A 45-year-old man comes to the emergency department with multiple hand lacerations sustained when he punched his hand through a window. The patient says he "momentarily lost control" when he came home from work to find that his wife had moved out of the home and taken their two children. Temperature is 37.2 C (99 F), blood pressure is 150/88 mm Hg, and pulse is 96/min. The patient has multiple abrasions and cuts on his right hand and is informed that two lacerations will require suturing. The patient is agitated and angrily says, "I've been waiting a really long time and have to get out of here and set things straight with my wife and kids. I don't have time for stitches anymore. You are all incompetent." Which of the following questions is most appropriate in determining the best next step in management of this patient?

Question

A 45-year-old man comes to the emergency department with multiple hand lacerations sustained when he punched his hand through a window.  The patient says he "momentarily lost control" when he came home from work to find that his wife had moved out of the home and taken their two children.  Temperature is 37.2 C (99 F), blood pressure is 150/88 mm Hg, and pulse is 96/min.  The patient has multiple abrasions and cuts on his right hand and is informed that two lacerations will require suturing.  The patient is agitated and angrily says, "I've been waiting a really long time and have to get out of here and set things straight with my wife and kids.  I don't have time for stitches anymore.  You are all incompetent."  Which of the following questions is most appropriate in determining the best next step in management of this patient?

Quizplus · Accepted Answer

This patient shows several signs that are concerning for potential violence, including a recent incident of violent/self-destructive behavior resulting in injury and escalating agitation and angry, demanding behavior in the emergency department. The self-harm incident occurred in the context of an acute and devastating loss. The meaning of his vaguely threatening statement ("have to get out of here and set things straight with my wife and kids") is unclear and a concerning sign for potential further harm to himself or his family. His agitation has likely been compounded by a long wait time, and the physician must respond to the patient's impatience to leave and at the same time perform a necessary safety evaluation. The potential for further violence should be addressed directly. The patient should be asked if he is having any thoughts or impulses to hurt anyone or himself. If the patient is feeling homicidal and/or suicidal, he should not be allowed to leave the emergency department and should be placed on hold, involuntarily if necessary. (Choice A) The disinhibiting effects of alcohol or drugs can increase the risk for violence, and asking the patient what he has used can aid in his overall management. However, this patient does not show signs of gross intoxication or withdrawal, which would require immediate treatment. The more critical issue is determining if he is having thoughts of harming himself or others because this would determine the need to hold him in the emergency department. (Choices C and D) These statements fail to address directly the patient's potential for violence. Determining if this patient is feeling homicidal and/or suicidal is the most critical step in management. (Choice E) Although this statement attempts to be empathic, it asks a closed-ended yes-or-no question in a leading manner that may irritate the patient and cause him to become defensive. It would be better to ask the patient to talk about what he is going through in an open-ended fashion (eg, "You have been through a lot today. How are you managing it all?"). Educational objective: In agitated patients, especially those admitted for self-inflicted injuries or recent violence, the potential for further violence should be addressed directly. Patients should be asked if they are having any thoughts or impulses to hurt themselves or others.

A 45-Year-Old Man Comes to the Emergency Department with Multiple