Pediatric Psychiatric Issues: The M-1 Hold

As many readers of this blog know, I'm a pediatric ER nurse. What that means is that I just don't take care of newborns and toddlers but also teens and young adults up to the age of twenty-one.

Particularly, in the last five years or so, I've helped care for an increasing number of patients that have been placed on M-1 holds. An M-1 hold (it may go by other names in your area) is essentially a mental health hold or involuntary placement into the hospital for a mental health evaluation.

In our hospital system, there's not a required length of stay but it does mean that, essentially, we take over custody of your child until this evaluation takes place. That means that you as the parent cannot take your kid from our facility and we can transfer them where they need to go without your consent.

Your child can be placed on an M-1 hold by two parties-- either law enforcement or a physician. Sometimes kids come in via police already on an M-1 hold.

A patient is usually placed on a hold for expressing thoughts of wanting to hurt themselves or others by making these statements to either a parent, school counselor, mental health counselor, physician or law enforcement officer.

When a patient makes these statements or requires medical treatment for self-harming (cutting too deep that the cut requires sutures) or outright suicide attempt (like drug overdoses) then they're placed on an M-1 Hold. Emergent or stabilizing medical treatment is always handled first.

When a patient is placed on an M-1 hold, the medical staff must provide for the patient's safety.

We have them change into scrubs of a particular color and confiscate all their clothes. This means everything but their underwear (excluding bras-- yes, they must remove those as well) and perhaps socks. Part of the reason for this is to keep them from fleeing (by taking their shoes) and also as a security measure so staff know that a person leaving the facility in those scrubs needs to be stopped. They also cannot wear hair bands, necklaces, or bracelets. All piercings need to be removed.

They are placed in a "safe room" which, at our hospital, is not the "rubber room" you might imagine but it is devoid of basically everything but the bed and a chair. No cords. No monitor. No alcohol hand gel.

The patient is asked to provide a urine sample. Girls are tested for pregnancy above the age of twelve. All are tested for drugs. If they give a concerning history for possible ingestion-- blood tests may be added to test for aspirin and acetaminophen which can be deadly overdoses.

The patient is then scanned for metal using a wand-type device that you see at airports.

At all times, the patient is under one-on-one observation by someone on our staff even if they have a parent present.

After that, the physician will have a talk with the patient alone, the parents alone and then both parties together if the patient agrees. After that, the physician touches base with the mental health staff to determine the best course of action for the patient.

With the advent of telehealth, some of these mental health evaluations can take place with face-to-face interaction over the computer. This has helped decrease the need for transfers but is a very lengthy process. Each interview mentioned above also takes place by the mental health counselor. Each interview can take 30-60 minutes.

If a patient is transferred, it must be by ambulance. Parents are not allowed to ride in the ambulance for this type of transfer. Again, this is a safety measure. It may be surprising but sometimes parents can complicate matters and for the safety of the EMS team-- they take only the patient.

I hope this provides insight into what will happen if your child is placed on an M-1 hold or you need it for a scene in your novel.

The Survivor's Side of Suicide: Part 2/2

Today, we're concluding author Julie Cantrell's post on what it's like living through a loved committing suicide.

You can find Part I here.

Welcome back, Julie.

When Robin Williams passed away, the world was abuzz weighing the controversial issues of mental illness, depression, and suicide.

While some people were unable to extend kindness or understanding, proving we have a long way to go in our culture’s recognition of chemical imbalances, the international conversation gave me hope. It proved that people are finally willing to say the word SUICIDE out loud, without the hushed whispers and back corner gossip.

Putting this word on equal footing with all the other words in our vernacular is important. It lessens the sting.

I consider this progress, and I am optimistic the forward momentum will continue.

It is time.

I write this blog today for several reasons:

§  One, I am proud to have been the sister to an amazingly bright spirit who left this world too soon and whose memory I want to keep alive.

§  Two, I want to increase understanding and support for the millions of people struggling with chemical imbalances.

§  Three, I want to offer support and empathy to all who have lost a loved one to suicide and encourage you to speak out loud to honor their spirit and to educate those on the other side.

§  Four, and most importantly, I have a very important message for anyone struggling with depression.

