and having a plan, but to what degree was she planning on carrying out the plan? Had she made any preparatory behaviors to follow through with her plan of overdosing? It was apparent that during the first visit the patient was exhibiting several imminent warning signs for suicide including, ideation, anxiety, hopelessness, and mood changes. 

During that second encounter, the patient was in critical condition so priorities were targeted at maintaining her physiological status as stable as possible, however our number one priority for this patient would be to ensure her safety. By implementing suicide/behavioral precautions, having a 1:1 sitter, removing all potentially hazardous objects from the room, and re instating another psych consult. Some of the biologic domain interventions for this patient would include proper monitoring of vitals signs, keeping her on a tele monitor (while keeping a close eye on her), allowing for her to rest. Making sure we tend to her self-inflicted injuries (i.e. GI bleed). For the psychological domain, it is imperative to instill hope within our patient and set her up with the appropriate resources to develop new coping strategies. We would want to make sure she knows that she is not alone. Besides establishing rapport and conveying therapeutic communication, it would be ideal to help the patient develop support networks, whether that is via her church community or reaching out to her kids and siblings out of state. Once the patient is stable it would also be beneficial to create a crisis plan so that she does not feel hopeless and alone. Moreover, once her status is stable enough the patient should be taken care of in an inpatient psychiatric setting to figure out the correct treatment before sending her home.

To this day, I am deeply saddened regarding the care my institution provided for this patient. This patient came in weeks prior asking for help and she was discharged to follow up on her own. There is a huge system-wide failure when it comes to addressing mental health and suicide here in the United States and this is a prime example. More resources need to be allocated in order to prevent future occurrences such as this one. As far as the patient, I was able to be part of the team that cared for her in the emergency department, multiple trips to the blood bank, and even helped transport her up to the ICU. I am hoping we did better this time and that she received the treatment she deserved.