Adolescent suicide: Sensationalism and sensitivity

Editorials

NewYork MovesOutfrom Medieval Emergency Medicine The recent brouhaha attendant to the criminal suit and grand jury findings in New York surrounding the tragic death of a young woman1-4 has catalyzed the teaching hospitals in New York State to re-examine, however reluctantly, an opprobrious attitude toward emergency patients, emergency medicine, and emergency medicine training. Already, the State Health Commissioner and representatives of the major hospitals in New York have advocated far-reaching changes (reported on in this issue of AJEM) that quite possibly will impact beyond the borders of the Empire State in the not-too-distant future. Accordingly, it is appropriate for all emergency physicians to note these developments. The Ad Hoc Committee on Emergency Services has provided a herculean service, but several important assumptions and conclusions need to be questioned. It is not sufficient to specify the presence of an “attending” without insisting the attending physician be appropriately trained for his or her duties. Quite simply, surgeons, internists, or family practitioners, however well trained, cannot be expected to provide high-quality care and supervision in the demanding specialty of emergency medicine any more than an emergency physician would be a satisfactory supervising surgeon, internist, or family practitioner. This distinction is particularly true with regard to the qualifications of the director of an emergency service. Although there may be other “relevant specialty areas” that could be considered for appointment, none of these, individually or collectively, can replace training and certification in the speciality of emergency medicine. Furthermore, terms such as “sufficient emergency services experience,” “equivalent training and experience,” and “a time considered rea-

sonable by accepted emergency medical standards,” are nebulous and subject to political mischief and manipulation. Standards have substance and credibility only when they are specific. Aside from the enormous financial costs these proposed changes will impose on many hospitals, the suggestion that attending physicians supervise 24 hours a day but not work for more than 16 consecutive hours per shift would be debilitating for our faculty (or any other specialty) in the academic arena. While one can question seriously the quality of emergency medicine faculty participation in the myriad of administrative, teaching, and research tasks that often occur immediately following a clinical shift, there can be little question that these activities are necessary. Regardless of gerrymandered schedules, these functions cannot consistently be delegated or deferred to tit the eight-hour hiatus proposed by the committee. It would be ironic, indeed, if this attempt to upgrade emergency care in New York, and perhaps elsewhere, is formulated in a way to shackle academic productivity and acceptance for our specialty in areas where it is most needed. J. DOUGLAS WHITE, MD

Washington,

DC

REFERENCES 1.Goldfrank

L: Emergency medicine in New York City, 1987. Ann Emerg Med 1987;16:820-821 2. Ervin ME: Meeting the demand for emergency care. Ann Emerg Med 1987;16:821-822 3. Lumpkin JR: A pointed reminder from a jury of our peers. Ann Emerg Med 1987;16:822 4. Nowak RM: Understanding the need for emergency medicine training. Ann Emerg Med 1987;16:822-823

Adolescent Suicide:Sensationalism andSensitivity Recently, the national media, spurred by events in Bergenfield, New Jersey, has focused its attention on teenage suicides. In the days that followed, the public 546

was told, through a blizzard of media coverage, of the graphic details that had shaped the lives and ultimately the deaths of these four young people. The

EDITORIALS

media also assiduously reported the numerous “copycat” adolescent suicide attempts and completions that occurred in other locales. Experts appeared on the network evening news to talk about previous similar clusters of teen suicides; newspaper editorials and stories extolled the need for awareness about suicide risk factors among the young. A New Jersey television station even sponsored a live call-in show featuring fellow students from the dead teenagers’ high school, school officials from Plano, Texas (a community that had in the past suffered a rash of teenage suicides), and a viewer poll on the ethical question of excessive media attention to the issue of adolescent suicide. The hot glare of television lights and the banner headlines raise some serious ethical, scientific, and clinical questions. Recent research has suggested that not only can suicides by teenagers occur in clusters and be imitative, but that televised news stories about suicides can trigger a significant rise in the national suicide rate among teenagers; the greater the publicity, the greater the increase in teen suicides.* Furthermore, it may be the case that “general information” or educational stories, or even fictional stories featuring suicidal behavior, are as dangerous as any detailed coverage of actual suicides2w3 Life imitating media has antecedents in life imitating art. The most famous case perhaps is Goethe’s publication in 1774 of The Sorrows of Young Werther, when, at the height of the Romantic movement, young people across Europe followed the hero’s example with an alarming literalness by shooting themselves dressed in Werther’s distinctive garb of blue waistcoat and yellow breeches4 The thorny ethical and scientific questions these studies raise about censorship of the media versus the public’s right to be informed (i.e., to actively participate in health policy decisions) will not be resolved easily or soon.3 Yet, the equation is not as simple as media attention on suicide equals heightened adolescent suicidal ideation or behavior. The effect of media attention on adolescent suicide has not always been consistent. In the past few years, Massachusetts has experienced several epidemics of adolescent suicide in the small towns surrounding Worcester. For example, one year ago the Emergency Mental Health Center at the University of Massachusetts Medical School recorded a triggering suicidal death of a local teenager that led to one additional adolescent suicide and at least six other known attempts. After the news broke about Bergenfield, we wondered if there would be any increase in the demand by adolescents or their families for crisis intervention services. Two weeks after Bergenfield, we reviewed our records to determine if there was any increase in ado-

