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Acute Psychiatric
Emergencies
Acute Psychiatric
Emergencies
A Practical Approach
Advanced Life Support Group
EDITED BY
Kevin Mackway‐Jones

This edition first published 2020 © 2020 by John Wiley & Sons Ltd
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The right of Advanced Life Support Group (ALSG) to be identified as the authors of the editorial material in this work has been
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Note to text:
Drugs and their doses are mentioned in this text. Although every effort has been made to ensure accuracy, the writers, editors,
publishers and printers cannot accept liability for errors or omissions. The final responsibility for delivery of the correct dose remains
with the physician prescribing and administering the drug.
Contents
Working group vi
Contributors viii
Foreword ix
Preface and acknowledgements xi
Contact details and website information xii
How to use your textbook xiii
1 Structured approach to acute psychiatric emergencies 1
2 Primary unified assessment and immediate psychiatric management 5
3 Secondary physical and psychosocial assessment 13
4 The patient who has harmed themselves 19
5 The apparently drunk patient 37
6 The patient behaving strangely 51
7 The acutely confused patient 63
8 The aggressive patient 75
9 Legal aspects of emergency psychiatry 91
10 Human factors 97
11 The patient experience 107
Index 111
Working group
Roger Alcock MB ChB, BSc(hons), FRCP Edin, DCH, FRCEM, Consultant in Emergency Medicine and Paediatric
Emergency Medicine, Forth Valley Royal Hospital, Larbert
Helen Bradford MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology
Mark Buchanan Consultant in Adult and Paediatric Emergency Medicine, Arrowe Park Hospital
Vanessa Craig MBBCh, BAO, MRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Mental Health
NHS Foundation Trust, Manchester Royal Infirmary
Sandrine Dénéréaz Paramedic – Paramedics School Director, École Supérieure d’Ambulancier et Soins d’Urgence
Romande, Lausanne, Switzerland; President, Commission for Emergencies Health Measures,
Lausanne
Fiona Donnelly BSc, MBChB, MRCPsych, PgDip Psychiatry, PGDip Health and Public Leadership, Consultant
Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital
James Ferguson MBChB, FRCSEd, FRCS(A&E), FRCEM, FRCPE, Professor in Remote Medicine, Robert Gordon
University; Reader in Emergency Medicine, Aberdeen University; Clinical Lead, Scottish Centre
for Telehealth and Telecare and Digital Health and Care Institute
Sarah Gaskell DClinPsy, PGDip, Consultant Clinical Psychologist, Head of Paediatric Psychosocial Services,
Royal Manchester Children’s Hospital
Elspeth Guthrie MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health
Sciences, University of Leeds
Damien Longson PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate
Dean, Royal College of Psychiatrists
Kevin Mackway‐Jones MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and
the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester
Metropolitan University
Laura McGregor FRCEM, MRCP, DTMH, DIMC, Consultant in Emergency Medicine, University Hospital
Monklands; Educational Coordinator, Emergency Medicine, Scottish Centre for Simulation and
Clinical Human Factors
Aaron McMeekin MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS
Foundation Trust; Honorary Lecturer, Academic Unit of Medical Education, University of
Sheffield
Working group / vii
Andrew McNeill Russell MBChB, MRCS, FRCEM, Consultant in Emergency Medicine, University Hospital Monklands
Rachel Thomasson PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences,
Salford Royal NHS Foundation Trust
Sue Wieteska CEO, Advanced Life Support Group
Damian Wood MBChB, DCH, MRCPCH, Consultant Paediatrician, Nottingham Children’s Hospital, Queen’s
Medical Centre
Contributors
Helen Bradford MA, DClinPsy, CPsychol, AFBPsS, Consultant Clinical Psychologist, Bradford Psychology
Fiona Donnelly BSc, MBChB, MRCPsych, PGDip Psychiatry, PGDip Health and Public Leadership, Consultant
Psychiatrist, Mental Health and Home Treatment Team, Wythenshawe Hospital
Richard J. Drake BSc, MBChB, MRCPsych, PhD, Clinical Lead for Mental Health, Health Innovation Manchester;
Honorary Consultant, Greater Manchester Mental Health NHS Foundation Trust; Senior Lecturer,
Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine
and Health, University of Manchester
Peter‐Marc Fortune FRCPCH, FFICM, FAcadMEd, Consultant Paediatric Intensivist, Associate Medical Director, Royal
Manchester Children’s Hospital
Elspeth Guthrie MBChB, MSc, MD, FRCPsych, Professor of Psychological Medicine, Leeds Institute of Health
Services, University of Leeds
Mark Hellaby MSc, Med, PG Cert, BSc(Hons) RODP, FHEA, North West Simulation Education Network Manager,
NHS Health Education England
Damien Longson PhD, FRCPsych, Consultant Liaison Psychiatrist, Greater Manchester Foundation Trust; Associate
Dean, Royal College of Psychiatrists
Kevin Mackway‐Jones MA, DH, FRCP, FRCS, FRCEM, Professor of Emergency Medicine, Manchester Royal Infirmary and
the Royal Manchester Children’s Hospital; Director of Postgraduate Medicine, Manchester
Metropolitan University
Aaron McMeekin MRCPsych, Consultant Perinatal Psychiatrist, Greater Manchester Mental Health NHS Foundation
Trust; Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield
Rachel Thomasson PhD, MRCPsych, Consultant Neuropsychiatrist, Manchester Centre for Clinical Neurosciences,
Salford Royal NHS Foundation Trust
Foreword
This text and the associated course are very valuable at many levels. Emergency mental health presentations in the UK have
increased out of proportion to other presentations, and care of these patients in crisis has become an essential core skill for
an emergency clinician.
Mental health and emergency clinicians may work in silos due to organisational structure and lack of experience of each
other’s fields. The APEx course teaches both emergency and mental health clinicians together, bridging the gaps in experience
and knowledge and allowing the professionals to learn from each other.
The unified approach of: A, agitation; E, environment; I, intent; O, objects; alongside the traditional ABCD approach gives
confidence to both sets of professionals to ensure safety. It uses a common language which has the potential to become a
universal language. It supports the important principle of assessing and managing a patient’s physical and mental health
problems alongside each other with equal parity.
A great strength of this course is high-fidelity simulation in a safe environment and this is supported by the excellent
material in this book.
Catherine Hayhurst
Chair, Mental Health Committee
Royal College of Emergency Medicine
Preface
Emergency departments offer open access healthcare 24 hours a day, 7 days a week, 365 days a year. The number of patients
attending these departments in England increased by 7.4% between 2010–11 and 2016–17 and is currently at an all‐time
high. It is unsurprising that a significant proportion of the patients attending emergency departments present with mental
health problems, and the number of patients in crisis is increasing at 10% per year and now make up more than 5% (one in
20) of all attenders.
Despite the high numbers of patients attending in mental health crisis (more attend with this presentation than attend with
chest pain), the vast majority of emergency department staff are not trained specifically to deal with patients with mental
health emergencies or, indeed, to deal with mental illness at all. A value clarification exercise that looked into emergency
mental healthcare in one emergency department in London established that the work most valued by the staff was trauma
‘because of the excitement and drama it provided’. The environmental values for good mental healthcare (privacy, quietness,
safety, calmness and having time) were noted to be the ‘antithesis’ of the environment found in the emergency department.
Experienced emergency department nurses noted a ‘deficit in mental health knowledge’ but were unable to further identify
the deficits. A key theme emerged of ‘a perceived conflict between two cultures’ which gives mental health a low status.
The course that this book supports (APEx) is designed to fill some of the gap and more closely align the cultures of care. The
content has been designed jointly by psychiatrists and emergency physicians and is presented in a structured manner.
Recognisable presentations (such as ‘overdose and poisoning’, ‘aggression’ and ‘behaving strangely’) are dealt with rather than
focusing on diagnoses. Primary assessment is achieved with a new bespoke structured approach (ABCD AEIO U) that is similar
to the more familiar ABCD emergency care approach to physical emergencies. Secondary assessment consists of parallel
physical and psychosocial history and examinations. Throughout the text close co‐operation between emergency and
mental health teams is emphasised as is the value of joint working.
Patients in mental health crisis clearly deserve better than they currently get. This book, and the APEx course it supports,
is for them.
Kevin Mackway‐Jones
Manchester 2019
Acknowledgements
We acknowledge the contribution of Satveer Nijjar, Independent Trainer with Lived Experience, ‘Attention Seekers Training’,
who provided her personal account to inform Chapter 11: The patient experience.
Contact details and
website information
ALSG: www.alsg.org
For details on ALSG courses visit the website or contact:

Advanced Life Support Group
ALSG Centre for Training and Development
29–31 Ellesmere Street
Swinton, Manchester
M27 0LA
Tel: +44 (0) 161 794 1999
Fax: +44 (0) 161 794 9111
Email: enquiries@alsg.org
Updates
The material contained within this book is updated on approximately a 4‐yearly cycle. However, practice may change in the
interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for
updates (www.alsg.org).
References
To access references, visit the ALSG website www.alsg.org – references are on the course pages.
On‐line feedback
It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone
6 months after his or her course has taken place asking for on‐line feedback on the course. This information is then used
whenever the course is updated to ensure that the course provides optimum training to its participants.
xiii
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1
CHAPTER 1
Structured approach to acute

psychiatric emergencies
Learning outcomes
After reading this chapter, you will be able to:
●● Describe the approach to preparing for an assessment for a patient with possible mental health problems
●● Recognise the importance of close working between emergency medicine and psychiatry staff
●● Recognise the importance of good communication
●● Identify a structured approach to managing psychiatric emergencies
1.1 Introduction
Psychiatric and behavioural presentations to emergency departments are common – if substance abuse is included in these
figures then some 35–40% of presentations (6–8 million each year in England) are defined as such.
Systematic assessment and management of a person with acute mental health problems in the emergency department or
other acute hospital setting can present major challenges. Key considerations include:
• Emergency department and acute hospital staff receive little training in managing psychiatric emergencies
• Responses of mental health staff can be delayed, inconsistent and unsystematic
• The acute hospital environment is often not conducive to the provision of good psychiatric care
This text seeks to provide a safe, practical system for practitioners.
1.2 Preparation
Before starting any assessment for a patient with possible mental health problems:
• Ensure that appropriate help is available (a person who is showing signs of acute behavioural disturbance requires a
team approach)
• Ensure there are appropriate facilities to assess the patient
• Gather any available information
There must be a safe area where people who are acutely disturbed can be assessed and managed appropriately.
Acute Psychiatric Emergencies: A Practical Approach, First Edition. Edited by Kevin Mackway-Jones.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
2 / Acute Psychiatric Emergencies
1.3 Close working between emergency and psychiatry staff

The safe and successful management of people with acute mental health problems requires close working between
emergency/acute hospital teams with liaison mental health teams. Each team needs to carry out their own tasks, be aware of
each other’s skills, and work collaboratively to ensure the best possible outcome.
1.4 Communication
Good communication and basic rapport building with a person with acute mental illness are essential. Communication is no
less important with families of patients and with clinical colleagues – especially between those of different disciplines.
Detailed records of current clinical findings, the patient’s history, prior mental health records, physical test results and
management plans must be completed, and communicated to staff who will be taking over the care of the patient when he/
she leaves the emergency department.
1.5 Consent
In an emergency, if it is deemed in the patient’s best interests, hospital staff have a duty of care to treat the patient, provided
treatment is limited to that which is reasonably required in that emergency situation.
As consent legislation and practice are complex areas with different practices in different countries and jurisdictions, we will
highlight the medicolegal aspects of patient care in relevant chapters, by detailing the principle of what they achieve.
Chapter 9 summarises legal aspects in more detail and maps the principle of the relevant laws. The details will differ depending
on the jurisdictions where the Acute Psychiatric Emergencies (APEx) course is available.
1.6 A structured approach

A structured approach will enable all clinicians (whether mental health trained or not) to manage psychiatric
emergencies optimally, so that patients receive high‐quality care. It will also ensure that important steps in the care
process are not forgotten. As it is common for mental and physical health problems to occur at the same time, both
require consideration.
A structured approach focuses initially on a primary assessment designed to identify and manage any immediate threats to
safety, either for the patient or for others. This involves a rapid assessment of ABCD physical risk and an AEIO psychiatric risk
assessment. These then inform the Unified assessment.
After a primary assessment has been completed and relevant steps have been taken to ensure safety, a secondary assessment
needs to be undertaken. This includes establishing the key features of the presentation. In particular, it is important to establish
whether the presentation is predominantly a physical health or a mental health problem (or a combination of both). This
process involves being able to interact with the patient in a manner which conveys understanding and empathy, builds
rapport, reduces anxiety and enables information gathering in an effective and efficient manner. Secondary mental health
assessment includes a focused conversational psychosocial history and examination of the mental state, while secondary
physical health assessment involves a focused physical history and full top‐to‐toe examination. Following on from this, an
appropriate emergency treatment and management plan can be identified.
The final phase of the structured approach is to stabilise the patient so that transfer to an appropriate care environment
can occur.
Throughout this text the same structure will be used so the clinician will become familiar with the approach and be able to
apply it to any clinical emergency situation.
Figure 1.1 shows the structured approach in diagrammatic form.

