“Perhaps the most concerning statistic regarding mental health problems relates to suicide. Those with mental illnesses have much higher suicide rates, and suicide is often considered a mental health disorder in its own right. Given this, recent statistics show that the rate of suicide in the U.S. exceeds 11 for every 100,000 people. This is so significant that suicide represents the 10th leading cause of death among all ages. Among those between 18 and 65, suicide is the fourth leading cause of death. In other words, suicide as a cause of death ranks higher than diabetes, stroke, homicide, and HIV infections. From every epidemiological perspective, mental illness represents a serious and devastating group of health disorders.”
President-elect Joe Biden was once one of the leaders in the idea that criminalizing drug offenses would lead to control of our country’s massive drug problem. The three-strikes laws filled our prisons with low-level drug offenders while doing nothing to actually get people OFF drugs.
Luckily, we have experienced a massive tide change in how we think about substance use disorders. Many states voted in this past election to decriminalize or even legalize marijuana, while Oregon legalized even “harder” drugs such as heroin and hallucinogenic mushrooms. Biden himself has turned away from a philosophy where law enforcement reigns as the rulers of how to deals with our drug problem, and has instead shifted to a public health perspective in which the focus will be prevention and treatment.
Many, however, are still skeptical of Biden due to his past actions and beliefs. As the data becomes available for how bad it has become during this pandemic, including 2020 overdose death totals, we will be able to see more clearly what is necessary. As a healthcare provider, I know that police involvement and jail time doesn’t help. I also know that at a certain tipping point, treatment may not work either unfortunately.
For example, I once cared for a man, a former alcoholic who had 30 years sober, living a stable life with a job. But then, his girlfriend left him. He went out and got drunk, started a fight, and fell down some stairs. He showed up in my ICU with a subdural hemorrhage (SDH) as well as a small subarachnoid hemorrhage (SAH)– both classic injuries from a traumatic fall. Over his days in the ICU, we talked at length about his sobriety and plans for the future. This was his first fall off the wagon, as you might say. He had a job and a house. He spoke to his boss, who guaranteed to hold his job for him until he got better. He wanted treatment after he recovered from his head injury. I had such hope for him.
He never came back to the ICU. But about 8 months later, I heard from a nurse upstairs “on the floor” that he had died. He drank himself to death, ended up homeless. He probably “lived” in one of the neighborhoods around the hospital, and recognizing him, the medics always brought him back to us. He had declared his “code status” to be DNR, meaning that if he were to experience a cardiac or respiratory arrest (ie, code), he did not want to be resuscitated. And he wasn’t.
In the end, I really think focusing on treatment and prevention will get people help earlier in the disease process, instead of landing them in jail over and over–or worse, finding them dead. We need to treat substance use disorders instead of punishing those who suffer from them.
Although numbers are back up to pre-covid levels, Instagram (owned by Facebook) still struggles with automated vs. people-driven content moderation. Developing smart AI computer tools to detect self-harm and suicide content has been helping proactively.
Highlighting the burden that social media companies now bear in the fragile mental health of young people, this article really reinforces the notion that suicide is contagious and highlights just how large a role social media plays in that contagion these days.
This is the tail end of Suicide Prevention Week, and while I have a lot to say about the healthcare providers role in assessing risk and intervening, I don’t want to not say anything because I can’t get my act together to say everything I want… classic perfectionist bullshit, right?
Last week, when I got home from work on the day the sky was orange, my sister (who I live with) met me at the door with a half-joking/half-not “so, this is gonna increase suicides, huh?” She walked away to the office to work from home.
I joked that I had been thinking the same thing on the way home. But my joke had a dark side. My thoughts had an edge of real questioning— why should I keep going through all this pain and heartache dragging my ass to work in one of the busiest ICUs in the area to care for the sickest of the sick. Why do I keep doing any of this? But the truth is that I’ve survived much worse things than this and found my way out of darker places. Maybe someday I’ll tell y’all about it.
Covid19 and the isolation it causes, as well as our new wildfires on the West Coast that prevent us from even going outside—many people find themselves in crisis. Even my therapist had to take an abrupt vacation to the East Coast.
It is times like this when people’s ability to cope becomes overwhelmed & when hopelessness can set in. Suicide Prevention Week comes at the perfect time to remind us to check on our friends and loved ones.
The following Instagram post is from my therapy “company.” I find it to be thoughtful and helpful right now. If you click through the pictures, I especially like the common misconception explanations about suicide. Spend a few minutes here if you have time.
My life largely revolves around my work. I go to work; I work; I think about work; I talk to others about my work. One of my roommates is a fellow ICU nurse and the other is an EMT. My best friends are nurses. I talk often in therapy about situations I encounter at work.
