Midshift. Pick up a new patient. Overdose. On what? Ibuprofen, about 10. How old? 16.
Explore This IssueACEP Now: Vol 38 – No 09 – September 2019
Fast thinking. Check vitals. Medical history. Last ED visit. Unremarkable.
See patient. What happened? Took 10 Ibuprofen. Why? Shrug.
What else today? Drugs? Tylenol? Antifreeze? Hand sanitizer? No to all.
Get to work. Exam unremarkable. Talk to the mom. We’re concerned.
Complete blood count. Metabolic panel. Tox screen. ECG. Chest X-ray. Salicylate level. Tylenol level. Ethanol level. Dial 1-800-222-1222. Toxicologist on call answers. Monitor the patient. Repeat the metabolic panel. IV fluids. Repeat vitals. Unchanged. Repeat exam. Unremarkable.
Slow thinking. What is it about this kid? What could I miss that would potentially kill him? Other ingestions? Don’t think so. The workup was negative. Kidney damage? No, repeat labs were fine, and he has been urinating without difficulty. Cardiotoxicity? No, initial ECG and repeat were both normal, no QT prolongation. Legit suicide attempt or emotional reaction to a fight with his mother?
I should dig into his history a bit.
Says here he was diagnosed with depression a year ago. He was started on escitalopram (Lexapro) but only took the one prescription. No refills since then. No other suicide attempts. No other hospitalizations. Let’s go talk a bit more.
Mom, is your son still taking Lexapro? No, he took it for the first month and then said he wouldn’t take it anymore. Didn’t like the way it made him feel. Any Lexapro in the house? No, he finished the initial prescription.
Patient, are you feeling depressed? No response. Have you seen a psychologist or counselor to talk through some stuff? Mom replies that there was a counseling session a year ago but nothing since then. Are you going to hurt yourself or others again? No way. Do you want to go to a psych facility or go home? Home.
Tidy up the chart. Speak to attending. Overdose. Ibuprofen. About 10. Workup normal. ECG normal. Repeat ECG normal. X-ray normal. Repeat labs normal. Vitals stable. Social work consult completed. Discharge? Attending evaluates. He’s go for discharge.
No. Stop. Disengage physician brain. Engage human brain. We got lucky this go-around, and I don’t think this was a legitimate suicide attempt, but what happens next time? What if next time he reaches for Tylenol, takes the whole bottle, and wrecks his liver? Or reaches for aspirin, takes the whole bottle, fries his kidneys, or stops breathing? Or reaches for alcohol or cocaine or opioids? I’m glad that social work saw this patient, but he’s already proven reluctant to get and accept help for his depression. I’ve done my job as an emergency physician. Now let me see if I can do my job as a human being who knows a thing or two about depression.
I reenter the room and sit down next to the bed. I speak to the patient directly now, despite his previous taciturn responses. I turn off the doctor voice, lean in, look him in the eye, and begin again.
Listen to me because this is important. We got lucky today, and this attempt to hurt yourself doesn’t appear to have succeeded. We are ready to send you home from the ED, and we have a whole bunch of symptoms we want you to look out for, but in the meantime, we need to talk. You could have seriously hurt yourself today or even killed yourself. Even if you weren’t really trying to kill yourself, you could have still done so accidentally. And then what? Regardless of what you believe or what you have faith in, no one knows what happens when we die. Even the life we already have is not guaranteed for another minute. We’re lucky to be walking around this planet because life is the first and greatest gift that we will ever receive.
But you’ve got this thing, this condition, this tendency, this burden of depression in your life. I know because I have it, too. And I’m here to tell you now that it never goes away fully. There will be times when it’s just a tiny whisper in your ear. There will be times when it’s screaming in your mind and dragging you underwater. There are ways you can manage it, and we’re better now than we ever were at treating it. But it will never fully leave you. It’s a part of you, just like it’s a part of me.
For 35 years, I somehow thought that I was the only one who felt this way or that I was weak for feeling this way. I was wrong then, and I now know none of those things are true. I have the benefit of a few years of age on you, and I’ve been dealing with this thing for longer, and I’ve gotten pretty good at managing it. But it took time and work to get here. If you get help and work to make yourself better, then hopefully you will get a handle on it, too. But I can promise you that if you try again to hurt yourself and you die, then your story ends there, and depression will have mastered you and not the other way around.
It may seem unfair that you have to deal with this. Maybe it is. But going through this trial of mental health can change you in positive ways, too. It will deepen your compassion. It will expand your empathy. It will give you the ability to someday have a conversation with someone who needs your help. You will be someone who can understand when others can’t. And trust me, that ability to help someone in need is a great privilege.
I’m not your parent. Even if I were, I couldn’t truly make you do anything you did not want to do. But I encourage you strongly to get help. I can only do so much from the emergency department. It’s up to you how you want to handle this, but don’t squander the gift of life you have been given. Stay strong, not by going it alone but by getting help and working to get better.
I get a nod and a smile. I then discharge him home with the contact info for an adolescent psychiatrist and some other resources for follow-up.
Are we all merely worker drones in the emergency department, dispensing medical treatments that anyone with a degree and a couple shifts under their belt could deliver? Occasionally, it can feel this way. But what we do in the emergency department always matters a little and sometimes matters a lot.
It’s the best job in the world. We are all good at everything. But each of us is great at perhaps one or two things. Seize these opportunities. Welcome them when they arise.
Engage physician brain. Bring human brain along. See next patient.