Chapter 1 Structured approach to acute psychiatric emergencies / 3
Prepare to see patient
VERY VERY Rapid

P
PRIMARY Resuscitation ABCD AEIO
R SEVERE SEVERE tranquillisation
I ASSESSMENT
M
A
and
R IMMEDIATE
Y
TREATMENT
NOT VERY SEVERE
UNIFIED ASSESSMENT
Put in place measures to minimise
psychiatric or physical risk
to patient or others
SECONDARY Focused physical history Focused conversational psychosocial

S ASSESSMENT and secondary examination history and mental state examination
E
C
O
N
D
A
R
Y
EMERGENCY Emergency psychiatric management/
Emergency physical treatment
MANAGEMENT consider mental health assessment
D
E
F
I
N
I
T
Determine disposal
I
V
E
C
A
R Reassess risk
E
A
N
D
D Handover
I Transfer
S
P Ongoing care plan
O
S
A
L
Figure 1.1 The structured approach

1.7 Summary
This book will introduce the structured approach in more detail and then explore its use in the common psychosocial
presentations to the emergency department.
5
CHAPTER 2
Primary unified assessment

and immediate psychiatric
management
Learning outcomes
●● Explain how to assess someone who is acutely disturbed
●● Describe how to take structured steps to ensure safety and minimise any potential harm to others
2.1 Introduction
The effective management of an acutely disturbed patient who has presumed mental health problems is a key emergency skill. By
using the basic techniques and strategies described, a safe framework can be established, from which a more detailed assessment
or intervention can then be carried out. It is essential that all staff who work in an acute hospital setting have these basic skills.
In the structured approach, the person who is acutely disturbed should have a primary assessment that includes ABCD and
AEIO risk assessments (see Figure 2.1). It may not be possible to carry out a full physical assessment because of the level of
disturbance, but consideration should be given to physical status and potential organic causes of the presentation.
In this chapter, we focus on the mental health assessment, but physical factors should always be considered, and accompanied
by a parallel physical assessment, when appropriate.
2.2 Preparation
Never approach a patient who is acutely disturbed by yourself. Wait until a sufficient number of appropriately trained staff,
police officers and security guards are present. The number required will depend upon the size of the patient, the nature and
degree of their disturbance, and the physical characteristics and resources of the facility in which you are working.
In most circumstances, there is time to gather information quickly before seeing the patient (e.g. if the patient is brought to
the emergency department (ED) by the family, the police or the paramedic emergency service). The aim at this point is to
access relevant information that will inform the rapid assessment.
Information may include verbal accounts from the family, paramedics, police, relevant others and the hospital record systems.
Ask and obtain answers to the following questions:
• Can you tell me about the behaviour of X whilst in your care?
• On a 10 point scale (0 being not disturbed at all, to 10 being extremely agitated/violent/aroused) how would you rate
this person’s behaviour?
• Can you tell me about/give me an example of the most extreme or disturbed level of behaviour you have witnessed?
• Do they speak English and, if not, what language do they speak?
Many mental health record systems have specific, designated subsections for flagging information about ‘risk of harm to self
and others’. However, ED or hospital staff may not have access to these systems. Make sure all relevant information is shared
between all staff involved with the patient.
Key factors to note are:

• A prior history of self‐harm
• A prior history of harm to others
• Alcohol and illicit drug use
• Prior history of severe mental illness
• Prior history of violence, forensic history (mental health treatment in a secure setting because of criminal behaviour) or
a criminal record
Before entering a room with a disturbed patient, make sure you have back‐up in terms of available staff who can help if
necessary. Have at least two other members of staff with you. There may already be staff or police officers in the room. Stay
close to the door and keep it open. Do not allow yourself to be trapped behind the door.
Make sure there is a way to sound an alarm, if needed, with a suitable response. Many ‘safe rooms’ in EDs do not have alarms
because of inappropriate, frequent use. So make sure you have a personal attack alarm, or that there is someone outside the
room who can call for back‐up.
It is usual for most patients to undergo triage from a member of the ED nursing staff soon after they present. However, if
patients are either very physically unwell (for instance if they have stabbed themselves) or are significantly behaviourally
disturbed, it may not be possible to do this. Do not assume that behavioural disturbance is due solely to mental health issues.
Seek relevant physical health signs or symptoms that need to be addressed.
The structured approach is applicable to patients of all ages, but consideration of developmental factors is vital when dealing
with both adults with learning disabilities and children and adolescents. For example, understanding of the irreversibility of
death typically develops in middle childhood, so may not be present in adults with learning disability or young children, and
this would need to be considered in an assessment of intent. There are additional considerations about child and adult
safeguarding. There is also an increased significance in the role of parents and carers who may be a helpful source of
information and support but may also be a potential risk.
2.3 Primary assessment – the unified assessment
Prepare to see patient
P VERY VERY Rapid

Resuscitation
R PRIMARY SEVERE SEVERE tranquillisation
ABCD AEIO
I ASSESSMENT
M and
A IMMEDIATE
R TREATMENT
Y NOT VERY SEVERE
UNIFIED ASSESSMENT
Put in place measures to minimise
psychiatric or physical risk
to patient or others
Figure 2.1 Structured approach: primary assessment

Chapter 2 Primary unified assessment and immediate psychiatric management / 7
The first priority is to ensure that the patient is kept safe (both physically and psychologically) whilst they are awaiting detailed
psychiatric assessment or are undergoing physical investigations. They must be prevented from either intentional or
unintentional harming of themselves or others. A fast and focused assessment is required to:
• Establish the level of physical and psychiatric risk
• Put in place appropriate measures to minimise that risk
Observe the patient. Note his/her conscious level, degree of agitation and current behaviour. Introduce yourself:
• ‘I’m X, I’m a doctor/nurse, I’m here to try and help you’
• Ask the patient their name and what they like to be called
• Ask them if they know where they are
• If they do not know, explain they are in a hospital, they are safe, and you are here to try and help them
As you are doing this, make a quick assessment of the patient’s overt physical health. Look for skin colour (pallor or flushed),
whether or not they are sweating, pupil size (pinpoint or dilated), any obvious injuries, any signs of self‐harm (ligature mark
around neck, scars to arms) or disabilities.
Ask the patient if they are hurt or in pain. If they respond positively, you will need to get details of their concerns to establish
the nature of the injury or their physical health problems. Ask them if it would be okay for someone to check their pulse,
temperature and blood pressure.
As you are doing this, make an assessment of their cognitive function, including basic orientation and attention.
• Can they give you their name and address and date of birth?
• Do they know where they are?
• Do they know the time of day, month and year?
• Do they understand questions?
• Do they respond appropriately?
Tell them that you need to ask them some brief questions to check that they are safe. Tell them that these are routine
questions.
2.4 Primary physical risk assessment

The primary physical risk assessment should focus on four key areas:
A Airway – patency and security

B Breathing – adequacy and effectiveness
C Circulatory – adequacy
D Disability – assessment of conscious level and pupils
ABCD problems should be addressed as soon as they are identified. It is outwith the scope of this book to describe the life
support techniques that might be necessary – patients should be moved to the resuscitation area as soon as possible and
physical resuscitation should be continued there whilst the AEIO assessment described below is carried out.
Go on to ask the following:

• Have you taken any tablets or anything else that might be harmful in the last 24–48 hours?
• Have you had any alcohol?
• Have you taken any street drugs, e.g. amphetamines, cocaine, spice, ketamine?
• Have you suffered a recent head injury?
• Do you have any physical health conditions, such as diabetes or epilepsy? Do you have any condition for which you take
regular tablets or medications?
• Do you have any allergies?
2.5 Primary psychiatric risk assessment

The primary psychiatric risk assessment should focus on four key areas:
A Agitation/Arousal
E Environment in which the patient is being cared for
I Intent of individual
O Objects that the patient has in their possession, which may be used for self‐harm or harm to others
This enables staff to carry out a quick assessment of risk of harm (to self or others) and of flight risk. This enables planning of
a risk reduction and containment strategy, which may or may not involve rapid tranquillisation.
(A) Agitation/Arousal
This assessment depends on a quick observation of the patient. Their level of arousal or agitation is determined according to
the following guide (Box 2.1).
Box 2.1 Level of arousal or agitation
LOW – can sit still during the brief assessment and is not unduly agitated
MODERATE – easily aroused, gets up and paces about, but then settles again, no overt aggression or severe distress
HIGH – pacing up and down, unable to settle for more than a few seconds, may include overt aggression or severe distress
(E) Environment
All EDs should have facilities where an acutely disturbed person can be assessed and, if necessary, can be given emergency
treatment.
Dedicated ‘place of safety’ suites should be available in every locality for the assessment of mentally ill people detained for
their own safety by the police. The police have the power to detain someone in a public place who they suspect is suffering
from a mental illness and is at risk of harm to self or others, and convey them to hospital or other suitable facility which is
deemed a ‘place of safety’ for assessment for their presumed mental health problems. This legal framework will be discussed
further in Chapter 9.
Standards, for example those from the UK Royal College of Psychiatry, suggest that EDs should only be used as a place of
safety where medical problems need urgent assessment and management. However, many patients who are behaving in a
disturbed manner may have underlying physical health problems, so will be brought to an ED.
Comparable facilities to those described here should therefore be available in every ED so patients with behavioural
disturbance can be cared for safely. Box 2.2 describes the Royal College of Psychiatry standards for place of safety rooms as
outlined in Standards on the Use of Section 136 of the Mental Health Act 1983 (England and Wales).
Box 2.2 Standards for place of safety rooms
• The psychiatric assessment facility must be a locked facility in order to be able to safely care for those who are disturbed
• Levels of staff required to support this facility, when in use, are up to three staff trained in physical intervention, who should be
available at short notice without compromising staffing levels and hence safety elsewhere. This is in addition to the staff carrying
out the assessment
• The room should accommodate six people to allow both treatment and restraint, have an observation hatch and be lit well, have
two outward opening doors at opposite ends of the room and have fixed, soft, comfortable chairs that cannot be used as a
weapon. There should be no ligature points. In addition, a clock should be visible to both patients and staff, there should be a
phone line with outside dialling, a panic alarm and CCTV. It should not be isolated and should be accessed easily for containment
and restraint and resuscitation teams if required
The following is compliant with the National Institute for Health and Care Excellence (NICE) guidance Violence and
Aggression: Short‐Term Management in Mental Health, Health and Community Settings (www.nice.org.uk/guidance/ng10;
accessed June 2019).
In the absence of such a facility, or if it is already being used by another patient, make an assessment of the environment in
which the patient is being contained. Note the following, using ADELLE as an acronym:
A Alarm – is there a panic alarm in the room?

