I am contracting for safety. Now let me go home

A health student who you know of has been having mental health issues. They have been doing an elective in your department and at least once or twice have been off. You have heard from your colleagues of this student. Upon starting a rather busy night shift, you see that they are back. Upon interrogation you find out that this is a qualified RN who is training in the N.P. program and has to do so many hours in the ED. They have been a qualified RN for a number of years and have worked for the Canadian Military where they served in Afghanistan and South Africa. After talking to them you recognize symptoms of PTSD stemming from experiences in the army as well as a sexual assault by another army officer which was never reported by this N.P. student. There is no drug use. There is no suicidality reported. They do cut their wrists. The student was supposed to work and decided to check in to be seen because they felt unable to work right now. After the interview, the student says “I am contracting for safety. Now let me go home”. What do you do?

3 thoughts on “I am contracting for safety. Now let me go home

  1. In my opinion this patient is not formable so you cannot force them to stay in the ER. However you can make a safety plan with the patient if they do become suicidal such as returning to the ER or calling a help line. If there are psych resources for PTSD available through the ER I would connect the patient with these. I would also dictate a note to the family doctor outlining my concerns and recommend they follow-up on the PTSD themselves or refer to psych.

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  2. Agree with Katrina. Also can consult urgent psychiatry, make a note/record of this, and have a frank discussion with her that she needs to follow up with these services, specifically since this is affecting her ability to work!

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  3. I would let her go home. Putting somebody on a form is a huge deprivation of their basic liberty, and as much as she needs help, keeping her in hospital against her will, and in the absence of any immediate safety red flags is not appropriate.

    I recently learned about the urgent psychiatry clinic, and I agree that this would be a very appropriate follow-up plan for her. Whenever in doubt, I have always found it very useful to give the resident of any consulting service a quick call, simply to ask them about what urgent clinics they have available, and what we can do in the Emergency Department to make those arrangements before discharging a patient home.

    For a patient like this, and especially a colleague, I think a phone call in 48 hours to check-in would be very useful. It would allow me to see how things are going, whether the wheels for her outpatient referrals are in motion, and if anything has changed since her visit.

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