One week after my brother died, we received notice that he had landed the career opportunity he wanted with the Department of Wildlife and Fisheries. That job may have been enough to offer him the key to that cell, the something to cling to, the reason for reason. Maybe, if he could have stuck it out one more week, he would still be alive today. Seven days, and he may have had hope again.

Today, when I see someone struggling for hope, looking for a signal, a reason, proof that their life matters and that the pain will indeed end, I think of my brother and that phone call that came one week too late.

If you are struggling with depression, please remember... you are in this world for a reason. You have a very important journey you must complete. You were born to accomplish something, something only you know. You will suffer, you will hurt, you will feel hopeless and alone at times. But you are not in that space forever. Keep walking, keep moving forward, and you will find your way through in time.

When you hit bottom, please remember this: You are loved. You are never alone. You were born with everything you need to survive this journey. You matter. And once you are on the other side, as you will soon be, then, you will look back with wiser eyes, the eyes of a survivor. You will know your soul survived the stretching season. And you will move through the world with greater empathy and understanding, a gift like none other. For you, sensitive one, are the blessed. And we need you here. In this life.

Be brave. Wage war. Hold fast to the light inside of you.

“For God hath not given us the spirit of fear; but of power, and of love, and of a sound mind.” 2 Timothy 1:7

This post will be shared across multiple platforms for National Suicide Prevention Week. Learn more about suicide prevention by visiting: http://www.suicidology.org/

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Julie Cantrell is the New York Times and USA Today bestselling author of Into the Free, which won Christy Awards for Best Debut Novel and for Book of the Year 2013. Cantrell has served as editor-in-chief of the Southern Literary Review and is a recipient of the Mississippi Arts Commission Literary Fellowship. She and her family live in Mississippi, where they operate Valley House Farm. Her new novel, WhenMountains Move, hit shelves September 1, 2013.

The Survivor's Side of Suicide: Part 1/2

I'm honored to have friend and NYT's bestselling author Julie Cantrell here this week with a poignant post about her brother's suicide.

Suicide seems to have come to the forefront with the death of Robin Williams but suicide is ever present. Last week was Suicide Awareness Week and I'm willing to do what I can (as a mother, nurse and author) to help raise awareness.

Thank you, Julie, for these words.

Suicide is one ugly word. It’s the kind of word that swings heavy from lips. The kind that is whispered, and stilted, never sung.

As an author, I build my life around words. Every word has worth. Even those words we are not supposed to say.

But suicide is the one word I do not like. I wish there was no need for such a word in our world. Especially since 1997, when my teen brother ended his own life two months before his high school graduation.

It is one thing to be on the other side of suicide, where you may offer prayer or casseroles or even a hug. It is another thing entirely to be on the side of the survivor, after a loved one puts a gun to the head or a rope to the neck or a blade to the vein.

That dark depth of despair is no easy channel to navigate because unlike every other form of death, this one was intentional. This one could have been prevented. This one carries immeasurable sting.

The what-ifs and but whys and I wonders never cease. They haunt all hours, whether moonlit or shine.

And the stares don’t stop either, the constant conversation that hangs silently between friends — at the grocery store, or in the church pews, or at the birthday party. No one says it, but they are thinking… That poor mother, how does she stand it? Or – That poor child, knowing his father took his own life.

What people on that side of suicide don’t understand is that we, the survivors left in the wake, are barely keeping our heads above water. We don’t want pity, or sympathy, or stares. We don’t want whispers, or questions, or help. We want one thing only. We want our loved ones back.

And there’s one simple way you can give this to us.

Talk about the people we loved and lost. Don’t dance around us as if their ghost is in the way. Acknowledge the lives they lived. Recognize the light they once shined. Laugh about the fun you once had together.

There’s nothing you can tell us — no detail too small, no memory too harsh — that will hurt us. We crave it all. We are hungry for any piece of time travel you offer. Bring us back, to that space, when the one we loved was in the here and now.

Suicide is something most of us struggle to understand. It is difficult to rationalize the selfish part of such an act. How could someone not care about the pain they would throw on their loved ones? How could someone not be strong enough to stay alive?