D Doors – which way does the door (or doors) open?
E Exits – how many exits are there, and how easy would it be for the patient to reach the exits from the room?
L Ligature points – identify any ligature points (including those in any bathroom or toilet facilities the patient may need to use)
L Location – how isolated is the room from the rest of the ED or ward? Is there any CCTV?
E Equipment – is there any equipment in the room (e.g. oxygen points, monitors) or items of furniture that could be used as a
weapon or have sharp edges?
Never allow a patient who is disturbed, or whom you have concerns about, to be left alone in a room that has ligature points,
or equipment or furniture that could be used to self‐harm.
Make an assessment of the environmental risk (Box 2.3).
Box 2.3 Environmental risk
LOW – alarm present, two doors that open both ways, exits are not easily accessible from the room, no ligature points and no
equipment or furniture that is harmful. Room is centrally located in the ED or ward area
MODERATE – no alarm, single door opens outwards, no ligature points or potentially harmful objects but room is close to exit
from ED and away from the central part of the department. No CCTV
HIGH – no alarm, single door opens inwards only, ligature points in room or potentially harmful objects, etc.
(I) Intent
Intent involves assessment of the current thoughts of the patient, not what they were thinking or believed in the past, but
what they are actually thinking or experiencing ‘right now’. There are four aspects of intent you need to assess quickly:
• Any current thoughts of harming self
• Any current thoughts of harming others
• Psychotic experiences that may lead to actions that involve harm to self or others
• Strong impulses or desires to leave the department
Current thoughts of harming self

Assess the nature, severity and frequency of these thoughts. Ask the patient directly how likely they are to act on these
thoughts in the next couple of hours. Assess how able the patient is to resist these thoughts.
Current thoughts of harm to others

Assess the nature, severity and frequency of these thoughts. Ask the patient how likely they are to act on these thoughts in
the next few hours. Establish whether the thoughts of harm to others are based on a wish to inflict harm on others (possibly
related to aggression) or are related to self‐protection arising from fears of persecution. In the case of the former, a calm and
non‐confrontative approach may be helpful, whereas in the latter, active reassurance that the patient is safe and staff are not
going to harm him/her may reduce anxiety/agitation.
Psychotic experiences
Certain psychotic experiences such as hearing voices commanding the patient to harm themselves, or others, or delusions of
control are associated with a high risk of self‐harm.
Establish whether the patient appears to be responding to external stimuli or appears very agitated or frightened. Try to
access the patient’s inner mental experiences by asking if anything is scaring or upsetting them or making them feel uneasy.
Go on to ask specifically about command hallucinations or delusions of control.
• ‘Are you hearing anyone or anything telling you to harm yourself or others?’
• ‘Do you feel controlled in any way by anything, or made to do anything you don’t want to do?’
Desire to leave
Check whether the patient is willing to stay in the department until they can be more fully assessed. Note if the patient
expresses thoughts about wanting to leave or if the patient has already tried to leave. Provide the patient with an estimate of
how long he/she will need to stay in the department and explain to them what is likely to happen during this time (e.g. will
they need more physical investigations, how long will the detailed psychiatric assessment take, etc.). Try to keep them
informed and updated about what is happening.
Make an assessment of intent (Box 2.4).
Box 2.4 Intent assessment
LOW – no suicidal ideas, or thoughts of harm to others, no command hallucinations or thoughts of wanting to leave
MODERATE – some thoughts of self‐harm or thoughts of harming others, or thoughts of wanting to leave, but the patient can
resist these thoughts
HIGH – thoughts of self‐harm or harm to others that the patient finds difficult to resist. Appears to be responding to or
experiencing hallucinations which the patient has described to have been commanding them to harm themself or others.
Actively wants or is trying to leave
(O) Objects
Establish whether the patient has any items on them or pieces of clothing that could either be used to harm themself or
others. The obvious items are firearms, sharp objects such as scissors or razor blades, or other items such as medication, illicit
drugs, plastic bags or batteries. Potentially harmful items of clothing include belts or scarves.
Take note of what the patient is wearing and, if they are amenable, ask if they would consider removing any items of clothing
that could be used to harm themselves (e.g. a belt or tie). Tell the patient you are doing your utmost to look after them and
ensure they are safe. Ask the patient if they have anything else on them that they could use to harm themself, such as tablets
or razor blades. Reassure the patient that their possessions will be kept safely for them.
The manner in which you broach these topics is more important than the actual words you use, and you will need to tailor
your body language, tone of voice, phrasing and timing to each individual person, according to their cue–response. Chapter 8
will focus in more depth on specific communication skills. Do not continue to ask questions if this process is increasing the
patient’s degree of agitation.
Make an assessment of risk from objects in the patient’s possession (Box 2.5).
Box 2.5 Risk from objects
LOW – no potentially harmful objects

MODERATE – patient denies having any harmful objects, but refuses to allow staff to check pockets or other items of clothing
HIGH – patient has potentially harmful objects that he/she is reluctant to hand over (e.g. razor blades)
2.6 Unified assessment and immediate treatment

You need to make a judgement as to the measures that need to be put in place to keep the patient safe in the department,
based upon:
• Information you have gained about the patient
• Physical degree of agitation
• Current environment in which they are being contained

• Likelihood they still have items on them that they could use to harm themselves or others
• Their current suicidal intent (or other high‐risk thoughts or behaviours)
By synthesising the ABCD AEIO elements into overall Unified risk assessment, you will be able to specify the degree of
observation that is required (ranging from no additional measures to one‐to‐one constant observation) and the number of
staff trained in physical intervention that need to be present either in the room or outside the room.
Table 2.1 provides a guide as to the minimum number of staff, trained in physical restraint, required according to the unified
assessment. There are no agreed published guidelines for staffing levels in such situations, and Table 2.1 has been reached by
consensus agreement between the authors of the APEx course. The red boxes indicate levels of risk where you should be
considering whether rapid tranquillisation will be necessary to keep the patient safe. Increase the number of members of staff
required according to the size and power of the patient, and other relevant factors. Not all combinations of the AEIO are
shown, but the examples included in Table 2.1 provide a quick reference guide.
Clinical judgement should always override the guidance in Table 2.1, which is a very basic starting point from which to plan care.
Table 2.1 AEIO assessment: minimum number of staff required for safe containment
Arousal/agitation Environment Intent Objects Containment

Low Low Low Low Nil
Moderate Low Low Low One staff
Moderate Moderate Low Low Two staff
Moderate Moderate Low Moderate Three staff
Moderate Moderate Moderate Low Three staff
Moderate Low Moderate Moderate Three staff
High Low Low Low Three staff
High Low High Low Four staff
High High High Low Six staff
High High High High Six staff
2.7 Rapid tranquillisation

This is discussed in detail in Chapter 8.
Rapid tranquillisation may be needed in some cases where the patient is extremely aroused and cannot be calmed down. It is
used when both psychological approaches and environmental management have been ineffective. Tranquillisation should be
administered orally if at all possible. If it is delivered parenterally then both patient and staff safety should be paramount. The
aim of rapid sedation is to render the patient into a state where they are calmer and less distressed, not to make them
unconscious. Lorazepam is usually given first (2 mg) orally or intravenously and it is recommended that further doses are not
given for at least 30 minutes. If lorazepam is insufficient then haloperidol (with promethazine) can be given intramuscularly. All
patients who have been sedated require regular monitoring (at least hourly or more frequently if consciousness is impaired).
2.8 Staff safety

If you find yourself alone with an acutely disturbed patient, do not approach them. Keep your distance (at least two arms’
length away). Locate the nearest exit and make your way towards it. Tell the patient your name, tell them you are a member
of staff and you are going to get some more help for them. Speak in a calm voice and keep looking at the patient, but do not
make intense eye contact. Do not turn your back. As soon as you can, leave via the exit and shout for help.
If you are concerned you are going to be attacked:

• Use your personal alarm if you have one
• Use the hospital alarm system, if one is installed and you can reach it
• Shout ‘fire’ (this is more likely to illicit a response from staff than ‘help’)
• Try to run or get away
If you are caught or seized by the patient, you may have to use basic techniques to extricate yourself. There are many courses
available that offer training in these skills.
2.9 Person‐centred care

All patients and healthcare professionals have rights and responsibilities. The focus in this chapter has been on the need to
conduct a primary physical and psychiatric assessment to keep someone safe in the ED department, whilst further physical
or mental health assessments are undertaken.
This does not obviate the need to adopt a person‐centred, values‐based approach to care in which people’s rights are
respected and efforts are made to develop a trusting therapeutic relationship. It has been shown that dedicated mental
health support workers, whose role is to provide reassurance, listen and engage with patients who are contained in a room
for their own safety, can have a positive impact upon the patient’s experience. Such workers can explain any legal processes,
help to de‐escalate tension or aggression, provide basic comforts such as food or drink, and help the patient to contact family
members or friends.
2.10 Legal framework

The legal framework under which staff provide assessment and care for patients with acute behavioural disturbance in the
ED will vary depending upon the nature of the person’s disturbance and their pathway to the department. A full discussion
of the legal framework, which covers acute psychiatric emergencies, is given in Chapter 9, including the role of advance
directives.
2.11 Secondary assessment

Once steps have been put in place to minimise the risk of harm to the patient or others, the ED team and liaison psychiatric
team should work collaboratively to undertake a parallel physical and full mental health assessment. The aim is to determine
the most likely cause of the patient’s disturbance and the most appropriate facility to which the person should be admitted.
In most cases the degree of disturbance will warrant an admission to either a medical ward or mental health facility.
2.12 Summary
It is important to use a structured approach to the assessment of someone who is acutely disturbed to ensure their safety and
minimise any potential harm to others.
13
CHAPTER 3
Secondary physical and

psychosocial assessment
Learning outcomes
●● Describe how to implement the structured approach to combined secondary physical and psychosocial assessment
●● Explain the structure of a focused conversational psychosocial history
●● Describe the mental state examination
3.1 Introduction
In this chapter we will explore the secondary assessment of both the physical and the psychosocial illness that may have
contributed to the acute psychiatric emergency. This element of the structured approach is shown in Figure 3.1.
SECONDARY Focused physical history Focused conversational psychosocial

ASSESSMENT and secondary examination history and mental state examination
Figure 3.1 Structured approach: secondary assessment
3.2 Focused physical history and examination

The principal aim of the focused physical history and examination are to:
• Explore whether there might be a physical element to the acute psychiatric presentation and, if there is, to determine
the appropriate emergency treatment
• Document the cause and examine any physical sequelae of the psychiatric emergency (such as wounds in self‐harm) to
determine necessary treatment
• Determine the physical health status of the patient
Before deciding that the patient is suffering from a psychiatric disorder you will need to consider whether there is an alternative
physical cause for their presentation. There are many physical illnesses that can present as psychiatric illnesses and these are
important to keep in mind especially if this is a first presentation. If the patient has an established diagnosis of a major mental
illness then it is less likely that the cause is organic illness, but this does not rule it out completely.
While a full secondary assessment (incorporating a comprehensive and systems enquiry, together with a head‐to‐toe physical
examination) might be needed to definitively determine physical health status, it is often neither necessary nor possible.
A pragmatic approach must be taken and best use made of available history and permitted examination. The vast majority of
patients in psychiatric crisis can be examined safely and adequately once they feel safe. Practitioners should remember, however,
that the required proximity to the patient for physical examination (a stethoscope length) puts them at increased risk of being
unable to escape if the situation suddenly escalates, and they should not undertake those physical examinations without a clear
risk assessment. It is better (and more informative) to ‘talk down’ an acutely agitated patient to persuade them to permit basic
observations, than to end up taking observations from and fully examining a very stressed restrained patient under duress.
Many practitioners will have their own approach to history taking and physical examination – and this book does not aim to
change well‐established and personal practice proven processes. For those who are looking for a system to follow or who
wish to change the one they currently use, the PHRASED approach to history taking is presented (Acute Medical Emergencies:
the Practical Approach (ALSG, 2010)):
P Presenting complaint
H History of presenting complaint
R Relevant medical history
A Allergies
S Systems review
E Essential family and social history
D Drugs
The physical examination that is necessary for the secondary assessment of the patient in psychiatric crisis is outlined in the
relevant chapters that follow. As previously mentioned, this may be constrained by the psychiatric crisis itself – a pragmatic
approach should be taken, weighing up the access to the patient, their compliance with the examination, the risk to the
clinician and the necessity of physical examination in determining future care and disposal. In extreme circumstances it may
be necessary to tranquillise the patient prior to examination (obviously at the cost of a clear history).
On occasion it is necessary to further investigate the possible physical causes or effects of the psychiatric crisis. The
investigations (blood tests, x‐rays, scans and others) should be as indicated by the findings of the physical history and
examination. There is no standard investigation panel for psychiatric emergency presentations, and no particular tests that
are universally needed to ‘physically clear’ the patient.
3.3 Focused conversational psychosocial history

