Nonaccidental Injuries

Nonaccidental injuries, such as suicide attempts and suspected child abuse, should ideally trigger early automatic mental health referrals. The need for PICU level of care signals a high degree of lethality of the suicide attempt or seriousness of the inflicted injury. The risk of reattempting suicide is about 15% in the aftermath of a suicide attempt (Donaldson et al. 2005), highlighting the need for comprehensive assessment, assurance of safety, and careful disposition planning. Because the patient may remain intubated and/or sedated in the PICU, the bulk of the consultant's work in this setting is often with family members and/or collateral contacts such as outpatient therapists. In such cases, further assessment with the patient may occur either later in the PICU stay or following transfer to a general medical unit. Family members of patients hospitalized following suicide attempts can present with a range of strong affective responses, including disbelief, shame, fear, worry, anger, vulnerability, and sadness. Cases in which a youngster has intentionally tried to end his or her own life can be unnerving, frustrating, and emotional for staff, particularly given the pervasive lifesaving themes of the critical care environment (DeMaso and Meyer 1996). The mental health consultant can offer guidance, education, and support around such counter-transference; begin the assessment of suicidality and safety with the patient; secure the availability of safety and prevention mechanisms (e.g., hospital security) as needed; and provide support for families.

Injuries sustained in cases of child abuse can invoke similar emotional responses by staff members. The mental health consultant is not invulnerable to such reactions and should be mindful of his or her own affective response in the face of such emotionally charged and often highly unsettling consults. Media attention and curiosity among other hospital staff may exacerbate these responses. In such cases, the consultant may be asked to provide assessment and/or support for patients and family members. Work of this nature is often carried out in close collaboration with social workers, child protective specialists, law enforcement officials, and forensic interviewers. The consultant is advised to remain in close communication with hospital legal services as well, and careful documentation is particularly warranted.

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