A 32-year-old man is brought to the emergency department after falling from a fourth-floor balcony of his apartment building. A witness at the scene reported that the patient stood on the balcony ledge for several minutes beforehand, looking down toward the street. His fall was broken by a tree, and he sustained multiple minor injuries, including abrasions and lacerations to his face and the extremities. The patient explains that he had a couple of beers and lost his balance while he was birdwatching. He has no medical history but reports that he has lost some weight and feels tired because he cannot sleep due to the loud street noise in his neighborhood. He lives alone and is worried about not being able to pay the rent if he does not find work soon. The patient drinks 3 beers on most weekdays and 4 or 5 beers on weekends but does not use illicit drugs. His vital signs, complete blood count, and comprehensive metabolic panel are within normal limits. Blood alcohol concentration is 0.005%. The patient's lacerations are sutured, and he is medically cleared. Mental status examination shows a thin, anxious man who is cooperative and oriented to person, place, and time. The patient makes poor eye contact and gives brief responses, repeatedly insisting, "Everything's fine, I'm okay. I just want to go home." He says he is not suicidal. Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old man is brought to the emergency department after falling from a fourth-floor balcony of his apartment building.  A witness at the scene reported that the patient stood on the balcony ledge for several minutes beforehand, looking down toward the street.  His fall was broken by a tree, and he sustained multiple minor injuries, including abrasions and lacerations to his face and the extremities.  The patient explains that he had a couple of beers and lost his balance while he was birdwatching.  He has no medical history but reports that he has lost some weight and feels tired because he cannot sleep due to the loud street noise in his neighborhood.  He lives alone and is worried about not being able to pay the rent if he does not find work soon.  The patient drinks 3 beers on most weekdays and 4 or 5 beers on weekends but does not use illicit drugs.  His vital signs, complete blood count, and comprehensive metabolic panel are within normal limits.  Blood alcohol concentration is 0.005%.  The patient's lacerations are sutured, and he is medically cleared.  Mental status examination shows a thin, anxious man who is cooperative and oriented to person, place, and time.  The patient makes poor eye contact and gives brief responses, repeatedly insisting, "Everything's fine, I'm okay.  I just want to go home."  He says he is not suicidal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Patients sometimes deny that they have made a suicide attempt, due to either stigmatization or a desire to reattempt. The physician has a duty to assess the likelihood that an attempt has been made and the risk for further self-harm. Despite his denial, this patient has likely attempted suicide and is at high risk for a repeated attempt. He has numerous risk factors for suicide, including features suggestive of depression (weight loss, poor sleep, anxious affect), unemployment, living alone, risk of homelessness (eg, worried about paying rent), and active substance use, as well as a likely recent attempt. Physicians should use their clinical judgment when assessing suicide risk and must always act to ensure patient safety. This patient should be hospitalized for his own protection, on involuntary status if necessary. It would be inappropriate and unsafe to manage his condition in an outpatient setting. (Choices A, B, and F) This patient should be hospitalized immediately for safety reasons. Although he may benefit from antidepressant therapy, psychotherapy, and social services, these interventions must initially take place in a supervised hospital setting due to his high suicide risk. (Choice D) Holding the patient for observation in the emergency department (ED) is indicated when factors are expected to resolve after a short period, making hospitalization unnecessary (eg, alcohol intoxication). This patient's blood alcohol concentration is negligible with no indication of an altered mental state. His suicide risk factors will not resolve in 24 hours without further intervention, and he should not be held in the ED unnecessarily, which would delay treatment. (Choice E) Although this patient's alcohol use should be addressed because it contributes to disinhibition and increases suicide risk, the priority is to ensure his safety. Educational objective: It is a physician's duty to use clinical judgment when assessing suicide risk. Even if a patient denies a suicide attempt, when a likely attempt has been made and the risk of further self-harm remains high, the patient must be hospitalized (involuntarily if necessary) to ensure safety. References: Civil commitment in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/22778709)

A 32-Year-Old Man Is Brought to the Emergency Department After