The principal aim of the psychosocial history at this stage is to:
• Engage in a dialogue with the patient that will contribute to the de‐escalation of the emergency
• Identify or exclude substance misuse as a contributory factor
• Further explore those issues of risk that informed the immediate decisions on the degree of supervision and risk
management required
• Identify non‐organic (‘functional’) symptoms that would support referral to an acute psychiatric service in the absence
of an organic cause
General principles
Allow the patient to talk freely initially so that they can tell you what has been happening to them and what has led to them
coming into hospital. A conversational style should be adopted. By spending some time at this stage you will uncover many
of the symptoms contributing to the mental state. The headings below constitute a focused psychosocial history, and should
sufficiently uncover the information needed to manage the psychiatric emergency at this stage:
P Problem
H History of presenting psychiatric problem, e.g. SLIPA
R Relevant psychiatric history and forensic history
A Allergies
S Substance (mis)use and self‐harm
E Emotional trauma
D Drugs
Chapter 3 Secondary physical and psychosocial assessment / 15
• Key symptoms contributing to presentation

• Duration of onset
• Past psychiatric history or previous similar episodes, including treatments received
• Prescribed medication (for psychiatric and non‐psychiatric reasons). Recent new prescriptions, or dose changes, are
particularly relevant (e.g. new prescriptions for steroids)
• Recent changes in physical health, including recent diagnoses, or the onset of physical symptoms; positive findings here
may require physical examination and further testing later in the assessment
• Recent physical or emotional trauma
• Recent alcohol or illicit drug consumption, with a brief screen for longer term misuse of or dependence on alcohol and
other substance/s
• Thoughts of self‐harm or harm to others, as a matter of routine, and follow through with more detailed questioning if
necessary
• Any previous forensic history – especially a history of violence
3.4 Secondary psychosocial (mental state) examination

Once you have a basic history, review which aspects of the mental state assessment you have already covered, and what may
require further specific exploration. The mental state examination consists of both verbal and non‐verbal elements, so even if
the patient is unable to give any coherent history, or is unwilling to engage in the assessment, you will be able to complete
the majority of the sections of the mental state examination by observing the patient. The mental state examination can be
structured using the mnemonic ABC SMITH:
A Appearance
B Behaviour
C Cognition
S Speech
M Mood and affect
I Insight and capacity
T Thoughts
H Hallucinations and illusions
Appearance and Behaviour

• How are they dressed? Patients with psychotic illness, mania, severe depression, alcohol and substance misuse, or
dementia may present with evidence of poor self‐care alongside inappropriate clothing for the weather. Patients with
mania may be dressed in bright or inappropriate clothes. Psychotic patients may be wearing odd items, such as
sunglasses on a rainy day, or tin foil on their head, giving you hints about underlying unusual beliefs. Do not be anxious
about being inquisitive if necessary
• How active are they?
◦◦ Underactivity (psychomotor retardation) – this may be seen in severe depression, severe physical illness including
head injury, and intoxication with both drugs and alcohol
◦◦ Stupor – the patient presents as mute with complete immobility although there may be occasional short periods of
excitement and overactivity. Stupor has a range of both physical and psychiatric causes including severe depression
and mania, catatonia, epilepsy and hysteria
◦◦ Overactive (psychomotor agitation) – may be due to mania, anxiety, acute drug intoxication, acute confusional state
or head injury
• Akathisia – agitation and restlessness due to neuroleptic medication
• Rapport – how does the patient relate to you? Patients may be overfamiliar if they have frontal lobe damage,
are intoxicated or are manic. A difficulty in forming a rapport and poor eye contact may be seen in severe
depression. Patients with psychotic disorders may appear suspicious, frightened, guarded and reluctant to give
you information
• Aggression – can be a symptom of many different conditions and is not necessarily pathological. For assessment and
management of aggressive patients please see the relevant chapters
• Abnormal movements are often non‐specific, but often indicate organic or functional pathology that may be relevant
to the emergency presentation:
◦◦ In particular look for tics, movements of the mouth or tongue, and abnormal movements of the upper and lower
limbs, and seek more specialised support if these are seen
◦◦ Patients may exhibit features of an acute neurological emergency, such as catatonia or features of chronic neurological
illnesses such as Parkinson’s disease or multiple sclerosis
◦◦ Patients with chronic schizophrenia can exhibit a range of movement disorders as echopraxia, stereotypies,
mannerisms, posturing or negativism. The chronology of these may indicate longer term mental health issues but,
again, if observed seek more specialised support
◦◦ Fidgeting with hair, clothes or nails may all be seen in patients with anxiety disorders or substance misuse
◦◦ Patients scratching themselves, repeatedly banging their head against the wall or rocking may be them trying to cope
with severe distress but should raise suspicions that the patient may have a learning difficulty
◦◦ Patients looking toward an unseen object or responding to unseen stimuli. This may indicate hallucinatory experiences
in any modality
Cognition
Psychiatric emergencies commonly have an organic contribution, with degrees of impairment of consciousness as a
significant contributory factor to the behavioural disturbance. Assessment tools for delirium are beyond the scope of this
chapter (bearing in mind that delirium can present with personality change, mood disturbance, anger, irritability, agitation,
anxiety, apathy, depression or any other affective state). However, any secondary assessment in a psychiatric emergency
should at least check for orientation in time, place and person, and check for signs of poor concentration such as an
inability to concentrate on the interview, or recite days of the week in reverse. Poor estimation of the length of the interview
is also a subtle sign of delirium. If there are signs of delirium/acute confusional state see Chapter 7 for full assessment and
management.
Speech
Think about the rate of the speech and form of the speech (the form of speech is described later, under ‘Thoughts’). Clarify
that the patient does not communicate via sign language because they are deaf, or only speaks a language other than
English. You may need to find an interpreter before continuing with your secondary assessment.
Some patients will present as mute. This may be due to expressive aphasia, aphonia, learning difficulty, catatonia or depressive
stupor. A reduced volume of speech may be related to a number of disorders including cerebrovascular accidents, severe
depression, schizophrenia and learning difficulties. Conversely, patients may talk rapidly, loudly or are difficult to interrupt. This
is most commonly seen in intoxication, mania and hypomania, and sometimes in anxiety.
Mood and affect

Your own observations on the patient’s mood state are important, although they rarely help differentiate between organic
and non‐organic emergencies. The important aspect here is to ensure that the mood and affect observed are integrated into
your understanding and explanation of the psychiatric emergency.
The patient could be:

• Depressed (multiple pharmacological and organic causes in addition to a range of psychiatric diagnoses)
• Elated (multiple pharmacological and organic causes in addition to a range of psychiatric diagnoses and intoxicants)
• Irritable; this is often overlooked as a psychiatric symptom, but can be the only feature of a range of disorders such as
intracranial tumours, hyperthyroidism and other organic disorders, intoxication, bipolar disorder or dementia, amongst
many others.
Chapter 3 Secondary physical and psychosocial assessment / 17
Insight and capacity

It should rapidly become apparent during the secondary assessment whether the patient has an understanding
of their symptoms and illness, whether they understand the treatment or investigations being offered, and if
they have capacity to consent for any admission, examination or treatment necessary. Capacity and insight should
be documented in every secondary assessment, with demonstration that appropriate steps have been taken in cases
where the patient does not have the capacity and/ or insight to participate in, or agree to, the clinical decision‐
making process.
Thoughts
This is a complex and detailed area of the mental state examination, beyond the scope of a primer on psychiatric emergencies.
In brief, this is where a description of how the patient is thinking is documented; of course this can only usually be inferred
from what they are saying. Two headings are used.
Disorders of thought – form

This is often identified by observing that the patient’s responses to your questions are not making sense. In its mildest form
the interviewer may wonder whether it is in fact the interviewer who is failing to concentrate! Some of the disorders of
thought include:
• Circumstantiality (the patient eventually answers the question with a lot of unnecessary detail)
• Tangential thinking (the patient starts off as if to answer the question but continues on various tangents, never answering
the initial query)
• Loosening of associations (strange or absent associations between elements of speech, which may be very mild so that
simple speech is normal but complicated ideas have their elements muddled up, or so severe that most sentences
become impossible to follow)
• Neologism (made‐up words)
• Flight of ideas (the patient jumps from one topic to the next, often with connections that seem odd and are difficult to
follow)
• Perseveration
• Echolalia (the patient immediately repeats your speech)
• Slow, simplified thoughts (e.g. in hypothyroidism, catatonia, depression, intoxication, fatigue) and thought block
Finding of any of these is probably significant, and as described earlier the important aspect here is to ensure that any
observed abnormalities of thought form are integrated into your understanding and explanation of the psychiatric
emergency.
Disorders of thought – content

Although exploration of the content of thoughts is relevant to a full understanding of the patient’s experience, it makes only
a limited contribution to the management of the emergency situation.
In broad terms, thoughts are either non‐psychotic or psychotic. In both cases, the causes can be organic or non‐organic, with
only very few experiences being strongly indicative of a specific diagnosis.
Non‐psychotic thoughts can be hypochondriacal, catastrophic, depressive, obsessional or phobic, for example. These can be
accompanied by emotions such as fear, hopelessness, anxiety and distress. Some ‘out‐of‐body’ experiences such as feeling
detached from their own body can be classified here, caused by severe anxiety or a range of organic disorders.
Psychotic thoughts are frequently frightening and very unusual experiences which are in almost all cases not normal, and are
not experienced by healthy people in day‐to‐day life. Examples of psychotic experiences include:
• Delusions, which are generally false and unshakeable beliefs that are held contrary to the patient’s normal culture and
experiences. Examples might include that the world has been filled with green smoke, or that aliens have filled the water
supplies with poison
• Delusions of control and passivity phenomena are very specific experiences of a delusional belief that some aspects of
the patient’s sensorium (thoughts, feelings, movements and sensations) are being controlled by an external agency, or
that there is some form of external control of the patient’s thoughts outside their control
• Overvalued ideas sit in‐between psychotic and non‐psychotic thoughts; these are ideas that are unreasonable and
strongly maintained with many elements of a delusional belief, but where the patient is able to recognise that the idea
may not be true or culturally appropriate
Under the heading of thought content the clinician should remember to check that there has been sufficient enquiry about
thoughts of self‐harm, and harm to others.
Hallucinations and illusions