My point is: I know medicine.
And I am once again flabbergasted by reports about police practices for “suspect” control that is dangerous, unnecessary, and I’m sure used most often against black men. Police are enlisting the help of EMS to inject those in their custody with Ketamine under the guise that they are suffering from a condition called “excited delirium.”
I regularly use Ketamine in the ICU and have assisted in procedures in the ED (emergency department) with it. I know why it’s used, it’s effects/side effects and most importantly the adverse effects that can occur with use.
Sometimes I feel like this moniker, which is often applied to healthcare or other frontline people who interface with vulnerable populations such as the very old or very young (teachers, I’m looking at you!), was a part of my personality before I became a nurse. And honestly, I do feel like everyone has a responsibility to help watch out for each other—or at least they should… because if we did, maybe we’d all be a little safer. Sometimes, though, it also feels feels like a burden, which is why I’m sure so many people turn the proverbial blind eye towards unsafe and potentially life threatening situations.
But the question that raises for me— how long can the blind eye truly continue to not see. Does the spirit see what the mind refuses to acknowledge? Is witnessing dangerous situations and yet doing nothing worse for your health than just finally mustering up the courage and admitting that it takes very little time to call someone for help?
I am a person who calls. Who reports. I believe that the consequences of not getting involved will impact me, as well as the victims of whatever violence or harm I am intervening in.
This started when I was in middle school, I realize now. I noticed a girl in my gym class with lots of injuries under her clothes while changing, and I talked to the guidance counselor about it. That counselor then reinforced my instincts about those types of injuries and the types of things I should tell her about. So funny to think back to so long ago to my childhood doing that for a classmate when I probably should have been trying harder to protect myself. But that was a different type of threat I was dealing with.
When I first moved to the “big city” I was also the “naive” girl who called police about the homeless person passed out on the park bench. I would still do the same, but I’d probably try harder to wake him up first, and I now know who to call for homeless outreach before the police (if it’s not a medical emergency).
I’ve had to report suspected elder abuse at work in the hospital… I’ve had to report actual abuse, once a sad case where an elder lady living with her grandson feared for her life and told us she was being forced to use drugs. Patients being abused by their spouses have refused help. I have reported things to Child Protective Services that I definitely shouldn’t talk about.
One thing I always struggle with, however, is how to report dangerous but not criminal behavior of individuals in the community that I think may be a risk to themselves or others. In other words, how do I get help for an acutely mentally ill person acting erratically who may or may not also be abusing some sort of substances?
My general rule is avoid doing anything unless the situation seems immediately life threatening. Erratic behavior +/- mental illness +/- substance abuse +/- person of color is not a good fit to police + weapon + restraint + jail.
But I live in the Bay Area, which has loads of homelessness and with it substance abuse and mental illness. Actually these three things are so linked that it is sometimes hard to tell which came first in any specific individual’s life. Twice I have had to call 911 because I needed highway patrol (the famed CHiPs) to come help a homeless person running around on the Bay Bridge— and no, not the part with a pedestrian path! A person running across 5-6 lanes of traffic on a bridge suspended over an ocean. Someone’s gonna get killed…. Someone might even be trying for that end?
I always have to stop and think before I call, though. Is this necessary? Will this do more harm than good? Is there imminent danger to the person themself or others? If there is immediate danger, I have to call. Even if that means someone spends the night needlessly in jail. It’s still better than a 20 car pileup on a freeway.
Should you call? Are you turning a blind eye? Is someone you know being abused? Are you being abused? Don’t be silent about it. Don’t let domestic violence just happen. Our silence about it perpetuates it. The same with violence against children, the elderly, the ill— whether physical or mental. Take a chance and use your voice. Now that we have learned the damage that silence causes, let us not continue to be silent about these issues. About black lives! About women’s lives! About children’s lives! About the lives of our elders and the mentally ill!
Today in California, Governor Newsom announced that he would like to do away with the “carotid hold”—a restraint technique taught to police and a modified version of which killed George Floyd.
Some consider the carotid hold and a chokehold to be synonymous but police departments have differentiated by saying that a chokehold comes from the front and brings with it a possibility of cutting off the airway while a correctly done carotid hold only compresses the carotid arteries, leaving the airway intact.
Graphic from article regarding San Diego police department procedures, linked below…
So, why was the kneeling that we all saw performed by a police officer in Minnesota a type of carotid hold? Because anything designed to compress the carotid artery—which will cut off blood flow to the brain and cause unconsciousness quickly—is this type of “hold.”
