Emergency Health

ER: Under Fire

Placement in psychiatric hospitals is always a tight situation, so my patient had been waiting in the emergency room for several hours while we tried to arrange for an appropriate facility. I was treating other patients when I heard a scream come from his room...

I work in a major inner-city emergency room. And as with all inner-city emergency rooms, there is tremendous turnover. From medical emergencies to minor lacerations, we see it all.

This one particular evening, we had a gentleman come in -his wife brought him in because she thought he was acting bizarre. He had a long psychiatric history, and she was worried that he wasn't safe. The wife told us that she was worried that he might hurt himself. We interviewed him and it was very clear that his bi-polar disease was flaring up. His speech was forced and rapid, and he didn't seem to be in control. There were psychotic features to his behavior.

After talking with him, the decision was made that he needed to be hospitalized. But getting a bed in a psychiatric hospital is not always easy, and it can take hours to wait for placement.

Unfortunately, for the patient's safety and for everyone's safety, patients who are unpredictable will sometimes be put in a locked room, because we don't have a staff to watch them one-on-one. We put the man in a locked room, took all his belongings away and put him in a gown. His wife had been extremely calming to him, so we allowed her to wait in the locked room with him.

Then, as I was seeing another patient, I heard a scream come from his room. I went and looked through the glass window, and watched as he grabbed a gun from his wife's purse, put the gun in his mouth, and shot himself. Turns out his wife was a police officer. She was off-duty. She forgot that she had her revolver in her purse. When she opened the purse to get a tissue, he saw the gun and on impulse, took the gun.

It was the first time I'd ever seen a gun fired in person. After he fired the gun, I opened the door and looked to see where the gun was. I couldn't see it. I closed the door to watch his wife. She didn't seem to have the gun. So I opened the door and took the wife out of the room. I saw the gun on the floor and kicked it out of the way.

I immobilized his spine, put a breathing pipe in and resuscitated him. It turns out that he did not aim the gun upward which would have shattered his brain and killed him instantly. He had shot a fairly high-powered weapon directly into his cervical spine, completely transecting his cervical spine. There was no exit wound.

The man was successfully resuscitated and we sent him to a major trauma center, and now he's a quadriplegic.

But the most difficult part about this experience for me was remembering that I felt relief. As I saw the gun, my very first thought was, 'I have a psychotic patient with a gun, roughly 6 to 8 feet away from me.' When he pushed the gun into his own mouth, I thought, 'At least he's not going to shoot his wife or me. Or a full emergency room of patients and staff.'

I think this was probably the least of the potential evils that could have occurred that night, but it doesn't minimize how awful it was. And how awful it was to be the patient's doctor and feel relief that he had chosen to shoot himself.

Dr. Jeffrey Hersh is a clinical assistant professor of Emergency Medicine at Tufts University and an attending physician of Emergency Medicine at Brigham and Women's/Faulkner Hospitals.