It was 4:30 am and I was sluggishly clicking through the emergency room waiting list. My lukewarm coffee has lost its aroma. Normally the crowd dies down around 2 am on night shift, but a new case popped up – a teenage girl. There has been an increasing number of child and adolescent cases in the emergency room this past month.
As a first-year medical officer in my 3rd month of a psychiatric emergency room posting, my duty is to see the patient then finalize the management plan with the child and adolescent consultant on duty. This also involves discussing with their parents for a corroborative account.
The 15-year-old girl who turned up was not accompanied by family, but by police. She was sitting alone on the 17th-floor window ledge of her home. Neighbours witnessed her dangling legs from across the building and called the police to rescue her. Like other teenagers that end up in the emergency room, she revealed that she got into a verbal dispute with her parents that night, had ongoing issues with friends and boyfriend, and was stressed about recent exams from crippling high expectations.
To see whether patients will need urgent admission, we ask about current and past suicidal attempts – the triggers, methods, and last acts such as a written goodbye note. We explore their intentions behind deliberate self-harm, including overdosing on medications, cutting themselves, and banging their heads against the wall as examples. If they are not for inpatient admission and are for discharge instead, we’ll make sure there is a safety plan in place with a family/friend (old enough) to watch over them the next few days to one week (depending on our assessment) while they rest at home.
Some other common complaints we see in children and adolescents in the emergency room are panic attacks and hallucinations.
Panic attacks are usually manifested from emotional stress and involve a range of physical symptoms that reach peak intensity before dying down. These symptoms can be sudden and functionally impairing, often scaring the patient as they feel as if they are about to die. An analogy would be feeling palpitations and nervousness anticipating a rollercoaster drop that evolves into a sustained chest-about-to-burst and stomach-clenching sensation during the drop. This uncomfortable experience can last up to 30 minutes.
Hallucinations in children and adolescents can vary in nature and origin. Sometimes the hallucinations are imaginary friends they never let go of, influenced by violent cartoons, manifested from unaddressed spirit-crushing stress, simply due to lack of sleep, or sometimes on rarer occasions, an indication of early psychosis. The latter of which will need urgent admission and monitoring.
So what can we do to help keep youths mentally healthy and prevent them from presenting to the psychiatric emergency room?
- Regularly check in with them for any stress they may have with friends/relationships, family, school
- Have a safety plan in place with them as well as yourself – knowing the helpline number (We have the Samaritans of Singapore SOS here and it’s 1800 221 4444) to call and where to go if they experience extreme distress
- Engage a school counsellor to monitor their mood and be their soundboard when you aren’t able to
- Keep them active (socially) – exercise, and encourage experiences that will improve their connectedness to friends, family, and the community
As for the young girl I saw at 4:30 am – she was admitted for observation overnight and reassessed in the morning. On discharge, she and her family were provided with a safety plan, a memo to the school counsellor for close monitoring daily the next few weeks, a referral to a community youth support program, and an early appointment with a child and adolescent psychiatrist. Though we have short encounters with patients in the emergency room, we try our best to de-escalate the immediate risk and provide as much help as we can when they are discharged. I didn’t care that my coffee lost its aroma or that I didn’t get to sleep on shift – what mattered most is that she was safe.
Thanita Pilunthanakul
IACAPAP Blog 