The 2:10 Appointment
By Dr. Martha Edwards.
Every morning, there’s a patient on my schedule that scares me a little. Sometimes a lot.
Yesterday it was the 2:10.
“Suicidal with plan” it said, under reason for visit.
At the very end of the day, as I began to exhale, relax my jaw, release the tension in my shoulders, I looked back on my visits and was surprised to realize that of all the encounters in my day that day, that was the one that gave me the most hope, the most satisfaction.
There was a time, not so long ago, when I would have insisted that this child be taken to the emergency department. The message she and her mom would have heard, despite any attempts from me to cushion my words, would have sounded something like this to them:
“There is something so wrong with you that I can’t possibly take care of you here, in a 15-20 minute visit slot, in a primary care office. I can’t help you.”
That’s not the case anymore.
Thanks to opportunities for me to gain knowledge about preventing teen suicide through our state’s quality improvement learning collaborative, and thanks to an increased focus on addressing mental health in children in our community, there were so many things that went right with this case:
This child had friends who cared enough and knew enough to talk to the adults around them, figured out how to contact this child’s parents and let them know she was struggling. Perhaps they had heard an “Ending the Silence” presentation by our local NAMI chapter and knew not to keep silent about this.
The child had parents who took the friends’ concerns seriously and immediately went to speak to their daughter. “I felt better within minutes after I spoke to them,” she told me. “That feeling passed.” Research tells us that if you can do something else for ten minutes when you are feeling suicidal–talking with someone, listening to music, drawing or creating–, that feeling will often pass.
A mom who did not hesitate to call the suicide prevention hotline 1-800-273-8255 (or text 741741 to reach a trained crisis counselor).
A triage system who no longer immediately defaulted to “Go to the emergency department” and, after determining that she was no longer having serious thoughts of hurting herself, put her on my schedule at 2:10.
A pediatrician (me) who felt as comfortable addressing this problem as she would any other potentially life threatening condition in the office, knew the questions to ask, the right things to say, knew to ask about firearms in the home and other weapons, knew to suggest locking other medications, knew about an app for them to download to help make a plan in case these feelings ever consume her again, had a list of counselors ready with specific recommendations to circle.
Mental health concerns have been rising in children over the last 20 years, so much so that the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association have declared a national state of emergency for child and adolescent mental health.
What would make a middle school student so distraught with the world that she wanted to end her life?
Simple. She’s paying attention: The news from Ukraine. State legislators bullying LGBTQ children who are already struggling with the challenges of being a teen. Natural disasters due to climate change. Adults who deny science, embrace misinformation and disinformation, and put children and the rest of us at risk. She brought up all these concerns during our short time together that day.
Her empathy and sense of responsibility are admirable. It’s hard to be an empathetic person in our world right now. And yes. These things are overwhelming right now to many of us.
She needed to be reminded that she is powerful and all the little things she does do matter—the way she treats her friends, the effort she puts into her school and community, the example she models for her siblings. She may not be able to change the situation in Ukraine right now, but she can impact the state of mind of a friend sitting next to her simply by being kind, and that’s important and world changing too.
But it’s ok to rest when that load is getting too heavy. She can share it with her family, with her friends, with a trusted counselor, and take a break from shouldering this big burden.
20 minutes turned out to be enough. She left with a plan and a follow up appointment. She will check in with her parents often, take space when she needs it, connect with friends. When she is feeling overwhelmed, she will remember to do one of the things that helps her feel better—creating art with yarn through her creative fingers, dancing, reading, walking her dog, walking with her parents.
They will connect with a professional counselor because her parents and friends are parents and friends, not professional counselors.
She’ll start some medication and check back in with me in two weeks, sooner if need be.
And if there is a time when all of these things aren’t helping her feel better, she may need to spend some time in a hospital getting better help from people who have additional tools and training to offer.
But not today.