Simulated Patient Scenario

Scenario Details

MDT Information

• Non-Urgent Response - Mental Health / Minor Injury
• 19-year-old has self-inflicted cuts to forearm
• Caller (patient) states bleeding is controlled but feels distressed
• Patient is alone at home address
• Denies suicidal intent on call

On Arrival

You arrive at a suburban house. The patient, a 19-year-old, meets you at the door. They appear withdrawn and tearful but allow you entry. They are sitting on the edge of their bed in their bedroom. You observe several superficial, linear lacerations on their left forearm, some with dried blood and some with minimal ongoing oozing. A tissue with some blood spots is nearby, along with a small craft knife/blade on the bedside table. The patient is holding their arm and avoiding eye contact.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (patient may be initially reluctant to disclose fully)

Vital Signs/Assessment (Initial)

Physical Examination

• Affected Limb (Left Forearm): Multiple (approx. 5-7) superficial, parallel, linear lacerations, varying length (1-4 cm). Edges clean. Minimal oozing, no active arterial or venous bleeding. No signs of tendon/nerve involvement (assess distal sensation and motor function). No signs of infection. Note presence of older, faded scars nearby.
• Mental State: Appears withdrawn, sad, quiet. Maintains intermittent eye contact. Speech is soft but coherent. Expresses feelings of distress, frustration, and regret about self-harm. Consistently denies suicidal ideation when asked directly ("I don't want to die, I just wanted the feelings to stop"). Appears to have some insight into behaviour as a coping mechanism.
• General: No other injuries noted. No signs of intoxication or overdose.

Assessment and Treatment

Appropriate Management Focus

• Prioritize Safety & Rapport: Ensure scene safety. Remove/secure the object used for self-harm safely. Adopt a calm, empathetic, non-judgmental approach. Build rapport before focusing heavily on wounds.
• Communication: Active listening. Validate the patient's distress ("It sounds like things have been really difficult for you lately"). Avoid judgmental language about the self-harm.
• Mental Health Assessment: Thoroughly assess suicide risk despite patient's denial (assess intent, plan, means, history, protective/risk factors). Differentiate NSSH from suicide attempt. Assess underlying mental state, mood, thought content.
• Wound Care: Assess lacerations. Cleanse wounds gently with saline/sterile water. Apply simple sterile dressings. Significant bleeding is not expected, but manage if present.
• Pain Management: Offer simple analgesia (e.g., paracetamol) if patient reports significant pain, though often minimal with superficial NSSH.
• Supportive Care: Offer reassurance and support. Acknowledge their courage in calling for help. Discuss coping strategies (without being overly instructive).
• Referral & Transport Decision:
  • Transport to ED is generally required for comprehensive mental health assessment, even if wounds are minor and suicide risk appears low. NSSH indicates significant distress requiring follow-up.
  • Explain the need for further assessment in a supportive way ("It's important we get you checked out and connect you with some support").
  • If patient refuses transport AND is deemed competent AND suicide risk is assessed as low (use caution, consult if unsure), explore alternatives like contacting a crisis team, GP, or family member (with patient consent). Document refusal thoroughly. However, transport is the safest option in most cases.
• Information & Resources: If appropriate and time permits, provide information on mental health support lines or resources (or ensure ED will do so).
• Teamwork & Communication: Discuss assessment findings and plan with partner. Provide clear, sensitive handover to ED staff, emphasizing the nature of self-harm (NSSH vs. attempt), current mental state, assessed suicide risk, and wound care provided.

Debrief Focus Points

• Understanding Non-Suicidal Self-Harm (NSSH) motivations and functions.
• Differentiating NSSH from suicidal behaviour (while acknowledging overlap/risk).
• Conducting a sensitive and thorough mental health and suicide risk assessment.
• Communicating empathetically and non-judgmentally with patients who self-harm.
• Appropriate wound assessment and management for superficial lacerations.
• Decision-making regarding transport and referral pathways for NSSH.
• Importance of documentation in mental health presentations.
• Crew welfare and managing emotional responses to self-harm presentations.