Illusions are the misinterpretation of a real stimulus, and arise in some mood states such as anxiety (e.g. misperceiving a
shadow as a potential assailant on a dark night due to increased anxiety). Illusions may contribute to distress and a psychiatric
emergency.
Hallucinations, on the other hand, are perceptions in the absence of a stimulus, and can occur in any sensory modality (taste,
smell, touch, sight and hearing). They are not usually part of a normal human experience and so should be considered as
significant in almost all cases. Auditory hallucinations (often ‘voices’) are generally non‐diagnostic – they are almost ubiquitous
in delirium, occur commonly in other organic disorders, and are frequent in a wide range of psychotic disorders. Other
hallucinations, however, should significantly raise suspicion of organic disorders or intoxication with illicit drugs.
Collateral information
Once this stage in the assessment has been reached it can be useful to obtain any collateral information available, this may
be from friends or relatives, staff in the department who have previous knowledge of the patient or previous medical or
psychiatric records. Collateral information can be particularly useful if the patient is unwilling to engage with the assessment.
3.5 Summary
This chapter has outlined both the physical and psychosocial secondary assessments. The elements of the structured
approach will be explored in more detail in the context of specific patient presentations in the following chapters.
19
CHAPTER 4
The patient who has harmed

themselves
Learning outcomes
• Describe how the structured approach can be applied to patients who have self‐harmed
• Perform a mental health assessment in patients who have self‐harmed
• Identify how to integrate the mental health assessment with the physical healthcare of the patient with self‐harm
4.1 Introduction
There are 200 000 presentations per year to emergency departments (EDs) in England following self‐harm. Not all people
who self‐harm have suicidal intent, but self‐harming behaviour is linked with a 30‐fold increase in the risk of future completed
suicide, as compared with the general population. There is also a high prevalence of psychiatric morbidity in those who self‐
harm, with over 80% suffering from one or more types (e.g. depression, anxiety disorders). Between 15% and 30% of people
will repeat self‐harm within a 12 month period, and these people are at even higher risk of suicide.
Many people who attend an ED following self‐harm report negative attitudes from hospital staff, which may cause an
unnecessary increase in their distress. This may arise from a lack of understanding of the nature of emotional pain (which can
be as severe as or even more distressing than physical pain), a lack of awareness of the high risk of eventual suicide of such
patients, or a lack of training of emergency staff to appropriately manage patients who present with self‐harm.
Many people who self‐harm have a background of childhood difficulties, including abuse and neglect and many have led
difficult and challenging lives. They are an extremely vulnerable group of people who find it difficult to cope with adversity.
Approximately 40% of people who die by suicide in England attend an ED in the year prior to death. The majority of these
attendances are either for self‐harm or a request for psychiatric help. Individuals who attend on multiple occasions for mental
health reasons or for self‐harm are at particularly high risk of suicide. Clinicians should therefore be alert to the risk associated
with such presentations and be able to assess and treat patients according to their risk profile and mental health needs.
4.2 General principles

National Institute for Health and Care Excellence (NICE) guidelines have suggested some general principles for all healthcare
professionals when helping people who have self‐harmed (NICE CG16, 2004). They are as follows:
• Always treat people with care and respect
• Take full account of the likely distress associated with self‐harm
• Involve the person who has self‐harmed in clinical decision making and provide information about treatment options
PUTTING IT ALL TOGETHER – THE STRUCTURED APPROACH TO ASSESSMENT
4.3 Preparation
People who self‐harm require assessment of both their physical and mental health. Whenever possible this should be conducted
in a flexible and fluid way, to increase efficiency and minimise any distress to the patient. It involves close, collaborative, working
between ED staff and mental health liaison teams, with each member of staff facilitating the work of others.
If the patient is acutely physically ill, medical care should follow the structured approach described in Acute Medical Emergencies:
the Practical Approach (ALSG, 2010) with a focus on primary physical assessment, with resuscitation, if necessary. A secondary
mental health assessment is not practical, feasible or indeed a priority in these circumstances.
Most patients will undergo a form of triage when they attend the ED; either as part of this process, or immediately following
it, a primary (AEIO) assessment must be carried out. This should include a plan for immediate management within the
department, which specifies the degree of observation required to keep the patient safe. In the case of the acutely ill
patient, this assessment should occur as soon as they are physically stable and conscious. Figure 4.1 shows the pathway
that most patients will follow within the ED, depending upon their risk status and whether they are intimating that they
wish to leave.
If the patient is transferred from the ED to an acute ward or intensive care unit before an assessment has taken place in
the ED, the patient should be assessed as soon as possible in the new environment. It may only be possible to carry out
a brief assessment of immediate risk at this stage, but a plan regarding the level of observation the patient requires must
be written in the medical notes and conveyed to all relevant staff. It should not be assumed that because the patient is
still physically unwell, he or she is free from risk of further self‐harm. Patients can and do commit suicide in the acute
hospital setting (either in the ED or on hospital wards), or leave the hospital precipitously with the intention of taking
their own lives.
Mental health staff should not wait until the patient is medically fit before carrying out an assessment. Risk needs to be
assessed and managed as soon as the patient is conscious, followed by a more detailed assessment, when the patient is
capable of participating more fully in the assessment process.
If immediate medical management is not required to save life, a more integrated physical and mental health assessment
should be conducted. A common error in the management of self‐harm is to delay mental health assessment until all medical
treatment is completed.
Chapter 4 The patient who has harmed themselves / 21
Triage
Include immediate assessment of risk
and willingness to stay for assessment
Patient wishes to leave?

No Yes
Primary(AEIO)
Assess capacity
assessment
Low or moderate High risk
risk
Take account of
emotional distress/
check patient Liaison psychiatric
Involve liaison team
will stay for opinion if unsure
investigations and
treatment
One-to-one If impaired,
observation do not allow Has capacity?
in safe area to leave
Yes
Begin medical management
History and physical examination
Ingestion: collect blood samples and consult TOXBASE
Allow to leave,
Ensure consent is obtained for each investigation or
but inform GP
treatment
Discuss with mental health liaison team

the likely time course and procedures involved
in the patient's physical management
Begin focused conversational psychosocial assessment,

whilst waiting for investigations, or further treatment,
or if no investigations or treatment are required
Figure 4.1 ED pathway for patients who have harmed themselves

4.4 Primary assessment – the unified assessment

Before any physical investigations are carried out, establish the following:
• Immediate or short‐term risk of further self‐harm or suicide (or harm to others)
• Likelihood of the patient leaving the ED before physical and mental health assessment can be carried out
Put in place measures to mitigate risk if either is deemed to be high, as outlined in Chapter 2. Use this structured approach if
the patient is highly aroused, agitated, aggressive or actively trying to leave the department. The following discussion assumes
that the patient is relatively calm and is able to participate in the triage process, as is the case for the overwhelming majority
of people who self‐harm. The approach follows the basic principles of an AEIO Unified assessment, but is specifically tailored
for people who have self‐harmed.
Triage – risk of further self‐harm or suicide

As part of the triage process practitioners will need to prioritise the patient with self‐harm for further clinical assessment. This will
require an integrated approach to the assessment of physical and psychiatric risk. A recognised tool should be used. One such is
the self‐harm algorithm in the Manchester Triage System in Emergency Triage, 3rd edition (ALSG, 2013), shown in Figure 4.2.
Emergency nurses are well versed in assessing physical risk such as that of breathing difficulties in someone with an insecure
airway. They are probably less experienced in the assessment of risk of further self‐harm during the brief triage assessment.
Questions about risk are best asked in context, when gathering information about what the person has actually done to harm
themselves. It may be useful to ask the patient the following:
‘And when you took the tablets (or cut your throat, etc.), what thoughts were in your mind at the time?’
Staff should note how the patient responds and if necessary then ask a supplementary question to clarify their response:
‘So when you took the tablets (or tried to hang yourself ), you intended to die’ or
‘So when you took the tablets, you didn’t actually intend to die.’
Triage staff should also enquire about immediate risk:
‘Do you have any current thoughts of harming yourself?’
‘Do you have any thoughts of harming anyone else?’
‘Are you okay to stay and wait in the department here until we can sort out the right help for you?’
If the patient responds to any of the above questions in a way which causes concern, then the patient is at high risk (priority 2)
of further self‐harm and measures to keep them safe should be put in place. This will involve either arranging for a member
of staff to stay with the patient or moving them to a location in the ED where they can be safely observed. The mental health
team should be involved at this stage, to help with the assessment process and help form plans to keep the patent safe.
Explain to the patient what you are doing and why.
‘Because it was a very serious attempt (or because you still have thoughts or harming yourself ) we need to keep you safe while we sort out
how best to help you. We will arrange for someone to come and sit with you in the department to keep you safe.’
In most cases, close observation will not be required and the medical part of the assessment will take priority at this stage.
However, if the person is identified to be at risk, a discussion should take place between the ED staff and the liaison team as
to how best to integrate the physical and mental health assessments.
Self-harm
Airway compromise
Inadequate breathing
Shock
Unresponsive child RED
Extreme aggression or agitation requiring
immediate restraint
Immediate risk of leaving before assessment
Immediate risk to self
Immediate risk to others
Acutely short of breath

Uncontrollable major haemorrhage
Altered conscious level
Severe aggression or agitation that may
require restraint ORANGE
High risk of leaving before assessment
Continuing self harm or high risk of further
self harm
Significant mechanism of injury
Severe pain
RISK
LIMIT
Uncontrollable minor haemorrhage

Marked distress
Moderate risk of further self harm YELLOW
Significant psychiatric history
Inappropriate history
Moderate pain
GREEN
Figure 4.2 Manchester Triage System: self‐harm chart. Source: ALSG (2013) reproduced with permission of John Wiley & Sons
Likelihood of the patient leaving the ED before physical and mental health assessment can
be carried out (flight risk)
Approximately 10–20% of patients who attend the ED following self‐harm will leave the department before a full assessment
has been completed. These patients are at higher risk of further self‐harm and eventual suicide. Of most concern are those
patients who walk out of an ED and go on to commit suicide within a few hours of taking their leave.
It is not always possible to anticipate or prevent such behaviour, but it is important to note if the patient appears restless and
agitated and to alert mental health staff early if this is the case. It is helpful to explain to patients that they will be seen as
quickly as possible, but they may have to wait for certain investigations to be carried out and for an assessment and help with
their problems. Patients should be asked directly if they are happy with this and are willing to stay and wait. If they appear
unhappy or ambivalent, discuss the situation with the mental health team, who should be available to give advice or quickly
see the patient to carry out a brief risk assessment.
If a patient leaves the department before a full assessment has been done, staff need to consider whether there needs to be
any further action. If staff had concerns about that person, but were not able to organise sufficient care to keep them safe, then
the police must be informed as soon as possible, with a request that the person should be detained using police legal powers.
If patients have capacity to make decisions about their care, they have a legal right to leave the ED. However, the assessment
of capacity following self‐harm is not straightforward and help should be sought from the mental health team, particularly if
the consequences of refusal are potentially life threatening. The assessment of capacity in this situation is discussed in more
detail later in the chapter.
Medical/surgical management
In the case of self‐poisoning, methods to minimise drug absorption may need to be considered, and specific toxicological
advice sought from the National Poisons Centres, either by accessing TOXBASE or by telephone consultation. Specific
antidotes may need to be administered, specific investigations may need to be undertaken and particular observation
regimens may need to be followed.
4.5 Secondary assessment

Notwithstanding these considerations, if the patient is conscious and alert, a mental health assessment can be undertaken in
parallel with physical assessment and treatment. This assessment is usually undertaken by a member of the mental health
team, but such assessments can be carried out by ED staff, if suitably trained.
Mental state assessment should begin as soon as possible following a physical assessment, and can take place whilst blood
results are awaited or other investigations are being considered. A detailed assessment, however, can only occur if the patient
is alert and fully conscious, and a period of waiting may be necessary if the patient is intoxicated. Flexible working between
the ED staff and the liaison mental health team should ensure both physical and mental health assessments are completed
in a timely fashion. If the patient is too intoxicated for a detailed assessment to be undertaken, the mental health team should
still be available to help the ED staff manage the patient if there are concerns regarding safety and risk.
Focused conversational psychosocial history

