Spot the Diagnosis! The Case of the Bloody Man

In Arts PRN, Featured, Medical Conceptsby Leah ZhaoLeave a Comment

As part of the Arts PRN series, we will intermittently be featuring pieces of historic art that hint at an underlying medical condition. They say a picture is worth 1000 words… can you Spot the Diagnosis after examining only a painting? Read on to learn not only about the art, but about these fascinating medical conditions. Who knows, maybe they’ll help you make a diagnosis some day (or at least help you out on Jeopardy)! After you read, consider submitting your own art to the Arts PRN Project.

This week’s Spot the Diagnosis features “The Anguished Man,” an anonymous painting inherited by Sean Robinson from his grandmother’s attic collection. This painting has a particularly strange story behind its creation… can you decipher the subject’s diagnosis?

Need a hint?

The artist of this painting was in significant emotional distress when he created this final piece by mixing in his own blood with the oil paint.1

What happened to this man?

The subject of this painting is a reflection of the internal state of the artist himself. Shortly after completing the painting, he committed suicide.1 Although this is a rather strange and eerie painting, the story behind the piece highlights an important but often neglected topic in emergency medicine: suicide assessment in the emergency department.

Suicide is, unfortunately, one of the major causes of preventable and premature death. In 2009, 3980 people died of suicide in Canada.2 Many patients who are contemplating suicide or have attempted suicide present themselves to the emergency department seeking help. They may also be brought in by concerned loved ones or bystanders. These patients represent a varied and often challenging population with a myriad of factors to consider when assessing individual risk. Like the creator of this painting, there are often warning signs that physicians must be vigilant to. Therefore, the emergency physician must have a strong and sensitive approach to assessing suicide risk in a fast-paced environment.

“People expect the emergency department to help someone in crisis with active suicidal thoughts. But most emergency rooms are ill-equipped to support someone who is actively suicidal. They are busy, chaotic places, often with no quiet or calming spaces.”

-Dr. Jennifer Brasch, psychiatrist and former pediatric emergency services director3

When to assess patients for this concern?

In addition to anyone who discloses that they are actively suicidal or who have just attempted suicide, there are many other patient scenarios where we should screen for suicide risk. Anyone presenting to the emergency department with an emotional or behavioral complaint must be assessed for suicidality, including those in acute psychosis. Patients who come in with suspected toxic ingestion, drug overdoses, or suspicious injuries also warrant a suicide assessment.4

What are the risk factors?

When assessing a suicidal patient, it is important to assess lethality factors in the following three categories:5

  1. Predisposing factors
    1. Existing mental health, substance use, and medical conditions
  2. Risk factors
    1. Acute symptoms or stressors that may trigger suicide
    2. “Is there anything in your life that is causing you distress right now?”
    3. “Have there been any changes to your life recently?”
  3. Protective factors
    1. “What is stopping you from killing yourself?”
    2. “What do you see yourself doing a year from now?”

There are many risk factors for suicide attempt and completion in those with suicidal ideation. Below are a list of “red flags” to ask about and watch out for when assessing patients. It is up to the emergency physician to piece together the patient’s story in determining their overall risk, but any one of these risk factors may warrant an admission for psychiatric assessment, either voluntary or involuntary.4,6

  • Previous suicide attempts
  • Concrete plan
  • Viable method – e.g. gun in house, prescription medication overdose
  • History of significant mental illness
  • Substance use disorder
  • Active psychosis
    • Command auditory hallucinations
    • Persecutory hallucinations
  • Agitation, aggression, irritability
  • Feelings of hopelessness
  • Elderly patients

It is crucial to use an empathetic and direct tone to establish rapport with the patient during your interview. Asking a patient whether they have thought about suicide or have a plan in place for suicide does not increase the likelihood that they will attempt suicide.7

What conditions must be ruled out?

Any patient who presents to the emergency department must be assessed for the presence of medical conditions that require emergent or urgent treatment. This is commonly called “medical clearance” and involves ruling out non-psychiatric causes of the patients’ symptoms, including intoxication or toxic ingestion, trauma, brain tumour, dementia, and other conditions. This is typically done by taking a history and physical examination, and tests are not necessary unless there is a specific concern.4

Patients who have an active concurrent medical condition must first be stabilized and managed from a medical standpoint before they are assessed from a psychiatric standpoint. As such, patients may be admitted to a medical or surgical service first while pending psychiatric assessment.

