JOHN SHUFELDT, MD, JD, MBA, FACEP
He watched her walk through the door at the end of a long, busy day. She was an attractive, well dressed, athletic-looking young lady with a warm smile, the kind of girl he’d want his teenage son to date someday.
“Slam dunk,” he thought. “This will be a quick visit and I’ll still get out on time.” The front office team registered her quickly. He suspected that they, too, wanted to get out on time. He followed behind her into the exam room, smiled as he introduced himself, shook her hand and sat down nimbly on the small metal stool which, unbeknownst to him, would become his chair for the next few hours.
Her eyes briefly met his when he shook her hand but then she immediately looked away. “Must be an STD or some other perceived embarrassing issue,” he thought as he studied her body language. After a few pleasantries, he inquired about why she was at the urgent care center.
“I’m a cutter,” she said in a matter-of-fact way as she pulled up her sleeve, exposing the numerous superficial lacerations on the volar aspect of her left arm. He studied her face for a brief moment and then turned his gaze to her outstretched arm. He noticed multiple old scars as well as some healing wounds and one deeper wound oozing blood. He believed he saw an exposed yet uncut tendon move up and down as she wiggled her fingers. “I think I need a stitch or two,” she remarked in a detached, flat tone.
“I suspect you need more help than that,” he replied as he continued to exam her hand and arm.
“Why do you do this to yourself? Are you trying to kill yourself?” he asked. “Of course not!” she replied in a tone changing from flat to indignant. “I do it because it helps me and because I want to do it. Now are you going to help me or not? I have a date tonight and this needs to be fixed.”
“I’m sorry to tell you that you are going to miss your date,” he said, “I need to send you to the emergency department so that they can evaluate you for suicidal thoughts and get you the help you really need.”
Hearing that, she immediately jumped off the examination table where she had been sitting and moved quickly toward the door. He jumped up and tried to bar her from leaving the room but was careful not to grab her or block her exit. He was on unfamiliar turf and he knew it.
“Wait, wait” he pleaded.
She spun around on her toes, and actually stepped toward him and said, “Look, I know I have a problem. I am not trying to kill myself. I just want you to fix this. How is this different from body piercing, or not being compliant with treatment, or taking drugs or even eating food that is not good for you?” Clearly, she had been through this discussion in the past and was well versed in the rhetoric and the logic others used and which apparently failed to persuade her.
“It just is,” he said, “Cutting is something you are actually doing, the others are…” his voice trailed off as he searched for the syllogism. “Exactly” she said. “It’s the same thing. Now if you are not going to suture me up, I’m out of here!” Variations of this discussion and this issue happen daily in urgent care centers across the county. What obligation does a provider have when faced with these murky issues of deliberate self-harm? This article attempts to provide some guidance to clinicians who run into these issues.
On one end of the spectrum are patients who do not follow doctor’s advice. These patients don’t quit smoking, refuse to take antidepressant medications, take their antihypertensive medications only intermittently or eat food that is not good for them. At the other end are patients who are actively suicidal. Those patients take intentional overdoses, drive a car unrestrained at high speeds into a fixed object or attempt to use a gun or knife to fatally harm themselves.
Somewhere between these extremes are patients like the young lady above who are hurting themselves in a typically non-life-threatening way. Self-harm (or self-mutilation in older literature) is defined as the intentional, direct injuring of body tissue (skin cutting is the most common form) most often done without suicidal intentions. There may be an increased risk of suicide in individuals who self-harm inasmuch as self-harm is found in 40% to 60% of suicides. However, generalizing self-harmers to be suicidal is typically inaccurate.
Self-harm is often associated with a history of emotional or physical abuse, and is most common in adolescence and young adulthood.
The behavior involves intentional tissue damage that is typically performed without suicidal intent. A common belief regarding self-harm is that it is an attention-seeking behavior. In most cases, however, self-harmers are very self-conscious of their wounds and scars and feel guilty about their behavior, which leads them to go to great lengths to conceal their behavior from others.
People who self-harm are generally not seeking to end their own life. Experts believe instead that they are using self-harm as a coping mechanism to relieve emotional pain or as an attempt to communicate distress.
Thus self-harm is being used as a coping mechanism to provide temporary relief of intense feelings of anxiety, depression, stress, emotional numbness or a sense of failure or self-loathing.
It sounds trite, but a provider’s obligation is to simply do the right thing. The right thing in medicine is to always put the patient’s interest first. If you determine a patient is harming himself or herself, what obligation do you have as a provider? Initially, it is important to check the patient’s competence. Does the patient realize the outcome of his or her actions? For example, if a patient takes a bottle of Tylenol and has no idea about the lethality of Tylenol, is this person competent to understand the potential outcome of his or her actions?
Once you determine that a patient is competent mentally, is he or she legally competent? Has the patient reached the age of majority? Check on your state’s statutes; generally in most states, a person who is under the age of 18 or not emancipated is not legally competent.
If a patient is legally and mentally competent, was the intent to commit suicide? If someone shows up at a center of their own volition and denies trying to kill themselves – and you believe them—then you are arguably not obligated to force the patient into some sort of treatment or mandate that the individual be transferred to the ED.
If you do not believe that a patient is actively trying to kill himself or herself, then your next obligation is to treat the injury with which the individual presents. For the young lady above, the provider should repair the wound–-after he repairs the lost trust. While repairing the wound, he should offer her some treatment options in a non-judgmental, non-threatening way.
At the end of the day, many people who engage in self-harming activities have been victims of some tragedy and need our empathy and support as opposed to judgment and threats. If, after talking to a patient, you determine that the individual is, in fact, incompetent or is trying to commit suicide, you are legally and morally obligated to ensure that person’s safety and facilitate transfer to the most appropriate place to receive care.
Epilogue: The patient missed her date and the provider and staff went home much later than anticipated. The provider spent about 90 minutes listening to the woman while repairing her wounds. The patient left with a number of options for support and treatment, which the staff found for her simply by searching the Internet. She felt she gained a confidant and possibly a future mentor for a future career in medicine; the provider left the center late that night, thankful that he was fortunate enough to take care of her and re-energized about his avocation.
