Author: Esther Sabel / Editors: Charlotte Davies, Lauren Fraser / Codes: PAP2, MHP5, PhC1, PhP1, SaC3, SaP1, SLO12, SLO5, SLO7, SLO8 / Published: 10/12/2019
Why is this a hot topic?
- It is a sign of serious distress.
- It is common (1 in 4 young people self harm ever), (1 in 10 repeatedly)
- It is strongly associated with suicide (especially repeated cutting)
- Suicide is one of commonest causes death in young people.
- 200% increase in self harm 1985-1995
If ever you have the opportunity to save a young person’s life – it is now.
I’m an EM Physician! – surely this is the terrain of psychiatrists?!
If you are thinking this, in some ways you are right – children presenting to the Emergency Department should certainly have a mental health assessment by a trained professional in children’s mental health. However, your initial approach is significant and should not be underestimated. The child (and family) are now in your department to have a life – saving ‘operation’ and your task is to prep them for ‘theatre’. The operations will involve detailed assessment and intervention. Sometimes this involves discussion of painful topics – after all, we must not forget that triggers for a young person to harm their body or consider taking their life may be unbearable. The only ‘anaesthetic’ is compassion and curiosity.
Just like any other clinical emergency this approach is: ABCDEFG
- A – Assessment and ‘Analgesia’ (Compassion).
Your history will be briefer than a psychiatric history but should cover the social circumstances, risks, intents and triggers. Don’t forget that you are an ambassador for the hospital. The young person and their family are likely to be experiencing shame and fear, probably in addition to the trigger behind the self-harm or overdose.
- B – Bloods and other physical investigations and treatments
If there has been an overdose, it is good practice to do paracetamol levels even if this was not the substance allegedly taken. Heightened distress can mean that inaccuracies may occur.
- C – Circulation (here when we say ‘circulation’ we are referring to the family and wider network)
The child is the heart of their own network and their close family members are likely to be part of the solution to their difficulties. Parents will need to help with risk management and care plans so they should be (in most situations) contacted if they are not already present. There may be a wealth of other professionals who can assist who may have prior knowledge of the child. These include school, social services, CAMHS professionals, primary care. As these professionals are typically only available by day, this may shed light on why the recommendations from NICE and the Royal College of Psychiatrists Guidelines are that children should be routinely admitted to a paediatric setting overnight following self harm. This provides an opportunity to ‘wrap the network around the child’ and bring other players in as also described by Kraemer, 2019.
- DEFG – Don’t Ever Forget (safe) Guarding!
Although the literature speaks of “mental health crisis”, in fact, particularly in children, it will frequently be an undisclosed safeguarding issue that underlies a presentation of self harm or a suicide attempt. It might be worth thinking of these presentations in a similar way to how you think of “Collapse? Cause” ED patients. You, followed by your psychiatric colleagues, have the task of working through the differential as per the diagram below.
It may be useful to have at the front of your mind that the recalcitrant teenager before you may be struggling with an unbearable ‘secret’ and that disclosing this will have profound and life changing implications. You may hear colleagues or parents referring to the child as “attention seeking”, with the unambiguous implication that the child is being a nuisance and is best ignored. Some stakeholders like to comment on the superficiality of the wound as an indicator. However please note that the depth of the wound is not necessarily proportional to the depth of the distress and in some situations the word superficial can be construed by patients as pejorative. Repetitive self harm (regardless of depth) is strongly associated with suicide as a long term outcome. Your response to those who propagate the “attention seeking theory” could be “well, what do they need attending to?”.
“Prepping for theatre” – The Task of the ED Assessment
- “Resuscitate” with compassion and curiosity
- Emergency Investigations and treatment, physical, mental, and SAFEGUARDING.
- Be kind! (To the patient and to the service)
- Convey the message that what has happened is serious
- As an EM physician – paediatric admission for under 16, strongly consider acute hospital admission for 16-17 (see below)
- Detection of previously undiagnosed mental illness
- Think ?organic
- Think about how to manage risk in the hospital, for example, risk of absconding
The ‘Operation’ – The Golden Hour – ‘Scoop and Run’ v. ‘Stay and Play‘
As we know, most tensions within the ED seem to be around speed and flow. Hospitals have become ‘No-Go’ Areas and recent policy documents such as the Crisis Care Concordat and the 5 Year Plan talk of parity between physical and mental health in terms of ease of access but also yet advocate for assessments elsewhere, in the community, supposedly for improving patient experience. The astute reader might wonder whether stigma still underlies part of this ethos “i.e get these (tricky, troublesome, uncomfortable, unpredictable) patients far away from my hospital”. Adolescent patients with the self harm/suicidal clinical predicament do not lend themselves well to a 4 hour target involving discharge. The current trends for swift mental health assessment are laudable but one needs to be mindful that it is not just a mental health assessment that should happen, but an intervention.
An intervention will involve some sort of change being effected, often in the network around the patient, that means that the reason for the self harm is no longer valid. For example, getting the recently estranged father of a teenage girl up to the hospital and explaining that when a teenager declines weekend visits with father’s new re-constituted family, it does not mean she wants no further contact.
The interventions carried out by skilled mental health professionals are akin to an appendicetomy for acute appendicitis. In these sorts of situations, they can’t be left till next week, or done in an outpatient clinic. Hence as much as political and managerial pressures dictate that patients like these should be rapidly discharged in a ‘scoop and run’ style away from/out of the ED – the actual ‘golden hour’ for the intervention to be effected, unlike with ATLS patients, is not typically within the first hour of treatment. And sometimes, trying to do these delicate interventions in the community, with families in turmoil alongside actively suicidal children, can feel as hair raising as attempting an appendicectomy in a car park.
NICE and Royal College of Psychiatrists Guidelines
The above section neatly illustrates the heart of the rationale for the NICE guidance and Royal College of Psychiatrists Guidance about why an (acute) hospital admission is par for the course in a child presenting to the ED with self harm. So that essentially, the ‘golden hour operation’ and the ‘wrapping the network around the child’ can be allowed to safely happen within the acute hospital setting. A vital stitch in time.
For 16-17 year olds, there can often be a grey area which is acknowledged in the Royal College of Psychiatrists Guidelines. The ‘blanket’ acute hospital admission is not insisted upon in all cases as per the under 16s. However, the guideline cautions against discharge without a very thorough psychosocial assessment in this even more risky age group, stating “If there is any doubt about safety or about quality of information, then acute hospital admission should be offered”. In practice, negotiating this when there are no physical health needs can be tricky in overstretched departments where paediatric wards are not on offer to the 16-17 age group and there is no obvious ticket into the medical ward. Clinically, the later in the evening or night that it is, the less of a capacity there will be to gather the network, who will be sleeping. Hence the chances of a genuinely successful intervention implementing discharge at night in a risky situation will be slim. As I often say to supervisees “if you can’t find any doubt (about safety or quality of information) and it’s 3am, phone me and I’ll find you some doubt!”.
Young minds may be a useful resources for young people who have been discharged, and are waiting for CAMHS follow up in the community.
This video on “teenage misadventure” or self harm may provide some context.