Tired before the long journey

Most articles related to rural health bombard us with problems, the solutions to which are often out of reach. We can classify most of the issues into large and sometimes intersecting domains; logistics, workforce, finance, and education. Also, most reports on medical education boast its universality. We can build the two arguments; 1) There is an apparent lack of a well-trained workforce in the rural and 2) We should solve this problem by incentivizing urban trained physicians to work in the rural. The second part of that argument doesn’t always hold; a discussion for other times.

A solution many governments, including that of Nepal, implement in solving the apparent lack of physicians is to produce more paramedics. I have before, and I continue to argue that paramedics have a significant role in rural health. Certain aspects of rural health deserve a bit more robust education and training. One such aspect is mental health.

A 67 years female visited a rural PHC. The endless excuse of a road through the forest, down the hill, and across the river brought her to a very dedicated health assistant. She complained of fatigue. “Do you have any abdominal pain?” asked the concerned provider. “No,” replied the old lady spontaneously. Almost as if she knew where this discussion is headed. “Are you bleeding from anywhere?” “No.” “Fever? Headache? Nausea? Vomiting? Diarrhea? Anything?” The old lady kept nodding no as the list of symptoms, as long as the road that brought her to the PHC continued. A multivitamin was prescribed before calling up the next patient. That week I talked about depression with my paramedics.

Mental health is an essential yet ignored aspect of health. As universal as that is, my two years in Beltar made me acutely aware of mental-health-related ignorance that prevails among the providers in the rural.
Paramedics we produce are not equipped enough to deal with a lot of mental health issues. After being a boss, a colleague, and a friend to many hardworking and dedicated paramedics in rural Nepal, I can confidently tell that they seek to understand more. The lack certainly is on the delivery side. We need to figure out ways to train our rural providers to better manage mental health issues.

While some rural health issues are extensive and require significant effort to solve, others are easy to address yet equally important. I sometimes wonder if we should incentivize physicians who serve in the rural for a limited time to train the paramedics who stay there longer. Being in the same room as the patient who could not articulate her symptoms of depression and the paramedics who, while being very attentive, wasn’t adequately trained to identify subtle signs of depression can be a good incentive. But I strongly argue that is not a good kind of incentive.

An update to the curriculum, refresher training and provision of adequate resources to learn about mental health can help the providers of rural help many of these patients who are “tired” before their long journey to the PHC.

Cite this article as: Carmina Shrestha, Nepal, “Tired before the long journey,” in International Emergency Medicine Education Project, May 5, 2021, https://iem-student.org/2021/05/05/tired-before-the-long-journey/, date accessed: September 21, 2023

Recent Blog Posts By Carmina Shrestha

Suicide – An Emergency Priority of Public Health Care

Suicide An Emergency

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1]. 

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone. 

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available. 

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance. 

References & Further Reading

  1. In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk 
  2. Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
Cite this article as: Leah Sarah Peer, Canada, "Suicide – An Emergency Priority of Public Health Care," in International Emergency Medicine Education Project, October 19, 2020, https://iem-student.org/2020/10/19/suicide-an-emergency-priority-of-public-health-care/, date accessed: September 21, 2023



The patient said he did not care about his stage IV ulcers. He refused antibiotics for chronic osteomyelitis until we gave him opiates. He denied all other non-opiate alternatives. “The patient has an opiate use disorder but also has pain,” said the pain and palliative doctor. In medicine, we try our best to explain all that a patient is experiencing with one diagnosis. A patient suffering from two different diseases as a diagnosis is frowned upon. But here was a seasoned doctor, speaking with his years of precious experience reflected in his white beard and even whiter apron, telling me that the patient I have barely started to present to him, had two diagnoses.

