Suicidal patients are an everyday part of life in the typical American ER. For a variety of reasons, the vast majority of the "suicide attempts" are not particularly serious, by which I mean that the methods most commonly seen are not terribly lethal, and the patients attempting usually didn't actually want to die. For example, consider a patient who impulsively grabs a knife and makes a few superficial cuts in his or her wrist while arguing with their spouse, who then dutifully calls 911, or one who downs a whole bottle of prozac and then immediately calls a friend to tell them what they have done. These are the "suicide attempts" we routinely care for.
These patients are often a huge pain in the ass. They are usually intoxicated, often combative and agitated, may require extensive workups to ensure that no actual life threats exist, and wind up spending hours and hours in the ER, weeping and wailing, puking charcoal all over and annoying staff with their dramatic and manipulative behavior. Occasionally a non-serious gesture winds up being more dangerous than the patient intended. ("You mean tylenol is dangerous?") Many a time an irritated nurse has approached me and grimly suggested that we publish an educational flier titled "Suicide: getting it right the first time."
If this makes it sound like we don't take suicide attempts awfully seriously, then you're right. Mostly it's due to the preponderance of minor suicidal gestures over real attempts. Don't think we're not professional about it -- we know how to rule out the serious threats and make sure that a safe disposition is accomplished. But we are not overly impressed with the low-level stuff we usually see. I think the relative absence of "serious" attempts in the ER may be due to the fact that the numerical incidence of real suicidality is low, compared to the gestures, and the selection bias that those people who really do want to end it all tend not to make it in to the ER.
They are called "completers," in the jargon, as they "complete" their suicide attempt. When a would-be completer comes into the ER, it changes the whole tone of the evening. A pall settles over the department; the place is unusually quiet and staff uncommonly grave. This guy really meant it. It's a weird feeling.
Like the guy I saw the other day. A classic completer: middle-aged male, rather heavy drinker, recently lost his job and losing his marriage. His wife came home to find him in the garage with the engine running, unconscious, with an empty vodka bottle and pill bottles in his lap. Only she came home earlier than he expected.
He came in intubated with a carboxyhemoglobin level greater than 40%, which means that 40% of his red blood cells were saturated with carbon monoxide and incapable of carrying oxygen. This starved his brain of oxygen and resulted in a loss of consciousness, and would have progressed to death if not interrupted. The outcome in this case was good; we "dove" him in a hyperbaric chamber. Oxygen in higher-than-atmospheric concentrations can rapidly displace CO from the blood, allowing for full or near-full recovery if brain damage has not already occurred. This individual had a short stay in the ICU and was discharged to a voluntary psychiatric hospitalization.
This was an uncommon case with a reasonably happy result; many serious-but-unsuccessful suicide attempts wind up causing devastating consequences, especially when the method is violent: handgun, hanging, and certain poisonings can cause permanent brain damage, spinal cord injuries, or other organ failures. It's all very sad. I probably feel more empathy for these folks and their families than I do for almost any other patient. How terrible must their perceived suffering have been to drive them to actually pull that trigger?
I am glad we don't see them too often, because it's a hard thing to stare in the face:
This guy really meant it.
17 March 2008
Posted by shadowfax at 10:29 PM