What are some acute management options?

If a patient is aggressive or agitated, a chemical or physical restraint may be needed to ensure the safety of the patient, staff, and other patients in the department. It is best to avoid restraints whenever possible, since they cause significant distress to patients and hinder physician-patient rapport. But if one cannot verbally de-escalate a situation, consider trying a chemical restraint first, such as a dose of Ativan, and then a physical restraint if necessary. 4

How to make disposition decisions?

Other than ruling out medical causes to the patients’ presenting complaint, the most important role of the emergency physician to actively suicidal patients is to determine their disposition. There are usually one of three choices: 1) admit patient voluntarily for psychiatric assessment, 2) admit patient involuntarily for psychiatric assessment, or 3) timely outpatient follow-up with a psychiatrist with appropriate education, resources and instructions given for the interim.

The decision for disposition is made based on risk for suicide completion and patient cooperation. Patients without any of the lethality risk factors listed above may be discharged home for urgent follow-up with a psychiatrist in an outpatient setting. These patients must be cooperative and express that they are both willing and capable of attending the appointment. However, if there are any risk factors or any other features on assessment that may jeopardize the safety of the patient, then they must be admitted to the hospital for assessment by a psychiatrist. Those who are cooperative and willing may be admitted voluntarily. In contrast, patients who are uncooperative, unwilling to stay, agitated or aggressive have to be involuntarily admitted on a Form 1 for psychiatric assessment within 72 hours of admission.8

One previously popular method physicians employed when discharging suicidal patients is to sign a “contract of safety” with them. This contract outlines that the patient will not kill themselves in the time before they receive follow-up care and is signed by the patient. However, these contracts do not actually prevent suicide and are no longer recommended.9

What to tell a patient being discharged home?

When discharging a patient with suicidal ideation home, the emergency physician should educate the patient on their condition, available treatment options, warning signs and how to respond, and methods to reduce suicide risk and lethality.8 The Suicide Prevention Resource Center has more information on brief suicide prevention interventions that may be performed effectively and efficiently in the emergency department: Click here to read.

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References:

1.
The Anguished Man: Painted in Artist’s Blood Before Suicide. The Post-Mortem Post. http://www.thepostmortempost.com/2015/03/30/the-anguished-man-painted-in-artists-blood-before-suicide/. Published March 30, 2015. Accessed June 11, 2018.
2.
Suicide rates: An overview. Statistics Canada. https://www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm. Published June 17, 2017. Accessed June 11, 2018.
3.
Strengthening Suicide Prevention in Ontario Hospitals: A Report from the OHA Task Force on Suicide Prevention. Suicide Prevention Community Council of Hamilton. https://spcch.org/wp-content/uploads/2017/10/2508_OHA_Strengthening-Suicide-Prevention_august.pdf. Published August 2017. Accessed June 11, 2018.
4.
Betz M, Boudreaux E. Managing Suicidal Patients in the Emergency Department. Ann Emerg Med. 2016;67(2):276-282. [PubMed]
5.
Mitchell A, Garand L, Dean D, Panzak G, Taylor M. Suicide Assessment in Hospital Emergency Departments: Implications for Patient Satisfaction and Compliance. Top Emerg Med. 2005;27(4):302-312. [PubMed]
6.
Targum S, Friedman F, Pacheco M. Assessment of suicidal behavior in the emergency department. Innov Clin Neurosci. 2014;11(9-10):194-200. [PubMed]
7.
Sood T, Mcstay C. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4):669-83, ix. [PubMed]
8.
Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments. Suicide Prevention Resource Center. https://www.sprc.org/sites/default/files/EDGuide_full.pdf. Accessed June 11, 2018.
9.
Stanley B, Brown G. Safety planning intervention: A brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;(19):256–264. http://suicidesafetyplan.com/uploads/Safety_Planning_-_Cog___Beh_Practice.pdf.
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Leah Zhao

Leah Zhao

Leah Zhao is a second year medical student at McMaster University. She spends most of her free time enjoying good food, going on outdoor adventures, and being a couch potato in front of her laptop.