I had taken care of this patient for some days now. In my head, I would associate all the requests he makes, everything he says, and every single complaint he has, to his addiction. “I do not have an opiate use disorder, I have a pain problem!” said the patient as soon as “addiction” was mentioned. The doctor said, “I know you don’t think you have opiate use disorder.” I thought that was clearly mentioned to calm the patient down. Later I would be surprised to know that the doctor actually meant it.

He gave me an ‘overly simplistic heuristic’ that had helped him remember what patients with substance use disorder are going through. “The first time a patient takes a substance, he feels the intended high. The effect remains for a couple times more. As the effect due to the same dose decreases with subsequent exposure, the patient increases the dose to get the intended effect. This seemingly linear relationship is a tricky one. Soon the patient will depend on the substance only to feel okay. Which, let us remind ourselves, the patient felt before starting to take any substance. Hence, many patients with substance use disorder, claiming they do not do it for the high, they do it because they cannot tolerate “normal” without it. Substance use disorder is a complex topic and one that deserves much more effort and attention than is the scope of this conversation but I hope this ignited an enthusiasm to learn more, in you” That night I read some papers on opiate use disorder.

I sometimes wonder if I am not as sensitive to suffering as my patients are. I wonder if what they taught me about signal transduction in my first year of medical school holds true for day-to-day emotions like it held true for addiction’s pathophysiology. The more we are exposed, the more we desensitize. “Being emotional is understandable but unnecessary and unhelpful”, says Sherlock Holmes in one of his many palimpsests. Maybe I was trying to objectively look at this patient of mine. So much so that it did not occur to me that the patient had stage IV ulcers. All I heard was a cry for the high, which, mistake not, was there. But there was something more, something that was hidden to my objective eyes. In focusing my attention on the patient’s mindsores, I was ignoring his very physical and painful bedsores. I dare say Sherlock was wrong. Only emotions can drive passion. People who are so passionate about the pathways and mechanisms of addiction and people who are emotional about the patients’ problems are the ones who we rely upon to solve this tangled problem of pain and addiction. I appeal to you to acknowledge that this is a complex issue. That is the sole intention of this article. And that is the first step in trying to understand and hopefully help patients with multiple sores.

Cite this article as: Sajan Acharya, Nepal, "Mindsores," in International Emergency Medicine Education Project, October 12, 2020, https://iem-student.org/2020/10/12/mindsores/, date accessed: September 21, 2023

A Study in Yellow

A Study in Yellow

In Brazil and many other countries around the world, we got used to know September as the suicide prevention month, represented by the yellow ribbon, with September 10th being the World Suicide Prevention Day. As said by Sherlock Holmes in “A Study in Scarlet,” “There is a scarlet thread of murder running through the colorless skein of life, and our duty is to unravel it, and isolate it, and expose every inch of it.” Despite the dramatic content of Holmes’s words, it is possible to draw a parallel with the current situation related to suicide in society. There is a visible red stain in front of us, and we need to unravel it, understand it, deal with it. Moreover, everything should start somewhere…

If we think about the role of the emergency department (ED) and the emergency physician in the suicide prevention and response, we will see that it is of indispensable importance, as many patients at risk of attempting suicide are sent to the ED in order to be evaluated and to stay in a “24h safe environment.” Also, many actual suicide attempts arrive at the ED requiring immediate care – for the patient and for the family. However, World Health Organization estimate that for every death by suicide, there are 20 suicide attempts, making us to questioning our capability to give extended care for those patients. Besides, if we look to the big picture, which has suicide one of the major preventable causes of death worldwide, we can ask ourselves how many patients with suicidal thoughts are seen at the ED every week due to other health problems and go unnoticed. The ED, along with the primary care in the communities, is the main entry door to the health care system and like no other, act as a nexus between outpatient and inpatient care. Gairin et al. have found that approximately 40% of people who died by suicide have visited an ED in the year before, one third of them because of self-harm injuries. (1) If we look to the last attendance before death, those who have presented with self-harm injuries presented less than two months before ending their lives.

