Crozet Annals of Medicine: The Razor’s Edge

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A long-time reader and mental health professional recently wrote to me asking for some discussion of mental health issues in the ED. It is a large part of our practice that I haven’t discussed in past columns. This is my reply.

I was an intern, three months into my medical career the first time I heard it: the clarion call of the Emergency Department.

“I need help in here!”

Nowadays I will rush toward that clarion call but back then I was a beginner and hesitant to be responsible for whatever unknown emergency was being heralded by the nurse’s frantic tone. There were upper-level residents and attendings around somewhere. Surely one of them would respond.

“I need a doctor in here, NOW!”

It was getting harder to avoid involvement and when the nurse backed out of the room and made eye contact with me in the hall, I was stuck. I had to go in.

A young healthy man was standing, backed into the far corner of the treatment room.  He held a razor blade in his right hand and it was poised to cut across his left wrist.

“If I don’t get some Demerol right now, I swear to God, I will kill myself right here and now,” he growled at me.

Demerol is an opioid pain medicine, not much used now because of widespread abuse potential.

As a general rule in the ED, we don’t negotiate with terrorists, but I did not know what else to do. Was this guy serious? He seemed to be. I tried to think what my senior residents might do in this situation. They were much tougher than me and probably would know what to do. I did not think about what my attending doctors might do, they rarely engaged in direct patient care back then.

Fortunately, at that moment Tony, a senior resident, arrived and took command of the situation. The patient repeated his demand and his threat.

“OK, OK, go ahead and cut yourself. We will just sew you back up. But you are not getting Demerol.” replied Tony. Wow, I thought, I wish I was that tough.

So, the patient did it. He calmly sliced his left wrist open. While the blood was flowing down his hand and onto the floor he held onto the razor and leisurely placed the blade to the left side of his neck.

“What are you going to do now, tough guy?” the patient asked the resident. Tony had no reply. We both stood there frozen, not sure what to do next. Clearly this guy was serious.

“Whose patient is this?” I asked the nurse. Perhaps we could defer to someone else.

“Elizabeth’s,” the nurse replied, with a subtle roll of her eyes. The nurses’ nickname for Elizabeth was Elizabeth the oblivious.

Elizabeth just had an unusual way of looking at things. No matter what was going on in the ER, she never seemed particularly concerned and often seemed a little detached from the chaos around her. It was hard to tell sometimes whether she was the wisest or the most clueless resident in the department.

At that moment Elizabeth showed up to check on her patient. She took in Tony and me standing helpless at the doorway, her patient bleeding in the corner, and the bloody razor in his hand.

“What is going on in here?” she asked us in an exasperated tone.

“Mr. Jones, give me that razor blade right now” she demanded, clearly annoyed with him.

She strode over to the patient and took the bloody razor from him with her bare hand. He was so surprised by her authoritative demeanor that he just passively handed it over.

“Now sit down while I go get some sutures for that wrist.” She breezed by us without another word and returned a short time later and calmly repaired his wound, all the while tut-tutting him for his impulsive behavior.

She was completely oblivious to any threat he may have posed to her or himself and ignored his demands for narcotics without any comment except a short simple “No.” Once the laceration had been closed Elizabeth gave him a stern lecture on the inappropriateness of his behavior and extracted a promise from him that he would never do it again. He sheepishly left the ED and was never a problem again.

That was the state of mental health care in the ER many years ago. We saw very few psychiatric patients, which was fortunate because we had little training or supervision. Anyone with severe psychiatric issues was treated at a state mental hospital. Most of those are now closed.

Those with less severe pathology were treated as outpatients or at private psychiatric hospitals if they had the means to afford it. No one really thought of the ER as a place to seek psychiatric care.

Unfortunately, those days are long gone and today we are buffeted by an ever-increasing demand for mental health services in the ED.

In the last decade alone, the rate of ER visits for mental health issues has doubled. One in eight patients in the ED is there for psychiatric complaints.

The most striking rise in psychiatric visits is in the pediatric population. In the last decade the rate of ED visits for suicidal thoughts or attempts has risen fivefold in the under 18-year-old age group. This can be traced directly to the rise of social media.

Social media exposure in kids has created a pandemic of mental unwellness. Time that used to be spent on in-person group play is now filled by solitary time spent scrolling on screens, and it is a lot of time. The CDC reports that 8- to 10-year-olds spend 6 hours a day on social media; 11- to 14-year-olds spend nine hours on screens, and 15- to 18-year-olds spend 7.5 hours a day on screens. This does not count school work done online.

Numerous studies have documented a clear association between amount of screen time and anxiety, depression, sleep deprivation, body image disorders and bullying. In a recent study, 16% of high school students said they were bullied through text messages or social media. One in three girls said they feel bad about their bodies when using Instagram, TikTok or Snapchat. Nearly half of surveyed teens blame their own overuse of social media for causing increases in anxiety stress and depression.

A study in Psychology Today found that 1 in 4 teens want their parents or schools to put limits on their screen time. Conversely, over half of the teens felt that their parents’ screen time routinely interfered with the teens’ attempts to talk to them.

It is time for parents and schools to put some limits on screen time. There needs to be screen-free times, such as mealtimes and for two hours before bedtime (exposure to the lights of screens delays sleep onset). No phones should be allowed in bedrooms. Two hours a day is a reasonable amount of screen time for most kids. For more help, go to www.humanetech.com/families-educators to start the conversation with your families. 

I know that to some contemporary parents these may seem to be extreme suggestions. All that I can say to that has been said better by my old college friend and tech columnist Kara Swisher.

“I leave you to your own devices. I mean that: your phone is the best relationship you all have now, the first thing you pick up in the morning and the last thing you touch at night.” 

We can do better. 

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