lescent visits with suicide as the presenting problem. We also asked the psychiatric staff if adolescent outpatients had mentioned the Bergenfield suicides in their sessions. Surprisingly, there was no increase in adolescent visits, suicidal or otherwise, nor did any of those adolescents who visited the Emergency Mental Health Center mention Bergenfield. There was also no increase in the rate of adolescent completed suicides. Of course, these data are only anecdotal, and they raise more questions than they answer. What explains this apparent nonreaction of the Worcester area teenagers to Bergenfield? What makes suicide contagious at one time or place but not another? In an area such as ours that has already suffered two epidemics of adolescent suicide, why was Bergenfield seemingly so remote a phenomenon this time for these young people? The answer is not that the Worcester area had systematically made massive efforts to combat further epidemics, as had Plano, Texas. In fact, there has been a mixed response by area schools on the use of school suicide prevention programs. It may take some time to answer these questions. Yet, there is certainly something that can be done by physicians in their day-to-day practice on this issue. Research has shown that suicidal adolescents frequently encounter health professionals before their suicides.5 Following a highly publicized suicide, when seeing an adolescent for a routine, minor, nonpsychiatric visit, the clinician has a unique opportunity to question the adolescent sensitively about whether he or she has heard about the suicide and how he or she feels about it. The potential role for emergency physicians is manifest. Such questioning may disclose the cardinal signs of clinical depression or the existence of a bizarre teenage ritual. (For example, closely knit groups of teens attend “pity parties,” drink alcohol, smoke marijuana, and talk about the best way to take their own lives. They also examine at these parties how their suicides will effect their families and “how sorry people will be when they are gone.“) While it is clear that further systematic research needs to be conducted on the role of the media and its relation to adolescent suicide,3 further research is also needed on the role of the physician, especially the emergency physician, as “invaluable first finder” in the recognition of adolescents at risk.5 LINDA GAY PETERSON,MD Department of Psychiatry BRUCEBONGAR, PHD Department of Psychology University of Massachusetts School Worcester, Massachusetts

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References 1. Phillips DP, Carstensen LL: Clustering of teenage suicides after television news stories about suicide. N Engl J Med 1986;315:685-689 2. Gould MS, Shaffer D: The impact of suicide in television movies: Evidence of imitation. N Engl J Med 1986:315: 690-694

1987

3. Eisenberg L: Does bad news about suicide beget bad news. N Engl J Med 1986;315:705-707 4. Goethe JW: The Sorrows of Young Werther. New York, Modern Library, 1971 5. Berman A: Adolescent suicides: Issues and challenges. In Bronheim SM, Magrab PR, Shearin RB (eds): Seminars in Adolescent Medicine: Adolescent Depression and Suitide. New York, Thieme Medical Publishers. 1986. DP .. 269-277

TerminatingUnsuccessfulAdvanced Cardiac Life Supportin the Field Despite two decades of progress in the management of sudden cardiac death, most victims of out-of-hospital cardiac arrest fail to respond to prehospital advanced cardiac life support (ACLS). In most metropolitan areas, paramedics rush patients in refractory cardiac arrest to the nearest hospital for continued efforts at resuscitation. The wisdom of this policy rarely has been questioned. Much has been learned about the optimal management of out-of-hospital cardiac arrest. Extensive clinical research has identified a number of factors (such as time from collapse to defibrillation) associated with increased chances of survival, and innovative strategies have been developed to improve those amenable to prehospital intervention. Relatively little attention has been given, however, to the problem of identifying patients for whom further provision of emergency advanced cardiac care is pointless. As a result, decisions to cease efforts following unsuccessful resuscitation are often clouded with guilt and self-doubt. In communities providing effective prehospital advanced cardiac life support, virtually all ultimately successful resuscitations are accomplished at the scene. Patients arriving in the emergency department following unsuccessful prehospital ACLS rarely respond to continued attempts at resuscitation. Of those who do respond to emergency department resuscitation, few survive to hospital discharge. While it appears that failure to respond to prehospital ACLS is highly predictive of death prior to hospital discharge, most of us continue to advise emergency transportation to the nearest hospital. Few of us dare to do less. It is always easier to keep trying when the alternative is pronouncement of death. Smith and Bodail have reported compelling data that confirm that most patients arriving in the emergency department in cardiac arrest have no reasonable hope of survival. An accompanying editorial by Eisenberg and Cummins2 acknowledged this fact but cited the “one slim chance” such patients have for survival as ample jus548

titication for continuing efforts. This is an argument that many find difftcult to rebut. A decision to transport a patient in refractory cardiac arrest, however, is not simply a choice between “doing something” and “doing nothing.” Substantial resources must be committed to carry a resuscitation attempt into the emergency department. An objective analysis of this issue, therefore, requires more than a discussion of possible benefits. One must also consider associated costs and risks. Transporting a patient to the hospital in refractory cardiac arrest following prehospital ACLS increases the time a paramedic unit will be unavailable for other calls. In a two-tiered EMS system with relatively few paramedic units, extending time in service lengthens the time remaining units must provide expanded areas of coverage. If additional emergency calls are received during this interval, paramedic response times may be unavoidably prolonged. High-speed emergency driving is dangerous. While design modifications have made ambulances safer, collisions involving EMS vehicles continue to occur. Between 1977 and 1985, a total of 165 motor vehicle deaths involving ambulances in operation were reported (unpublished data, Fatal Accident Reporting System, National Highway Traffic Safety Administration). The rate of serious but nonfatal injuries to drivers, passengers and pedestrians following EMS vehicle accidents is undoubtedly higher, but the magnitude of this figure is unknown. After the ambulance arrives in the emergency department, a team of doctors, nurses, and support personnel must be rapidly mobilized to continue the attempt at resuscitation. In busy emergency departments, resuscitation efforts may require staff to delay or defer care of other emergency patients. If the emergency department resuscitation effort is successful, the patient will be admitted to an intensive care unit for what is often a stormy hospital course. Few patients survive prolonged periods of cardiac arrest