Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Self-harm / Suicidal Ideation
• 22-year-old female, distressed, superficial cuts to arm
• History of Borderline Personality Disorder
• Argument with partner reported
• Patient currently alone at home

On Arrival

Paramedics arrive at an apartment. The patient lets them in; she is visibly distressed, tearful, and angry intermittently. She is sitting on the sofa, holding her left forearm, where several superficial linear cuts are visible, with minimal active bleeding. There are tissues scattered around, and perhaps an overturned photo frame. The patient may initially be reluctant to engage or may demand attention intensely.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Patient interview, Collateral from Friend/Partner via phone if possible)

Vital Signs/Assessment

Physical Examination (Focused)

• **General:** Appears stated age, emotionally distressed (labile affect - switching between tears, anger, flat affect), restless or withdrawn.
• **Wounds:** Assess self-harm injuries (location, number, depth, length, contamination, haemostasis). Typically superficial linear cuts on forearms/wrists in this scenario, but assess thoroughly. Check for other injuries.
• **Signs of Overdose/Intoxication:** Assess for toxidromes if substance use suspected (pupils, vital signs, neurological status).
• **Mental State Exam (Key Focus):**
  • **Appearance/Behaviour:** Variable - tearful, agitated, withdrawn, poor eye contact or intense staring.
  • **Speech:** May be rapid, pressured, loud, or quiet and monosyllabic. Content focused on distress, relationship issues, self-criticism.
  • **Mood/Affect:** Predominantly dysphoric, anxious, angry, sense of emptiness. Affect is often intense and reactive/labile.
  • **Thought Content:** Preoccupation with relationship conflict, fear of abandonment, self-deprecating thoughts. **Assess suicidal ideation thoroughly:** thoughts, intent, plan, access to means, past attempts, protective factors. May express hopelessness.
  • **Perception:** Usually no frank psychosis, but may experience transient stress-related paranoid thoughts or dissociative symptoms (feeling unreal/detached).
  • **Cognition:** Usually grossly intact orientation, but attention/concentration impaired by distress.
  • **Insight/Judgement:** Often limited during crisis; insight into BPD diagnosis may vary. Judgement impaired regarding coping/impulsivity.

Assessment and Treatment

Appropriate Management

• **Prioritise Safety:** Ensure scene safety (remove potential means of harm if safe to do so). Maintain awareness of patient's potential for impulsivity.
• **Establish Rapport & Therapeutic Communication:** Crucial for BPD. Use a calm, patient, non-judgmental, validating approach. Acknowledge the intensity of their emotional pain ("This sounds incredibly difficult for you right now"). Active listening. Be reliable and consistent. Avoid judgmental language or minimizing their distress.
• **De-escalation:** Focus on verbal techniques. Allow patient to express feelings. Set clear, calm boundaries if behaviour becomes overly demanding or inappropriate.
• **Risk Assessment:** Conduct thorough suicide/self-harm risk assessment. Explore ideation, intent, plans, access to means, history, and protective factors. Take all expressions of suicidal ideation seriously.
• **Assess Capacity:** Determine if the patient has the capacity to refuse treatment/transport (often impaired during acute crisis).
• **Manage Physical Injuries:** Clean and dress superficial wounds appropriately. Assess need for further medical treatment (e.g., sutures - unlikely for superficial cuts but possible).
• **Address Medical Concerns:** Rule out significant overdose or other acute medical issues contributing to presentation. Check vital signs, BGL.
• **Sedation:** Generally AVOIDED unless extreme agitation poses an immediate risk of harm that cannot be managed verbally or with presence. Focus is on de-escalation and supportive care. If sedation is necessary (rarely), use minimal dose cautiously per protocol.
• **Involve Support Systems:** Encourage contact with therapist, family, or friends if appropriate and potentially helpful (with patient consent if possible).
• **Transport:** Transport to Emergency Department for comprehensive mental health assessment is indicated due to self-harm and suicidal ideation. Explain the need for assessment clearly and calmly.
• **Mental Health Act:** Consider need for involuntary transport/assessment under relevant mental health legislation if patient lacks capacity and refuses transport despite being high risk. This often requires specific procedures/personnel (e.g., police, authorised mental health practitioners) depending on jurisdiction.
• **Pre-notify:** Provide clear handover to ED including diagnosis of BPD (if known), presenting problem (self-harm, SI, trigger), risk assessment findings, mental state exam key points, and management provided. Emphasise the need for mental health team assessment.
• Documentation: Detailed documentation of assessment (especially risk assessment and mental state), communication strategies, interventions, and rationale for transport.