But here’s the truth: suicide was not the cause of my brother’s death. Depression was the cause of his death. And depression is a beast unlike any other. It is an illness we still struggle to cure, despite all the therapeutic and pharmaceutical intervention available today.

Sometimes, even with all the help in the world, a person cannot see through the pain. They cannot imagine a better day ahead. They see only more hurt. And when I say hurt, I mean suffering. Blood-zapping, brain-numbing, soul-bursting agony.

Imagine this: you wake every day as a prisoner. You are trapped in a cell with no freedom in your future. You are tortured — physically, emotionally, psychologically. The anguish never stops. Just when you think you cannot survive another blow, it comes again. More pain.

You try to ignore the ache. You cannot. You try to numb the hurt. You cannot. You try to rise above the pain. You cannot. The brutality persists. And you see no end to it.

If you knew you had to endure only one more round of abuse, or one more month, or even a year, or longer — If there was an end in view, you could be strong enough to handle it. You could take whatever is thrown at you because you want, more than anything else, to live.

You are a sensitive soul and you have so much left in you to give. You want only to love and be loved. But the cell has you trapped. You have tried everything. There is no end to the insufferable situation.

A person with depression becomes suicidal when they finally give up all hope. When they accept that nothing they do, no matter how long they survive, no matter how many medications or prayers or therapists they turn to, the pain will never end.

Can you imagine the pain you would have to be in to take your own life? Can you imagine the fear of a suicidal person (regardless of faith), daring to face the unknown because even the possibility of eternal hellfire or permanent purgatory or absolute absence seems less scary than another day in this world?

We'll conclude with Part II on Thursday.

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Julie Cantrell is the New York Times and USA Today bestselling author of Into the Free, which won Christy Awards for Best Debut Novel and for Book of the Year 2013. Cantrell has served as editor-in-chief of the Southern Literary Review and is a recipient of the Mississippi Arts Commission Literary Fellowship. She and her family live in Mississippi, where they operate Valley House Farm. Her new novel, WhenMountains Move, hit shelves September 1, 2013.

Killing Autism: The Case of Kelli Stapleton

Normally, I would put this post under Parents Behaving Badly, but the case of Kelli Stapleton makes this not so easy and may shed light more on a dysfunctional mental healthcare system than of a mother callously wanting her autistic daughter out of her life.

One thing I've learned from my years of pediatric nursing is that child abuse/child homicide is a multifaceted issue. Families under stress with limited resources can bring a violent component into the household as a way of managing tension. In no way am I justifying this as appropriate behavior but I can also understand how some people make these choices.

Kelli Stapleton is accused of trying to kill her autistic daughter, Issy, in a murder/suicide attempt by lighting two charcoal grills inside a van. The pair were found unconscious but both have survived.

Kelli's husband, in this People piece, says he'll never forgive her for her alleged actions.

If her actions prove true, then she should be punished, but perhaps this is a case where forgiveness and mercy should be given out in spades.

Autistic kids can be violent. But the services available to help families deal with these children are paltry at best. Even before the Sep, 2013 event, Kelli Stapleton had been on local news the previous March discussing her plight at the hands of her violent daughter. You can watch the video below which details how violent Kelli's daughter had become.

In one instance, Kelli had been beaten unconscious during one of Issy's violent outbursts. She was desperate to find mental health services in her community. Finally, she did find a residential facility that agreed to take Issy's case to the tune of $800.00/day. Part of the news piece below states the family was looking for additional financial support to keep her in residential treatment for six months. While in treatment, the residential staff determined that her outbursts were a result of her hearing the word "no" and she used violence to get to the person or thing she wanted.

What parents is not going to occasionally say no?

I've worked with families of autistic children. It is no easy road. I would never justify this mother's alleged actions but I can also understand someone coming to the end of their rope in a situation like this and perhaps making a choice out of desperation when there seems to be little light in hopes of continued community support.

I think what we need to consider is how paltry and ineffective our mental healthcare system is and what the repercussions of that can be.

Kellie Stapleton's trial is set to start this September.

What do you think? If Kelli Stapleton is convicted of these charges, are they understandable or unforgivable?