It is best to start the mental state assessment with a brief introduction and an explanation of the purpose of the assessment,
followed by an open question about the episode of self‐harm:
‘Could you tell me a little about what you’ve done?’
Try to establish the sequence of events leading up to the self‐harm and what the patient actually did. How did he/she come
to have thoughts of self‐harm? What precipitated the episode? Was the self‐harm planned or impulsive? Establish how he/
she came to seek treatment in the ED.
There are many reasons why people self‐harm, one of which includes a wish to end life. The most common reasons are shown
in Box 4.1.
Box 4.1 Reasons why people self‐harm
• Wanting to die
• Wanting to die and not wanting to die
• As a way of regulating/relieving distress
• Having time out
• To seek a reaction from others
• To express anger towards self or others
• To stop feeling isolated
• To avoid suicide
A lot of information can usually be obtained from the patient by asking relatively few questions and many of the key points
you need to know may be answered naturally during the flow of the conversation. As the assessment continues, you will
need to focus upon the points below, if they have not already been addressed.
Assessment of risk
Identifying patients at ‘high risk’ of suicide or further self‐harm is the aim of most assessments following self‐harm. However,
in reality this is very difficult to do and most risk factors have very low predictive power.
It may be helpful to think of predicting risk as similar to trying to predict the weather. The weather forecast can be reasonably
accurate over the short term (24 hours) but the longer the range, the less accurate it becomes. This is because weather is
influenced by a complex, interacting pattern of meterological systems which are in constant flux. This is not so dissimilar to
human behaviour, which is also subject to continual modification and change. The computer programs used to predict the
weather are considerably more powerful and sophisticated than the rather crude assessments that are carried out in the ED
to predict future self‐harm or suicide. Therefore, any professional undertaking an assessment in an emergency situation
such as the ED, should focus upon the short‐term risk (a few days), and be cognisant of the uncertainty of the clinical
process. The main role of risk assessment is not to predict the future but to manage risk in the short term.
It is helpful to group the information gathering into five key areas (SLIPA):
S Suicidal thoughts at the time of self‐harm

L Lethality of the episode
I Intent now
P Protective factors
A Adverse factors
SLIPA
Suicidal thoughts at the time of self‐harm
This refers to the thought processes the person experienced at the time of the self‐harm episode. The patient may already
have been asked about this during triage to assess any immediate risk. If so, acknowledge this:
‘I know you may have been asked this when you first came to the emergency department this evening, but could you tell me about what was
going through your mind when you …’
Depending upon the patient’s response, you can then clarify their intent by asking:
So at the time you … you wanted to die and intended to kill yourself?’ or
‘So at the time you … you just wanted a break, a kind of timeout and you didn’t have thoughts of actually wanting to end your life?’
Although the patient may have been asked this previously, it is important to establish it for yourself. The previous questioning
will have been carried out in the context of a brief triage/screen, and the patient may have minimised their intent.
Lethality of the episode

Establish the likelihood that the episode of self‐harm would have resulted in death. This includes the nature of the self‐harm,
the steps the patient took not to be discovered, and the preparation and planning involved in the episode (Box 4.2).
Box 4.2 Potential high lethality of episode of self‐harm
• Violent method (e.g. hanging, gunshot, stabbing, jumping from height)

• Patient would have died without medical intervention (includes self‐poisoning)
• Avoided discovery (e.g. checked into hotel, drove to a remote place, ensured he/she was alone)
• Made plans to kill self (e.g. bought rope, stockpiled medication)
• Anticipated death (e.g. made will or wrote a note which clearly implies patient intended to die)
• Made no active efforts to be found after the self‐harm episode and did not seek help
Violent methods such as hanging, jumping off a high building, shooting or stabbing oneself are methods that are highly likely
to result in death. Taking large amounts of medication such as paracetamol or aspirin, or taking poison, are also high‐risk actions.
A degree of preparation and planning such as stockpiling medication, or trying to avoid discovery by checking into a hotel or
driving to an isolated location, all convey greater intent.
Find out details of the pathway to treatment. Was the person discovered by chance or did they play an active role in seeking
help following the self‐harm episode? In the latter case there may still have been suicidal intent but the person changed his/
her mind shortly after the self‐harm episode, or the person may not have intended suicide and may have had some other
reason for the action. Some people leave notes, which may or may not indicate suicidal intent.
Intent now
This refers to whether the patient has any current thoughts of self‐harm or suicide. This can be established in two ways.
• Does the person have any regrets that the self‐harm episode did not lead to death?
• Does the person have any current thoughts of self‐harm?
Protective and Adverse factors

Consider these two areas together as they often refer to aspects of the patient’s life which can either be protective or stressful,
e.g. a job can be stressful or protective or both. Common aspects are personal relationships, family and friends, job, housing,
finances and criminal charges.
Approximately 70% of all self‐harm episodes are precipitated by some kind of interpersonal problem, e.g. marriage break up,
bereavement, domestic abuse, miscarriage or argument. So always enquire about this aspect of the patient’s life, and find out
about their living circumstances. Are they living alone, or if they are living with someone, is this a supportive relationship?
Assessment of these five SLIPA areas provides the basis for the assessment of risk to which other relevant factors can be added
to produce an overall risk profile. As stated earlier this is not an exact science and advice from a more experienced professional
should be sought if there are concerns or doubts about the process. Some examples of how a risk profile is constructed are
given later in this chapter.
Demographic or historical risk factors

Identified risk factors are listed in Box 4.3. Individually these factors have low predictive power, as they have been identified
from large longitudinal cohort studies, in which basic information recorded in patients’ notes has been used to predict later
suicide. Such studies rarely include detailed information obtained by assessing people’s actual mental states at the time of the
self‐harm episode. We suggest that the demographic/historical risk factors should be combined with the information
obtained from SLIPA, to enhance the accuracy of the risk assessment. Many patients who present with self‐harm have at least
one or two or more of these demographic/historical factors (e.g. male and unemployed), so it is difficult to make clinical
judgements based upon these factors alone.
Box 4.3 Demographic or historical risk factors for suicide
• Male
• Middle or older age
• Living alone
• Previous history of self‐harm
• Previous history of severe mental illness (includes schizophrenia, bipolar disorder and depression)
• History of drug dependence
• History of violent behaviour
• Frequent ED attendances
• Alcohol problems
• Unemployed
• Socially isolated
• Severe or long‐term physical illness
Co‐morbid mental illness

Self‐harm is not a psychiatric diagnosis in itself. It is a behaviour which signals that an individual is not able to cope with a particular
situation or set of circumstances. Self‐harm is often associated with mental illness, as mental illness often impairs an individual’s
ability to cope. Approximately 70% of patients who self‐harm have a co‐morbid mental illness, and mental illness is a strong risk
factor for suicide. Often there is a pattern of symptoms worsening or building, which lead up to the self‐harm episode.
Appropriate treatment of any co‐morbid conditions may reduce the risk of future self‐harm or suicide. Patients with severe
mental illness, either schizophrenia or bipolar affective disorder, who have self‐harmed must have a detailed assessment from
a mental health professional to ensure an appropriate treatment and management plan is put in place.
The most common co‐morbid problems associated with self‐harm are depression or substance misuse. Key symptoms for
depression include persistent low mood for at least 2 weeks or longer, poor sleep, poor appetite, weight loss, poor
concentration, morbid thoughts, inability to enjoy things, low energy and drive, irritability, fatigue, guilt or a feeling that life is
not worth living. Box 4.4 lists all of the most common symptoms of depression. Feelings of hopelessness have been linked to
an increased risk of suicide and should always be enquired about.
Box 4.4 Common symptoms of depression
Mood symptoms
• Persistent low mood
• Diurnal variation in mood (typically worse in the morning)
• Anhedonia – being unable to enjoy things
Physical symptoms
• Poor sleep – early morning wakening or repeated waking throughout the night or difficulty getting off to sleep
• Poor appetite
• Weight loss
• Lack of energy
Cognitive symptoms
• Guilt
• Hopelessness
• Belief that life is not worth living
• Suicidal ideation
• Feeling a burden on others
• Poor concentration
• Forgetfulness
Alcohol and drug problems

Many episodes of self‐harm occur in the context of taking alcohol or drugs. This may indicate an underlying problem with
alcohol or drugs, which will increase the likelihood of further episodes of self‐harm if the problem is not addressed. Try to
ascertain how much alcohol or drugs the patient took prior to the self‐harm and whether this made a significant contribution
to the self‐harm act. Does the patient recognise the contribution that alcohol or drugs made, and want help to cut down or
abstain?
Try to establish how much alcohol the patient consumes on a weekly basis, and the amount of illicit drugs the patient takes.
Screen for any evidence of alcohol dependence, particularly if the patient is likely to be admitted, as they will need to be
started on an appropriate withdrawal and vitamin replacement regime by the admitting team. The management of patients
with alcohol and drug‐related problems are covered in detail in Chapter 6.
Co‐morbid physical health problems

The risk of suicide is significantly elevated in patients with severe physical illness. Screen for any physical health problems,
particularly those associated with excessive alcohol consumption; including a history of fits, liver problems, neurological
problems or gastrointestinal disorders. Have a high index of suspicion for patients who self‐harm in the context of terminal
illness. Although an individual may come to a careful and thoughtful decision to end their life in the context of a terminal
illness, a sudden or impulsive action is unlikely to have been thought through, and often indicates the patient is struggling to
come to terms with the illness, or may have become depressed.
Developing a risk profile

Start with the information from SLIPA and use additional relevant information to build the profile, as in Figure 4.3. This
will include taking account of demographic and historical factors, and the presence or absence of mental illness. The
information from SLIPA should carry the most weight, as it is most directly related to managing current risk, with
‘co‐morbid mental illness’ also important. The demographic and historical factors should be used as adjuncts but not
as stand‐alone measures.
SLIPA
Demographic and Co-morbid

historical factors mental illness
Risk profile
Figure 4.3 Building a risk profile in self‐harm

4.6 Case examples

Case 4.1
A 42‐year‐old Polish man, Aleksander, jumped 40 feet from scaffolding, resulting in
multiple fractures to his back and pelvis. His right lower leg had to be amputated at
the scene as it became trapped in the scaffolding on his way down. Aleksander had
worked as a labourer but had been unable to find work for several months prior to
the episode, and was about to be evicted from his flat. He was estranged from his
wife who was preventing him from having access to his 9‐year‐old daughter, whom
he had been unable to see for several months. He had been low in mood for
several weeks prior to the self‐harm episode. He intended to die.
My risk assessment
Case 1: Developing a risk profile
SLIPA Suicidal thoughts at time of episode: yes

Lethality: very high
Intent now: no current intent when assessed in hospital
Protective factors: none identified
Adverse factors: inability to find work, low income, homelessness, lack of access to
daughter; social isolation; amputation of leg will impair likelihood of being able to work
again as a labourer in the future
Demographic or historical factors Male

Middle aged
Homeless
Social isolation
Unemployed
Co‐morbid mental illness Evidence of a depressive illness developing in the weeks prior to the self‐harm
episode. No alcohol or drug misuse
Overall risk profile The overall risk profile in this case is high as most of the SLIPA items are positive; the
patient also has four demographic/historical risk factors and in addition is suffering
from a depressive illness
The patient requires immediate treatment for his physical injuries and fractures with
admission to an orthopaedic ward. He will require close observation (one‐to‐one) on
the orthopaedic ward by a mental health nurse, and a full mental health assessment,
when he is medically more stable and alert
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Soft music from within stole upon the air, and sweet voices sang:
Warrior! rest; thy toil is o’er,

The trumpet’s sound calls thee no more,
The Eagle Standard floats on high,
But closed is its defender’s eye.
Strewn flowers above the honored dead,

Shed fragrance o’er his hallowed bed;
Let the unfading Amaranth twine
With Cypress and the Eglantine.
Glory to Him, whose home of love

Waits to receive his soul above!
Glory to Him, whose mighty power
Supports the Christian’s dying hour!
Christian! now thy warfare ends;

Thy God his gracious love extends;
Through Him the victory is won;
The triumph gained, the conflict done.
The reign of the depraved and barbarous persecutor of the

