Mrs. Jones, 78 years old, arrived in the emergency department (ED) via ambulance. She was alert and oriented, but was having episodes of lost consciousness. She was put on the cardiac monitor and her vital signs were obtained. Her cardiac rhythm was normal. Her vital signs were as follows: Temperature 97.3°F, Pulse 43, respirations 26, blood pressure 100/58 and O2 saturation of 94% on room air. Additionally, Mrs. Jones was vomiting and had 2 loose, incontinent stools. She was pale, cool to touch and diaphoretic. Auscultation of her lungs revealed expiratory wheezes.
Her brother reported finding her in her living room on the couch. He reported that she was difficult to rouse, and becoming concerned, he called 911. Prior to the ambulance arriving, Mrs. Jones vomited several times and her brother noted a significant amount of partly dissolved pills in the emesis. Upon checking her medicine cabinet, he found several prescription bottles empty and some over the counter medications open in the cabinet. He brought these medication bottles to the ED. Poison control was contacted and they recommended giving her activated charcoal to absorb the medications. The charcoal was offered and Mrs. Jones refused, stating that she wanted no treatment and had attempted to kill herself for a reason.
Upon speaking to her brother, it was learned that her husband had died about one year earlier and that she had several new diagnoses in the last few months; including: Diabetes mellitus, anorexia (with marked weight loss), sleep disturbances, and mild dementia. She had been having difficulty with the management of these new illnesses and was still grieving for her husband.
Because it was an attempted suicide, a crisis management team was called to assist with the case. The doctor went in and spoke to the patient and she still refused all treatment. A discussion of what to do then followed. Legally the ED staff could force treatment on her because emergency, life sustaining care does not require consent. This is true after a suicide even if the patient refuses care. But, the question was: Should they try to force care on this woman? If nothing was done she would most likely die, but there wasn't a lot that could be easily forced upon her without causing harm. How could you force her to drink the charcoal? When the crisis team arrived they went directly into the patient's room. They tried to persuade her to accept treatment, but could not.
The team decided to allow the brother to speak to her to see if he could persuade her. While the brother was speaking with Mrs. Jones, she lost consciousness. Poison control was again consulted and they recommended a stomach lavage and suctioning for the unconscious patient. This was performed. Blood was also drawn to check the levels of the various meds she had taken. The results of these tests showed dangerously high levels of Physostigmine, a cholinergic, and atropine was given to treat this toxicity.