Medical Question: Suicidal Pregnant Patient

Lisa Asks:

I just found your site and it looks great! I'm writing my first mystery novel and I have a character who attempts suicide by taking an overdose of Ambien. She is discovered in time and pumped out, but I'd like to know:

If she was unconscious when they found her, would they give her adrenaline or anything to wake her up, or just let her sleep it off? Would she be on oxygen or on an IV with some sort of drugs to counteract the sleeping drug? If her family visited her right afterward is there a chance she'd still be sleeping? Would she be in a regular ward or the ICU on the first day? Or would she be shipped right to a psych ward?

Jordyn Says:

An unconscious patient is approached in a very step-wise fashion. This is drilled into medical people from the day they start school. Are they responsive? If not, open the airway. Is there anything in the airway that needs to come out? If not, the airway is clear. Is the patient breathing? If yes, how well? What are her breath sounds? What is her oxygen level? Does she have signs of respiratory distress? If the patient is not breathing well, she'll be assisted at that point. Next, is there a heartrate? If so, is it adequate? What is the blood pressure?

Actually, this has recently been reversed by the American Heart Association. Generally, there is a quick pulse check first. If no pulse... CPR is started right away. Then after a round of compressions, the patient is assessed for breathing. The components I mentioned above still apply.

 Based on this assessment, the EMS crew would determine what interventions need to be done. There are two medications that can be given as reversal: Narcan and Flumazenil. These only work for opiates and benzodiazepines.

 Adrenaline is Epineprhine. It would depend on what her other vital signs were at the time of her discovery. We don't give epinephrine just for unconsciousness. If she doesn't have a pulse and is not breathing and she has a particular arrhythmia (v-fib, v-tach, pulseless electrical activity) then these would be an indication for epinephrine. If she requires epinephrine, she likely will need someone to breathe for her as well.

 One thing I noticed is that you say her "stomach has been pumped out". This really isn't part of emergency care for overdose anymore. Many people don't understand what it means. We basically shove a garden hose down your throat and irrigate the stomach out with saline. The issue became that the risks of the patient having complications from the procedure were not worth the risk (risk to benefit ratio). Such complications could be inhaling vomit into their lungs and developing pneumonia or creating an electrolyte imbalance from using large amounts of saline to clear the stomach.

Generally, if a patient is discovered within one hour of their ingestion, we will give activated charcoal which is essentially ground up charcoal mixed with sugar. It looks like black sludge. The patient can either voluntarily drink it or we can put a tube into their stomach and give it that way. This medication will absorb the drug from their stomach, bind it so it becomes inactive, and then they poop it out.

Heidi adds:

It's pretty tough to over dose on Ambien unless it was your intention, so I'd definitely call that a suicide attempt. We'd probably monitor her ( on the obstetrics floor) for twenty four hours, put in a psych consult and have a sitter (a suicidal patient can't be left unattended).

You can keep a baby on the monitor starting at about 24 weeks, any GA (gestational age) before that you use a Doppler. We probably wouldn't keep her on the monitor but we'd admit her so she couldn't leave. Basically scare her into staying for "the sake of the baby" if nothing else. That way if she goes AMA (against medical advice) the hospital is not liable for either her or the baby.

Most level 2 and above hospitals see 24 weeks as the cut off for viability and there lots of things we can do to keep the fetus alive in cases of PPROM (Premature Rupture of Membranes), accidents, that kind of thing and with the right staff and facility you can maintain the viability of a 17 weeker.  

As for Ambien, we'd watch her more for maternal sake then baby. L&D nurses are good at getting the real story too, better than the counselors sometimes.  Ambien in a nut shell: 24 hours observation, intermittent monitoring, sitter, and consults. To get mama back in the game we do bedside ultrasounds so she can bond with baby and turn up the monitor so she can hear the baby, make life more real for her.  Nurses little tricks.

Any other thoughts for Lisa?

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Lisa Mladinich is the author of "Be an Amazing Catechist: Inspire the Faith of Children" and the founder of AmazingCatechists.com and Catholic Writers of Long Island. Her weekly catechetical column can be found at http://www.patheos.com/About-Patheos/Lisa-Mladinich.html