1. Panelists: Jessica Keith, PhD Tawnia Lola, RN Tulika Singh, MD Moderator:Aimee Sanders, MD, MPH Mental Health Crises

2. 2.2 million living women Veterans Of 350,000 women Veteran VA health care users, ~ 35% had at least one mental health diagnosis

3. 44yo Veteran Mental health history ─PTSD ─History of MST and childhood abuse ─Psychiatric hospitalizations Today, during outpatient mental health appointment, made vague self-harm statement Escorted to ED, but no report provided Becky

4. First Response

5. 5 Direct Communication

6. Trauma-informed Care SafetyTrustworthinessChoiceCollaborationEmpowerment

7. Trigger Responses

8. Minimize Likely Triggers BUT… Unexpected touchLoud or angry toneCrowding or cornering

9. Be Ready to Recognize When a Veteran is Triggered and Respond

10. Comfort and Safety

12. Effective Communication in a Crisis Situation

13. Do not act in ways that: REACT R estricts E scalates A voids C oerces T hreatens

14. Slow breathing Visceral Name objects in room Visual Name favorite animals, colors, songs Mental Notice and feel floor, wall or chair Physical Grounding Technique

15. Compassionate care Successful use of grounding technique Answers questions and leaves bathroom Prefers taking to female staff

16. Next Steps in Care TriageSecondary nursing assessmentSuicide assessmentMedical evaluationMental health

17. Vital signs: normal Pain: 2 LMP: 1 week ago Suicidal ideation ESI: 2 Triage 1:1 monitoring Safety Additional information Secondary Assessment

18. Medical Evaluation Suicide & mental health assessments – “Do you have a plan to harm yourself?” – “Have you done anything recently to harm yourself?” – Risk factors for suicide – Review of systems

19. Physical exam Suicide & mental health assessments Medical Evaluation

20. Physical exam Suicide & mental health assessments Lab testing Medical Evaluation

21. Physical exam Suicide & mental health assessments Lab testing Additional diagnostics as indicated Medical Evaluation

22. Suicide Assessment Ask directly and matter of factly – Means and accessibility – History of self harm – Protective factors Review chart for risk factors – Past attempts – Significant life changes – Medical problems – Social withdrawal

23. Becky’s ED Course

24. Other Considerations How would this case change if Becky didn’t meet hospitalization criteria?

25. Take Home Points Slow down Promote good communication

26. Take Home Points Slow down Promote good communication Provide choice Recognize and respond to triggers

27. Take Home Points Slow down Promote good communication Provide choice Recognize and respond to triggers Establish a trusting therapeutic relationship Provide trauma-informed care

28. Jenny 28yo Veteran “At the end of her rope” Frequent ED visits ─Migraines ─GI symptoms ─URI symptoms ─Depression ─Suicidal ideation Mental health history ─Anxiety ─Depression ─Borderline Personality Disorder Jenny

29. Managing Initial Reactions

30. Vital signs: normal Pain: 3 LMP: 3 weeks ago No suicidal ideation ESI: 3 Triage Communicate expectations Safety Additional information Secondary Assessment

31. Intimate Partner Violence (IPV) Red flags – Repeated medical visits – Complaints of stress, anxiety, depression – Recurrent physical symptoms Headaches and chronic pain GI distress Pelvic pain, gynecological problems Vague physical complaints – Childbearing age women

32. Intimate Partner Violence Screening

33. IPV and suicide assessments – Direct screening questions Medical Evaluation

34. Physical exam – Injury patterns or signs of trauma Face, head, breasts, abdomen Symmetric / bilateral Inconsistent with the explanation Various stages of healing Delayed presentation IPV and suicide assessments Medical Evaluation

35. Lab testing Physical exam IPV and suicide assessments Medical Evaluation

36. Additional diagnostics as indicated Lab testing Physical exam IPV and suicide assessments Medical Evaluation

37. Jenny’s Case Develops

38. If she says yes… Make eye contact Respond with empathy ValidateAvoid judgingAsk detailsShare that she is not alone

40. If she is not ready to leave… Provide information on IPV Be clear that violence or threats are not okay Review warning signs of escalation Discuss option should violence escalate Refer to community resources, support groups, crisis hotlines Involve ED care team, including social work

41. Internet Safety and other information from the National Coalition Against Domestic Violence: http://www.ncadv.org/protectyourself/ MyPersonalSafetyPlan.php or from the National Network to End Domestic Violence: http://nnedv. org/projects/safetynet.html From the National Coalition Against Domestic Violence: www.ncadv.org/protectyourself/MyPersonalSafetyPlan.php

43. Other Considerations How would this case change if Jenny was pregnant?

44. Other Considerations What if Jenny had her young children with her in the ED?

45. Take Home Points Express empathy Ask screening questions

46. Take Home Points Document Respect decisions Express empathy Ask screening questions

47. Provide resources Risk assessment Document Take Home Points Respect decisions Express empathy Ask screening questions

49. Resources Sharkansky, E. Sexual Trauma: Information for Women’s Medical Providers. Washington, DC: US Department of Veterans Affairs, National Center for PTSD, 2014. http://www.ptsd.va.gov/professional/treatment/wome n/ptsd-womens-providers.as http://www.ptsd.va.gov/professional/treatment/wome n/ptsd-womens-providers.as Suicide Prevention Resource Center. Suicide risk: A guide for ED evaluation and triage. Bethesda, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, n.d. http://www.sprc.org/sites/sprc.org/files/library/ER_Suic ideRiskGuide8.pdf http://www.sprc.org/sites/sprc.org/files/library/ER_Suic ideRiskGuide8.pdf

50. Resources The Safing Center. Domestic violence/intimate partner violence national resources. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. http://www.bedford.va.gov/services/Safing_Center/IP V_National_Resource_List.pdf http://www.bedford.va.gov/services/Safing_Center/IP V_National_Resource_List.pdf The Safing Center. Signs that you might not be safe in your relationship. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. http://www.bedford.va.gov/services/Safing_Center/Ris kforexperienceIPV.pdf http://www.bedford.va.gov/services/Safing_Center/Ris kforexperienceIPV.pdf