And while people are already arguing whether or not this applies to the case of George Floyd, if you watch the video, it is clear that while Mr. Floyd is lying prone on the ground with his head turned to the side, former officer Chauvin is kneeling on the side of his neck directly on his carotid artery. Only occluding one (instead of both sides) would certain prolong the process of cutting off blood to the brain and causing unconsciousness, but a person could certainly still lose consciousness. And here’s the important part: once Me. Floyd loses consciousness, his neck relaxes and any attempt he was making to protect his airway is compromised. So at this point, it is likely that Chauvin had not only cut off the supply of blood to his brain causing unconsciousness but was also cutting off the air supply to his lungs as Mr. Floyd’s neck relaxed and changed position.
The bottom line is this: no oxygen getting to the lungs, no blood getting to the brain. From this point, it only takes seconds (maybe as little as 10) for a person’s heart to stop. So Mr. Floyd then experienced a cardiac arrest, as confirmed by the autopsy. His heart had stopped. The only thing that would have saved his life is CPR and immediate intervention by health care professionals. A delay of more than 3 minutes guarantees at the very least a brain injury and at the very worst the outcome we have.
Why am I so fixated on this issue, you might be thinking??? A few reasons.
The goal of a correctly performed carotid hold is unconsciousness. Why should this ever EVER be the goal of the police?
A correctly performed carotid hold should last for less than 30 seconds and once the “goal” of unconsciousness is met, the subject then needs to be correctly positioned in order to not sustain further injuries and he now needs medical attention.
It is very difficult to perform a carotid hold correctly, which is why some view it synonymously with the choke hold (which purposefully cuts off your air supply by applying pressure to your trachea).
But accidentally slipping into a choke hold, which seems like it would be very easy (especially if the subject is struggling) is not the only medical danger of of a carotid hold. Applying pressure to the carotid arteries can cause tearing of those arteries (called a carotid dissection) or it can loosen atherosclerotic plaques in the arteries which then shoot into the brain, causing one or more strokes. Let’s look a little closer at these 2 medical complications, shall we?
Carotid dissection: this is where the artery tears from the rough pressure being applied to it. It can also happen from having your neck adjusted at the chiropractor, vigorous exercises, etcetera… you probably won’t know this has happened right away because despite the fact that we call it a dissection, it is not normal for all the layers of the artery to tear and for you to bleed spontaneously or prolifically into your neck. Usually, only one layer out of three tears, and the body’s response is to send in all your clotting products to fix the small tear. This is the problem, though! In trying to fix itself, your body creates a loose “clot” of platelets and other things which easily break off from the inside of the artery. Because the arteries carry blood to the head at a pretty substantial pressure, this clot, or embolism as we call it, will go up into the brain traveling as far as it can in the arteries until it gets stuck. Everything beyond it then is NOT receiving oxygenated blood flow. You are now having what we call an embolic ischemic stroke. Since it is being caused by a carotid dissection, you could actually have many at the same time as multiple thrombi cut off the blood flow in different arteries in your brain. This complication could start occurring days to a week after the event which caused it— and the early symptoms are quite hard to recognize sometimes..
Like a dissection, the second complication is also an ischemic stroke at the root— but the cause of ischemia in this case is from broken off pieces of atherosclerotic plaques in the carotid arteries. This is the mechanism for how heart attacks occur as well and was the driving force behind trying to get people to call strokes “brain attacks.” I am glad that never caught on, but I understand why they tried.
In the end, my thoughts keep returning to this: a medical professional would never screw around with someone’s carotid arteries—why should the police who are not trained to understand the permanent harm they can do.
The closest we come to purposefully compressing the carotid arteries is a technique for lowering a dangerously high heart rate called carotid massage. Even during this procedure, our goal is not to block blood flow to the brain though—we are trying to “massage” or activate the bundle of nerves surrounding the carotid artery below the jawline which will trigger your heart rate to go down. This procedure is almost always done by a doctor, although an ICU nurse may be trained for this, and it can cause the type stroke I mentioned above. This is a procedure of last resort. And you can listen over the arteries with a stethoscope for a carotid “bruit” which would indicate turbulent blood flow and most likely significant atherosclerosis that is a direct contra-indication to carotid massage. In this case, we would not use this procedure in this patient.
Diagram from American Stroke Association, linked below. Learn more about ischemic strokes…
First, do no harm. The ethical principle that guides healthcare professionals. we struggle every day to do no harm, as patients kick punch & bite us. As patients berate us verbally, as families demand care for their ill loved ones that we know will prolong their suffering but provide little chance of recovery. We do it with a smile and a gracious heart. Because we are taking care of human beings. People who suffer and make mistakes just like we do. People who celebrate life’s victories and milestones just like we do.
When will the police start doing no harm? Carotid hold & other violent restraint techniques need to end.
