Suicide: risk factors and therapeutic considerations in the emergency department.

Emergency physicians often encounter covertly and overtly suicidal patients, and can thus play a key role in the prevention of suicide. The epidemiology and diverse presentations of suicidal behavior are reviewed. We then provide a detailed approach to the assessment of suicide risk, and criteria for safe discharge from the emergency department (ED). Finally, management considerations for the ED are discussed.

Suicide: risk factors and prevention in medical practice.

Suicide is a preventable cause of death that increasingly affects younger age groups. We review the epidemiology of suicide in the general population, in psychiatric patients, and in medical/surgical patients. The essential role of the primary care physician in preventing suicide is examined.

The crash of Continental 1713: the impact on hospital-based personnel.

Psychological morbidity is a common finding in rescue personnel following a disaster. However, no serious attention has been given to the possibility that hospital-based personnel are also at risk. Therefore, 12 to 16 months after the crash of Continental 1713, 15 subjects who had worked with crash victims and their families only while in the hospital, were given a structured interview. Eight of 15 said they developed at least one symptom in each domain of Post Traumatic Stress Disorder within 2 weeks of the crash; of the remaining 7 subjects, all endorsed at least one re-experiencing symptom. Half also reported serious disruptions at home and in their work with other patients. Thirteen subjects also experienced significant worries about flying and 4 actually changed travel plans. Subjects were still symptomatic at 12 to 18 months, though to a lesser degree. We conclude that the emotional effects of disasters on hospital-based personnel are not trivial.

Alcohol intoxication, injuries, and dangerous behaviors--and the revolving emergency department door.

Suicides, homicides, motor vehicle crashes, and other violent deaths and injuries are linked inextricably to alcoholism. The association of injury and alcoholism should be particularly obvious to Emergency Department (ED) physicians. We sought to determine the extent to which intoxicated patients in an ED were properly diagnosed, counselled, and referred for substance abuse care. We reviewed the charts of 153 consecutive patients seen in a teaching hospital ED who had blood alcohol levels above 100 mg%. Most were male (70%), white (62%), young (mean age, 34 years) and severely intoxicated (mean BAL, 245; range, 109-558 mg%). Forty-six per cent of visits were for trauma; half of the patients were victims of violent assaults. The intoxicated patients received extensive medical and surgical management: an average of five tests or X-rays were performed per patient; 75% received at least one medication; at discharge 48% were referred for followup to medical or surgical clinics. In contrast, few patients were evaluated for dangerous behaviors or referred for treatment of alcoholism: only 19 patients (12.5%) were asked about depression, suicide, or homicide; 15% were advised to stop drinking; 13% received a referral to a psychiatrist, mental health worker, or alcohol rehabilitation facility. Forty-seven per cent of patients received "stat" intravenous thiamine (although the Wernicke-Korsakoff syndrome is rare). In contrast, only 16% received a stat on-site psychiatric consultation (although dangerous behaviors are common in alcoholics). There was a strong, statistically significant negative association between the occurrence of an injury and the decision to initiate treatment and referrals for alcoholism.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients who leave without being seen.

We conducted this study because very little is known about patients who leave without being seen. A total of 4,868 patients were registered in an emergency department during a six-week study period. Sixty-eight (1.4%) left before treatment was completed; 97% (66 patients) left before ever being seen by a physician. Thirty of the 68 patients were interviewed later in followup A comparison group of 23 patients who did not leave prematurely was also selected and matched for age, sex, urgency of chief complaint, and time of presentation. Fourteen of these patients were interviewed later. Patients who left without being seen (LWBS) and nonLWBS patients did not differ in waiting time in the ED. The two groups also did not differ in the spectrum of chief complaints. Twenty-two of 30 LWBS patients were suffering from acute psychological distress at the time of their visit, however, compared to only one of the comparison group (P = .0005). The walkouts reported recent deaths of relatives or friends, recent bouts of alcoholism, acute financial problems, suicidal thoughts and behavior, court appearances, pregnancies and miscarriages, new people in the home, acute illnesses in relatives, and other psychological and social crises.

Emergency room medical clearance: an educational problem.

The term "medically clear" has a greater capacity to mislead than to inform correctly. The overuse of this term, especially in emergency room settings, may indicate difficulties in medical education and in the consultation/referral process between psychiatry and other specialties; further, it results in poor patient care. Nonpsychiatric physicians may prematurely refer patients as medically clear because of their unfamiliarity or discomfort with clinical psychiatry. Psychiatrists often ask for medical clearance of patients to hide their discomfort with or antipathy toward clinical medicine. The use of emergency room settings for interspecialty collaboration and training helps minimize the underlying difficulties that lead to the use of this term by fostering psychiatric skills in nonpsychiatrists and a sense of medical identity in psychiatrists.

Assessment of psychiatric emergencies in medical practice.

Acute psychiatric emergencies, often encountered in medical practice, demand rapid evaluation and treatment; routine measures are not enough. A scheme for acutely assessing such crises is outlined, and some of the more common emergencies are discussed.

The somatic complaint: a ticket of admission for child abusers.

Primary care physicians should be alert to potential or actual child abusers who use somatic complaints as their ticket of admission to the health care delivery system. Five patients who presented in this manner will be discussed along with salient features of child abuse. Suggestions for approaching those abusers who use functional complaints as their ticket of admission will be outlined.

Impending child abuse. Psychosomatic symptoms in adults as a clue.

Adult patients involved in or threatened by the possibility of committing child abuse may develop acute functional symptoms that result in their seeking emergency medical help. Three cases are presented as examples of this relationship. In two, the functional symptom was paralysis or paresis. In the third, symptoms were more diffuse. Recognition of the association between functional symptoms and child abuse may permit intervention before serious child injury occurs.

A case of petit-mal status: a diagnostic dilemma.

The author describes a case in which the "crazy" behavior of a woman with petit mal status (PMS) was initially misinterpreted in an emergency room situation. The diagnosis of PMS was confirmed by electroencephalography. The author notes the need to consider the possibility of this diagnosis when there is a history of seizures in conjunction with an altered state of consciousness.