Panelists Jessica Keith PhD Tawnia Lola RN Tulika Singh MD Moderator Aimee Sanders MD MPH Mental Health Crises 22 million living women Veterans Of 350000 women Veteran VA health care ID: 765531
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Panelists: Jessica Keith, PhD Tawnia Lola, RN Tulika Singh, MDModerator: Aimee Sanders, MD, MPH Mental Health Crises
2.2 million living women VeteransOf 350,000 women Veteran VA health care users, ~35% had at least one mental health diagno sis
44yo VeteranMental health history PTSD History of MST and childhood abusePsychiatric hospitalizations Today, during outpatient mental health appointment, made vague self-harm statementEscorted to ED, but no report provided Becky
First Response
5 Direct Communication
Trauma-informed Care
Trigger Responses
Minimize Likely TriggersBUT…
Be Ready to Recognize When a Veteran is Triggered and Respond
Comfort and Safety
Effective Communication in a Crisis Situation
Do not act in ways that: REACT R estricts E scalates A voids C oerces T hreatens
Grounding Technique
Compassionate careSuccessful use of grounding techniqueAnswers questions and leaves bathroomPrefers taking to female staff
Next Steps in Care
Medical EvaluationSuicide & mental health assessments“Do you have a plan to harm yourself?”“Have you done anything recently to harm yourself?”Risk factors for suicideReview of systems
Physical exam Suicide & mental health assessments Medical Evaluation
Physical exam Suicide & mental health assessments Lab testing Medical Evaluation
Physical exam Suicide & mental health assessments Lab testing Additional diagnostics as indicated Medical Evaluation
Suicide AssessmentAsk directly and matter of factlyMeans and accessibilityHistory of self harmProtective factorsReview chart for risk factorsPast attemptsSignificant life changes Medical problemsSocial withdrawal
Becky’s ED Course
Other ConsiderationsHow would this case change if Becky didn’t meet hospitalization criteria?
Take Home Points
Take Home Points
Take Home Points
Jenny28yo Veteran“At the end of her rope” Frequent ED visitsMigrainesGI symptoms URI symptoms Depression Suicidal ideation Mental health history Anxiety Depression Borderline Personality Disorder Jenny
Managing Initial Reactions
Intimate Partner Violence (IPV) Red flags Repeated medical visits Complaints of stress, anxiety, depression Recurrent physical symptoms Headaches and chronic pain GI distress Pelvic pain, gynecological problems Vague physical complaints Childbearing age women
Intimate Partner ViolenceScreening
IPV and suicide assessmentsDirect screening questionsMedical Evaluation
Physical exam Injury patterns or signs of trauma Face , head, breasts, abdomen Symmetric / bilateral Inconsistent with the explanation Various stages of healing D elayed presentation IPV and suicide assessments Medical Evaluation
Lab testing Physical exam IPV and suicide assessments Medical Evaluation
Additional diagnostics as indicated Lab testing Physical exam IPV and suicide assessments Medical Evaluation
Jenny’s Case Develops
If she says yes…
If she is not ready to leave…Provide information on IPVBe clear that violence or threats are not okayReview warning signs of escalationDiscuss option should violence escalateRefer to community resources, support groups, crisis hotlinesInvolve ED care team, including social work
Internet Safety and other informationfrom the National CoalitionAgainst Domestic Violence:http://www.ncadv.org/protectyourself/MyPersonalSafetyPlan.php or fromthe National Network to EndDomestic Violence: http://nnedv.org/projects/safetynet.htmlFrom the National Coalition Against Domestic Violence: www.ncadv.org/protectyourself/MyPersonalSafetyPlan.php
Other ConsiderationsHow would this case change if Jenny was pregnant?
Other ConsiderationsWhat if Jenny had her young children with her in the ED?
Take Home PointsExpress empathyAsk screening questions
Take Home PointsDocumentRespect decisions Express empathy Ask screening questions
Provide resourcesRisk assessmentDocument Take Home Points Respect decisions Express empathy Ask screening questions
ResourcesSharkansky, E. Sexual Trauma: Information for Women’s Medical Providers. Washington, DC: US Department of Veterans Affairs, National Center for PTSD, 2014. http://www.ptsd.va.gov/professional/treatment/women/ptsd-womens-providers.asSuicide Prevention Resource Center. Suicide risk: A guide for ED evaluation and triage. Bethesda, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, n.d. http://www.sprc.org/sites/sprc.org/files/library/ER_SuicideRiskGuide8.pdf
ResourcesThe Safing Center. Domestic violence/intimate partner violence national resources. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. http://www.bedford.va.gov/services/Safing_Center/IPV_National_Resource_List.pdfThe Safing Center. Signs that you might not be safe in your relationship. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. http:// www.bedford.va.gov/services/Safing_Center/RiskforexperienceIPV.pdf