With all of this in mind, what strategies we can use to assess suicidal thoughts and behavior at the ED? Which reliable tools are available for emergency physicians to recognize and classify these patients? Let’s take a look at the last American College of Emergency Physicians (ACEP) recommendations.



IDENTIFY suicide risk – actively ask about suicidal ideation.

  • Evidence shows that as many as 10% of suicidal patients may not disclose ideation unless asked (1) 
  • In the other hand, none of the standardized questionnaires and methods currently available have strong evidence supporting its use as a universal screening tool at the ED.
  • As there is no universally accepted standard reference for suicidal ideation, the sensitivity and specificity of these methods are unknown.
  • The authors’ conclusion is that suicidal ideation should be screened in the ED, as recommended for other authorities (2,3).


COMMUNICATE with the patient.

  • Actively ask maybe not enough when we talk about mental health problems with patients and make them feel comfortable is the first step to improve the communication 
  • The ED is not what we can call a “cozy” or “receptive” environment for most of the patients, so the authors recommend providers try to make it an emotionally-safe place, using methods to improve physical and mental comfort of the patient (i.e giving blankets if its cold, providing food, do not stigmatize)
  •  Ask open questions as “what’s that been like for you?” and be clear on what you are asking when necessary – prefer “are you thinking about ending your life?” over “are you gonna be ok?”.


ASSESS for (medical) life-threats and ensure (environmental) safety.

  • The authors did not find ED-based studies assessing this topic specifically, but a consensus emerges when we think on the best practice for this step of evaluation: A complete history, a good physical exam, mental status assessment and laboratory testing as needed.
  • Regarding the environment, besides the strategies commented before (communicate), the best practice and the common sense tell us to keep the environment as safe as possible and free any kind of weapons and other objects that could be used for self-harm (sharp objects, loose wires, medications, etc.).
  • Continuous monitoring should be done in all patients with suicidal ideation, as no ED-based studies are addressing whether all patients should be observed continuously or not.

RISK assessment

  • This step assumes that, regardless of how the patient was identified (first step), there is suspicion of potential suicide risk.
  • Even though there is no reliable and easy to use tool to predict which patients will try to commit suicide in the near future, there are lots of evidence establishing risk and protective factors for a suicide attempt. 
    • Risk factors: previous suicide attempt, access to lethal means, current impaired mental status or psychiatric illness (psychosis, depression, mood changes, anxiety crisis), substance abuse, external stressors such death of loved one, financial crisis, divorce.
    • Protective factors: family and friends support, established mental care, with patient’s good adhesion, cultural and/or spiritual beliefs
  • The authors do not recommend any specific risk assessment scale. The evidence for that comes from a meta-analysis from Carter et al.(4) that investigates the predictive validity of risk scales in determining the level of risk. According to the data from this study, the currently available tools have low accuracy, so the authors recommend not to use one scale alone to determine if the patient can be discharged home or not.
  • With this in mind, the recommendation is that all patients identified as being at potential risk of attempt suicide should go under one standardized tool for risk assessment, using this as a complementary tool, along with mental status examination, history taking and evaluation of risk and protective factors.

Some scales and risk assessment tools to know

  1. Columbia Protocol – link
  2. Patient Safety Screener and Tip Sheet (PSS-3) – link
  3. Secondary screener from ED-SAFE – link

REDUCE the risk

  • Safety Planning Intervention is a collaborative process in which patient and provider develop a plan on what to do if the symptoms worsen. It usually involves contact with trusted individuals, lethal means counseling, hotlines, and local resources in the community. 
  • The adherence of ED on this practice is very low, although some evidence shows that safety planning could reduce future suicide attempts (5).
  • Hospitalization is a complicated topic in this scenario. As seen on recommendations above, it is difficult to formally classify a patient as a “high-risk” for suicide in the near future. Knowing that the authors recommend hospitalization for those patients who “felt to be likely to attempt suicide after the discharge,” and voluntary admission should be preferred over involuntary.