Christians had closed with the succession of Servius Galba, a new
era had dawned upon their fortunes; and, although the “blood of the
Martyrs” had proved “as seed to the Church,” yet the season of
peace and quiet, which now ensued served to foster and ripen the
Christian graces, which, in those days of cruelty and inhuman bigotry
acquired a stern and almost gloomy character. The mild and
beautiful religion of our Saviour, when allowed its free course, in the
sweet scenes of domestic life, shone with a more benignant lustre,
and its votaries, no longer shuddering with the terror incident to
human nature, at the consequences of avowing their faith, fearlessly
taught and practised its heaven-born precepts.
The virtues of the noble family whose fortunes we have been
following, were expanded beneath the rays of the sun of prosperity,
and, for ages, some of the most undaunted defenders of the
Christian faith were ranked among its descendants. Connected with
illustrious and powerful houses, they were no longer exposed to
persecution themselves, and, were enabled, by their influence, not
only to promote the rapidly progressing cause of Christianity, but to
save many of its disciples from suffering in the days of trial, which
ensued in some of the subsequent reigns.
We have now closed our tale of the early Christians,” said Herbert,
“and, tho’ it is a simple story, and pretends to no romance or mystery,
yet it is not destitute of a moral.” “Very far from it,” said Mrs. Wilson,
“who can read the short, but well authenticated account of the death
of Nero, and contrast it with that of the aged Christian, or even with
the last moments of the erring but misguided Sybil, without saying,
‘Let my death be that of the righteous.’”
“Well, my little brother,” said Herbert, addressing Charles, “you
have very kindly abstained from criticisms during the course of our
reading. Now tell us if you have discovered any discrepancies,
through the narrative, as you are now, no doubt, by your
acquaintance with Roman history, able to discover.” “You are
laughing at me, Herbert, but I will tell you one error. It was not Nero, I
believe, who compelled the Senate to sanction the election of his
horse to the consulship, but Heliogabas.” “I think you are right,” said
Herbert. “He was, however, a kindred spirit; and now, we will
compare notes upon our improvement this winter; beginning with
you, Charles, of whose progress I can, in some measure report,
being your instructor.” “And, besides my regular lessons,” said
Charles, “I have read more than half through Rollins Ancient History
aloud to Susan.” “And,” said Susan, “besides listening to Charles,
while I sewed, I have reviewed the History of England, and read
Cowper’s Task, not to mention reading the newspaper, etc., etc., and
all this in addition to my Latin lesson with Herbert.” “Please do
explain those et ceteras, my pretty cousin.” “Not I,” she replied, “I
cannot burden my memory with any more of my multifarious
occupations.” “You have forgotten that we have read the Pilgrim’s
Progress again.” “Ah! true,” said Susan, “and the life of the good old
dreamer; now, for as good an account of your winter studies, my
dear sister and cousin; but I am inclined to believe you will be
deficient unless you dignify with the name of study the art of making
bread, puddings, and pies, etc.” “One of the most useful studies,
Susan,” said Herbert, “only not leave the rest undone.” “Do not
imagine we have become mere household automatons,” said
Elizabeth. “In addition to a tolerable stock of the knowledge to which
Susan refers, we have read Gibbon’s Decline and Fall of the Roman
Empire and Hunter’s Sacred Biography, besides reaping some
benefit from Charles’ reading.” “And I have initiated Elizabeth into my
little stock of French,” said Mary, “but, Herbert, we shall not allow you
to be sole catechist; we shall require an account of the manner in
which you have spent your solitary hours, which, I am sure, have not
been few.” “Must I make full confession,” said he. “Full and free,
without prevarication or equivocation.” “Seriously, then, dear Mary, it
requires no little labor to retain my position in my class, the other
members of which are now pacing the halls of old Harvard, in
addition to those pleasant employments enjoyed in common with the
rest of you.” “Setting apart a little time,” said Susan, laughing merrily,
“devoted to the Muses. Ah! Herbert, I have made the discovery,
partly by my own sagacity, and partly by the tell-tale expression of
Aunt Wilson’s countenance, that you are the author of much of the
poetry which has entertained us this winter.” “’Twas but the
amusement of a passing hour, dear Susan, and if it has been a
source of interest to you, an important end is attained.” “And you
must continue that interest, my son,” said Mrs. Wilson, “if it will not
interfere with other duties. I think,” added she, addressing Mary and
Susan, “that your parents will approve your winter employment, and
that in after time you will review them without regret.” “That I am sure
we shall,” said Mary.
Chapter XIII
They had borne all unmoved; disease and death,

The pangs of famine, hard and weary toil;
That, to their sons, they might bequeath a land,
The home of liberty. Shall those sons now
Barter the rich inheritance?
Some days had passed after the conversation which closed the
last chapter. A cold stormy evening found our little family without
visitors and prepared, as they drew around the table, which
displayed a goodly collection of needlework, etc., to listen to Herbert
as he read from a manuscript provided by Mrs. Wilson for the
entertainment of the evening.
Years have passed away and the events of the War of the
American Revolution are mingling with the obscurity of the past, the
glorious achievement of our liberty has opened a new era in our
history, “old things are done away,” but the imagination delights to
linger around the scenes of what seems now “olden times”; scenes
of peril and distress, but, over whose remembrance a deep interest,
a magical charm, is thrown by the knowledge that our kindred and
friends bore important parts in the drama, and that the closing act
was the freedom of our country. Many were the events of deep and
thrilling interest which are now buried in oblivion, or known only to
those immediately concerned. The reminiscences which are the
subject of these remarks may be wanting in that intense interest, but
as being a delineation of the times, of their manners and feelings,
and true, in all their main incidents, they may claim some share of
attention. It was towards the latter part of May, 1775, but a short time
before the memorable battle of Bunker Hill, that a horseman,
wearied and worn with travel, exposed to the rays of the burning sun,
on a day of uncommon heat for the season, and whose horse
seemed sinking with fatigue, turned into a shady lane, leading from
the more public road to a small cluster of buildings, in the
comparatively thinly settled town of Malden, about four miles from
Boston. As he entered the pleasant shade, formed by the apple trees
which skirted the road, he permitted the tired animal to slacken its
pace, first casting an anxious and inquiring glance about him.
Apparently seeing no immediate cause for fear, he continued to ride
slowly; removed his hat, and wiping his warm and dusty brow,
appeared to breathe more freely. His dress was that of a gentleman,
and his countenance, though pale and disturbed, was intelligent and
open. After pursuing this pace for about half a mile, the cool and
pleasant sound of running water directed his attention to a watering
place, at the side of the road, and the renewed spirit of the steed,
and his evident wish to taste the luxury, induced his master to
dismount, and lead him to the fountain. At this moment a small dog
springing up, and barking vehemently, he perceived a woman seated
upon a bank near. He started, for his looks and manner had
indicated that he sought concealment, and, aiming a blow at the
waspish little animal, was preparing to remount his horse. “Come
back, Faith,” said the woman, sharply, then, as the dog slunk back to
her feet, she continued, in an apologetic tone: “He can’t do much
harm, sir; he has seen his best days; only he might frighten the
beast, though, to be sure, he looks too tired to mind a trifle.” “Do you
live in this neighborhood?” said the traveler, permitting his horse to
graze the green herbage around the watering place. “Just over the
edge of yonder hill,” said she, “but it’s something of a walk, and I’ve
nobody now to do my errands since John has gone.” “Do you know
Capt. B.’s family? Is he at home?” “Know the family! That’s what I do;
at home? No; bless your heart, no; at home! indeed, you’ll find no
able-bodied men at home now, more especially the Captain. Where
is he? Did you say? That’s what I don’t know. Sent on some service
or other; left every thing, sir, family, land, cattle, and all at loose
ends, for the sake of his country; for the matter of that, old Sam
Lynde, who has lost one leg, and is nearly seventy, is the only man
left behind; and he would be glad to go; I can tell you. The country is
all in arms, sir, it’s as much as ever the reg’lars over in Boston can
get any food to eat, or wood to burn.” Without waiting to hear more
the questioner turned his horse. “Well,” said she, in a low soliloquy,
as he rode away, “I shouldn’t wonder if he was a Tory, for his face
didn’t brighten a bit when I told him how alive and stirring our people
were; I’ll warrant Faithful mistrusted him, or he wouldn’t have been
so spiteful.” So saying she rose, and passing through a stile, into a
path which led through a meadow, bent her course in the direction
she had indicated as her home.
Meanwhile, the rider had pursued his way; as he passed he
regarded the objects around him with much interest and, when he
arrived at a spring of water at the side of the road, about a mile from
the last stopping place, he rested his horse upon the little stone
bridge which crossed the stream proceeding from the spring. Gazing
earnestly upon the pleasant spot, overshadowed by tall trees, a train
of sad, not unpleasant, reflections passed through his mind. Who,
that after long years of absence, has revisited the spot where his
infancy and childhood had passed in the bosom of affection, but can
sympathize with such reflections? The well remembered perfume of
the mint and sweet herbs which grew around the never-failing spring
in rich profusion revived in his memory the playful hours of youth; he
could, in imagination, see the never-to-be-forgotten form of his
mother, as she came down the avenue which led to the house, to
watch the sports of her children, could retrace the pleasant smile and
beaming glance of her eye as she witnessed their little feats of skill
and strength, and hear her kindly voice warn them of danger; and a
mild but grave face of his father, as he would sometimes join them,
and, leaning over the balustrade of the little bridge, would address to
them some remark of affectionate interest, was present to his mind,
as if but a day had intervened. Where were now those kind
guardians, where the happy group which had then mingled in sweet
communion? The grave had closed over the first, and time, absence
and civil dissension had separated the last. As these thoughts
saddened his heart, tears filled his eyes, but the heavy roll of cannon
from some ship in the harbor aroused him from his reverie and,
turning from the spot which had awakened these memories, he
passed up the avenue we have referred to, to the mansion of his
birth, and now the residence of the family of his brother. All was quiet
around, except, at intervals, the merry laugh or gleeful shout of
childish mirth echoed from the green lawn, where he saw three little
beings pursuing their happy sport. “The children of my brother,” he
thought, but they were too far for him to distinguish them particularly.
Alighting and approaching the door, he saw an elderly female seated
and engaged in knitting. As he drew near she looked up, and, after
scanning his countenance attentively a few moments, she rose
hastily, dropped her work, and ejaculated: “Mercy upon me, Mr.
Nathaniel! Is it you?” “It is indeed myself, Prudy; how has it
happened that, after so many years, you have not forgotten me?”
“There is not one of your family I shall forget while I have reason,”
said she, “but the news reached us that you had sailed for England
and I never thought to see you again.” “I am now on my way to
Boston, to embark in the first vessel that leaves the harbor for the
home of my ancestors, but I am escaping from enemies, my good
Prudy, enemies to me and, as I believe, to their lawful king. Will you
afford refreshment to one whom you no doubt believe to be a traitor
to his country?” “You should not talk so, Mr. Nathaniel; you are in
your brother’s house, though, may be, if he were here, he would look
upon you with a frowning brow; yet his wife will not, I am sure, and I
will but let her know you are here before I take care of you and your
horse.” She then led the way into the house and, showing him into
an apartment, she left him alone. How well remembered was the
prospect from those windows! The pleasant green that sloped from
the house, the old pear trees at the foot of the declivity, while, in the
distance, but directly opposite, lay the town of Boston, with its tall
spires, and the harbor, with its masts. There was the clump of walnut
trees where he had gathered nuts and, near by, the old apple tree
which had obtained the name of “mother’s tree,” because it bore an
apple which was her favorite fruit, and even as he gazed, the old bell
of Brattle Street Church, with its deep tone, struck its well
remembered chime. There is something in the breath of spring that
especially revives the memory of the past and it was with many a
sweet and sad recollection that the wanderer lingered near the
window and turned reluctantly at the opening of the door. The wife of
his brother greeted him with affectionate kindness and her sympathy
and soothing words cheered his heart. In answer to her wish that he
could stay with them, could enter into the feelings of his countrymen
and aid them in their exertions for freedom from unjust exactions, he
said: “It is in vain, dear Hester, to think of it; though I may feel as you
do, that our king has been misled by evil counsellors; that he has
imposed harsh restrictions upon these colonies, and, by these
means, alienated the affections of the people, still, in my opinion, my
allegiance is due to him and to him it must be paid. Other influences
have contributed to strengthen my early attachment to the English
government; since I last saw you I have been betrothed to the
daughter of a British officer, most amiable and beloved, and have
had my hopes and anticipations blasted by her death. Her country
must still be mine; but I have been almost a martyr to my loyalty, for I
have been seized as a Tory, accused, though most unjustly, of
transmitting intelligence to the royal army, immured in close
confinement, and, though not harshly treated, yet debarred from
communication with my friends. The hours spent in such solitude
were dreary enough, uncheered by sympathy or affection, though
not abandoned by hope, for I still trusted in the exertions of those
who, I was confident, would use their utmost endeavors for my
release. I was not mistaken in my expectations, for two days ago, as
I paced my gloomy apartment in solitary musing, the door was
unlocked and a person entered who had a few times officiated as my
jailor. He performed some trifling offices and, as he retired, left the
door ajar, casting, as I thought, a significant glance at me. I followed
at some distance, but, losing sight of him at the foot of the stairs, I
passed out at the door; and, seeing a horse, prepared for a journey,
fastened to the railing, I mounted without any hesitation, concluding,
I have no doubt rightly, that the means of escape were thus provided
by friends. I have scarcely allowed myself rest or refreshment, being
fearful of pursuit, and, by changing horses, I have at last arrived so
near the place of my destination, which is Boston, from whence, as
soon as possible, I shall embark for England; for I can not join
against my countrymen in this contest. You will sympathize with me
in this resolution, my dear sister?” “Yes,” said she, “but you are
exhausted and must stay here until you are refreshed.” “No,” he said,
“if I can elude the Argus vigilance of your excited populace I shall be
in Boston tonight and, besides, I must not subject your good
husband to the mortification of knowing that his Tory brother has
obtained an asylum under his roof. I know too well his
uncompromising zeal in behalf of the colonies and his determined
animosity to those whom he considers their enemies.” Prudy now
entered and placed upon the table the refreshments she had
prepared, with many excuses for what she termed the homely fare;
but the fine fish, the fresh, though coarse, bread, and sweet butter
needed no apology and were duly appreciated by the way-worn
traveler. To renew what she called his exhausted spirits she had
prepared what was, at that time, a luxury, a cup of tea, and, as he
inhaled the perfume so grateful to the wearied frame, he smiled at
the good woman and said: “How is this, Prudy, are you not too much
of a patriot to use this prohibited beverage, and in the house, too, of
one of the most determined rebels against his king?” The color
mounted in the cheeks of the faithful domestic as she prepared to
make an energetic defence, but her mistress replied, with a ready
smile: “Nay, brother, you must not quarrel with your physician, or the
medicine, though it be contraband. Your brother, being far away, is
not responsible for the misdemeanors of the two lonely inhabitants of
his deserted home. And, truly, this cheering herb is now only used as
a medicine. We join heart and hand, however, with our brave
countrymen in deprecating the tyrannical laws which have deprived
us of many comforts, besides, this more especially,” she said, and
the tears glittered in her eyes, “of the society of those nearest and
dearest to our hearts.” “God grant, dear Hester, that this most
unnatural war may soon cease, for, if continued, misery and
extermination will be the fate of these flourishing colonies.” “We hope
for better things, brother, the united exertions of so many true and
noble hearts as are scattered through the country, with the help of
God, in a just cause, will effect miracles.” Three beautiful little girls
now appeared at the door and, being told by their mother to
approach, received the caresses of their uncle. The eldest was a
bright and beautiful child of nine years, full of life and animation; the
second a mild, sedate and quiet little creature of five, and the
youngest a fair, rosy and plump little one of two, whose every step
was a bound and whose joyous laugh exhilarated the listener. “You
are happy, Hester, in this little group; they are very lovely and health
and light-hearted pleasure is expressed in every motion.” The praise
of these objects of her affection brought a bright glow of satisfaction
to her cheeks. “Ah,” said she, “if their father was but with us; while
danger and death surround him we can not be happy.” The tears that
again filled her eyes at this recollection dimmed the flush of affection
and Prudy, who was most devotedly attached to her, said, with some
indignation: “Shame upon the tyrant who has cast such a shadow
over our happy homes! I must say what I think, Mr. Nathaniel, if he is
your king. What business had he to interfere with our rights, and to
impose taxes upon us to support his unjust wars and wicked
extravagance?” “He has had bad advisers, Prudy, and the time will
come when he will be advised of this.” “Too late for his good,” said
she. “Our people would not have known their strength, perhaps, but
when they once find it out they will no longer live subjects to
England.” “Perhaps you are right,” said he, “and when these cruel
difficulties are all settled, my good friend, we will yet hope to meet
and discuss these questions amicably. I must now leave you, my
kind sister, with my prayer that the blessing of Heaven may rest upon
you and your dear family; and you, Prudy, you, who watched over
my youth, and was ever kind and affectionate to the wayward boy”—
his voice faltered—“if I never meet you again on earth, may we meet
in Heaven!” The good woman now sobbed aloud as he shook her
hand, and no less affectionate was the farewell upon the part of the
mother and her little family. “You will let us hear of your safety, dear
brother, before you leave the country?” “If I possibly can; I am not,
however, without serious fears of being apprehended this side of
Boston.” At this moment an energetic but cracked voice was heard,
singing the chorus to one of the patriotic songs of the day:
“So, one and all, my merry boys,

