When a rape is reported somewhere in our county, police investigate and, if they think a forensic rape exam is indicated, the patient is brought to our emergency department for that exam. The victim is not seen by our emergency physician unless some issue comes up that the specially trained Sexual Assault Response Team (SART) nurse is not able to deal with.
Recently, while the SART nurse was doing the exam, the patient said that being raped had made her suicidal and, when she got back home, she was going to kill herself.
This information was passed to me and I went to talk with her. She was emotionally upset, as you can imagine. She admitted to saying she was going to kill herself but she had just said it because she was upset, not because she was going to follow through on the threat. She just wanted to go home.
This put me in a tough position. By law, if I think patients are suicidal, I have to place them on a psychiatric hold and get them to our psychiatric emergency room for help. If I don’t do so, I have broken the law. This also offers a challenging moral dilemma. If I sent such a person home and she did kill herself, I would certainly be at fault and would feel terrible about it.
We see people all the time who come in on a hold with clear documentation of suicidal behavior who totally deny it once they get to the emergency department. They either change their minds or they lie because they just don’t want to be on a hold. Was this patient like them or was she really just upset and misunderstood by the SART nurse? I had to decide whether to believe that she had just said something that she didn’t mean and let her go home or put her on a hold and send her to emergency psychiatry.
After talking to her for quite a while, I told her I was obliged, under law, to send her to psychiatry to get her help that would not be available if she just went home. When I told her that, she pleaded and begged to be allowed to go home. When that didn’t work, she went ballistic and started hollering and screaming that she was just going to leave.
When she went off, the staff called security. Soon, three big guys in blue uniforms were standing at the door of her room, which only made her more hysterical.
You can imagine how bad I felt. First, she is raped, which is horrible. Now, instead of the calm, understanding environment we try to provide victims of rape, we are threatening to tie her down to a gurney with leather restraints. It made me feel really bad, though I recognized I made the right decision, given the circumstances presented.
Fortunately, she quieted down and went peacefully off to talk with the psychiatrist. When she got there, she was calm and cooperative. She told the psychiatrist she felt safe and was glad she was there. She acknowledged she really needed help.
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