EXTENDED CARE beyond the ED visit

  • There is good evidence that follow-up contact after the ED can help reduce the risk of subsequent suicidal behaviors.
  • The follow-up contact can be made by letters, phone calls, postcards and even in-person visits.
  • Of course, a follow-up with a mental health professional is key to good care of these patients.

How about us?

Despite all the fame and social prestige traditionally linked to doctors, it is well documented that physicians, residents and medical students experience one of the highest rates of depression and suicidal behaviors among all professions. More than that, physicians can have a risk of suicide from twice to even six times higher than the general population depending on the country (6,7). And it starts early: almost 50% of medical students experience burnout before residency (8). High rates of depression, sleep deprivation, substance abuse, stressful work environment, burnout, easy access to and wide knowledge of lethal means, all of these contribute to killing our colleagues, professors, students, and friends. Four hundred physicians per year in the US (6,7) – more than once per day. Speaking specifically of emergency physicians and residents, the specialty had always reached the top 5 in the burnout rankings (8) and less than one third will seek for help, according to a Medscape survey. We have been trained to save lives, but sometimes we also need to be saved – from ourselves.

If you are in crisis, experiencing burnout symptoms, feeling sad or suicidal, or know a friend who is, please seek for help as soon as you can.

Further Readings


  1. Gairin, I., House, A., & Owens, D. (2003). Attendance at the accident and emergency department in the year before suicide: Retrospective study. British Journal of Psychiatry, 183(01), 28–33. doi:10.1192/bjp.183.1.28
  2. Suicide Prevention Resource Center. Caring for adult patients with suicide risk: A consensus guide for emergency departments. 2015; http://www.sprc.org/sites/default/files/EDGuide_full.pdf. Accessed May 30, 2018.
  3. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.
  4. Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387-395.
  5. Miller IW, Camargo CA, Jr., Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570.
  6. Stehman CR, Testo Z, Gershaw RS, Kellogg AR. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. West J Emerg Med. 2019;20(3):485–494. doi:10.5811/westjem.2019.4.40970
  7. Kishore S, Dandurand DE, Mathew A, et al. Breaking the culture of silence on physician suicide. National Academy of Medicine. 2016. Available at: https://nam.edu/breaking-the-culture-of-silence-on-physician-suicide/Accessed March 15, 2019.
  8. Burnout in medical students before residency: A systematic review and meta-analysis Frajerman, Ariel et al. European Psychiatry, Volume 55, 36 – 42
Cite this article as: Arthur Martins, Brasil, "A Study in Yellow," in International Emergency Medicine Education Project, September 30, 2019, https://iem-student.org/2019/09/30/a-study-in-yellow/, date accessed: September 21, 2023

Managing Psychosis In The ED

Case 1.  It is a quiet Wednesday night in the emergency department when you suddenly hear someone coming down the hall continuously spouting out a string of profanities.  You leave the comfort of your chair to see what the commotion is all about only to find a 37-year-old female brought in by police for altered mental status.  She is acutely agitated on presentation, spouting obscenities non-stop, refusing to answer questions and uncooperative with a physical exam.

Case 2.  As you are pondering your next step, you see the paramedics wheeled an older gentleman past you and into the next room.  You step into the next room to get a report.  The family is at the bedside and states the patient is an 82-year-old male with a history of hypertension and BPH who has been increasingly confused and aggressive over the past two days.  You note that he is mildly tachycardic when you hear the PA system announce, “Security is needed in the critical care hallway.”

Case 3.  A nurse pops her head into the room and requests your immediate assistance.  You follow him down the hall and see your charge nurse along with three security officers trying to hold down a male patient.  The patient, who appears to be in his late twenties, is actively kicking and trying to bite and spit at the medical staff.  He appears flushed and diaphoretic.

by Michelle Chan, Nidal Moukaddam, and Veronica Tucci from USA.