Be up, and bravely doing;
We’ll drive the British o’er the seas,
And fairly prove their ruin.”
“There,” said Prudy, hastily wiping her eyes; “there’s old Sam
Lynde, going with the market cart, over to Charlestown; now, if we
could but make him think you were sent by your brother, he never
would suspect you to be a Tory, and then you might go safely.” She
went out in haste and they soon heard her voice at the door
conferring with the old man: “People are so suspicious now, you
know, Sam,” said she, “that he might be stopped and hindered, when
it is of so much importance that he should be there by sundown.” “I’ll
see to it; I’ll see to it,” said he, as he adjusted his basket, and
mounted the vehicle with difficulty. “Well, wait a minute,” said she,
and, returning, she told them, what they had already gathered, that it
would be expedient for him to proceed immediately under the
auspices of the old gardener. With a most affectionate but sad adieu
they parted, fearing what proved but too true, that they should never
meet again on earth. This was but one of the many parting scenes of
that eventful period; that season of civil war, for it truly deserved that
name, though three thousand miles of wide ocean lay between the
contending nations. Families were divided, father against son and
brother against brother; kindred ties were severed and the heavy
cloud of domestic dissension hung over this once peaceful country.
But, confident in a just cause, a band of noble spirits joined in a holy
league to resist oppression, to rise above the crushing hand of
tyrannical power, and force their way to freedom. It was a glorious
resolution and gloriously did it triumph.
The soft breeze of evening, laden with the sweets of spring, stole
over the fading landscape, the light tinkle of some solitary cow-bell
and the shrill and monotonous notes of the frogs alone breaking the
stillness immediately around the anxious listeners who were awaiting
the return of the old market man, which, they hoped, would relieve
their suspense as to the safety of the fugitive. But, notwithstanding
the calm repose of this scene was undisturbed, the busy sounds of
life were heard in the distance, for, though the road to Boston by the
highway was four miles, yet the distance across the marshes, which
lay opposite the house, was but little over a mile, and the roll of the
drum, with other martial sounds, was distinctly heard. Sad and
depressing the thought that weighed upon the mind of the mistress
of the mansion; her little ones were at rest and all was quiet around,
but how long would it remain so? Her husband was far away, the
time of his return uncertain, if, indeed, he would ever again return.
The enemy were becoming more and more incensed at the insults
and aggressions of the colonists, who, in their turn, were burning
with indignation at the tyranny of the regular troops, as they were
called, and each day produced some new cause of hatred and
defiance on both sides. Scarcely a ray of hope lighted the deep
gloom of the future and, though striving to resign herself and her all
into the hands of Almighty Love, her heart throbbed with anxious
fears. The good Prudy sat near, plying her knitting needles, which, in
those days of simplicity, before the inventions of modern times
rendered their use obsolete, or, at least unfashionable, were
indispensable accompaniments of the female; and, with the earnest
freedom and interest which her long residence in the family
warranted, endeavored to wile away the melancholy which shaded
the brow of her mistress. “It seems but a few days,” said she, “since
they were all children and I, though not quite so young, as blithe and
happy, for never had a poor orphan ever found a happier home than
I had. I was treated as one of the family and as long as I live I shall
cleave to it. The sight of Mr. Nathaniel has brought old times to my
mind and I can not abide the thought that the son of his father is a
Tory, but he never had the firm judgment of his brother. Trust in the
Lord, my mistress, and all will be right, let what may happen. It is a
great lesson to learn but, once learned, it serves us all the rest of our
lives. I much wonder old Sam is so long coming; he is not gone,
usually, more than two hours.” “He is old and infirm, Prudy, and we
need not wonder if we do not see him before morning; but we will
watch some time longer.” And, changing the conversation, they
conferred upon their household affairs and domestic matters in
which the kind handmaid took an affectionate interest. Another hour
passed and, becoming convinced that something had occurred to
prevent the return of the old man, they retired to rest.
“Would it have been better, mother,” said Elizabeth, “if the colonies
had been contented to remain under the English government? When
I hear of these sad times of war, I am almost tempted to wish they
had continued in quiet subjection.” “The exactions and
encroachments of the parent country,” said Mrs. Wilson, “were too
flagrant; the colonists would have dishonored their ancestors had
they borne unmoved the tyranny of the English ministry, but it was
long before they could divest themselves of the feeling of
dependence upon England, the home of their fathers, and break the
tie which had bound them to their laws and institutions. They
submitted to many petty abuses and extortions, they petitioned and
remonstrated for the redress of more palpable ones, and it was not
until a series of gross insults and unpardonable neglect of every
appeal to the justice of the king and his ministers had aroused the
indignation of the people of these States to a pitch that could not be
controlled that they had recourse to arms as a last resort.”
“And the result showed,” said Herbert, “that the God of justice was
upon their side, and fought their battles, for, surely, there was never
a more apparently hopeless cause than that of the united colonies,
against their powerful oppressor.”
“Here is a young hero,” said Susan, turning to Charles, “who would
have joined heart and hand with his countrymen. I wish you had
marked how he winced at your unpatriotic question, Elizabeth.”
“Notwithstanding which question,” said Herbert, “I am very sure if
our gentle sister had lived in those days she would have assisted
energetically in melting the weights of the old clock for bullets, or any
other measure deemed necessary by the fair enthusiasts of those
trying times.”
“I am very sure, dear brother, however much I might deprecate the
war, and its train of evils, the comforts of those dear to me would
have been uppermost in my thoughts.” After cheerful conversation,
they separated for the night.
Chapter XIV
A charm lingers over the tales of the past,

The grey mist of time o’er their beauty is cast;
Its thin texture heightens the power of the spell,
And the mystic enchantment we would not dispel.
A mild and pleasant morning tempted the young party to a walk,

which was rendered more delightful by anecdotes related by Herbert
relative to the first settlement of the place, with which he had
become familiar from his intercourse with some of the aged people
of the town, and which caused many a laugh from their quaint
simplicity. He pointed out to them the site of the first building erected
for public worship, for the earliest object with our pious ancestors
was to provide a suitable place in which to bow together before the
God who had guided them over the wide waters to this pleasant
home; and the bell, which even at this time summoned the
inhabitants to their devotions, was the same which was sent by kind
friends from England for the service and ornament of the original
sanctuary. It was a spot, retired from the village, upon the seashore,
and, though the sacred building had long since been removed, there
was a quiet loneliness about it, which seemed suited to the purpose
to which it had been dedicated. “When we return home,” said
Herbert, “I will read you some lines founded upon an anecdote
connected with the old church which formerly occupied this situation;
the moss-grown tombstone, covered with so many ancient
inscriptions, which you remember, Elizabeth, we have so often
endeavored to decipher, covers the remains of the good minister,
who figures as one of the characters, but I cannot hope to inspire
you with the same interest which I felt, when in my twelfth year, I first
listened to the story from the lips of a good old dame, who is no
longer among the living.” At the appointed time, after their return
home, he read the following lines; which they decided should be
called
A Tradition of the Year 1650
Time was, when tyrant power in Britain’s Isle
Ruled with despotic sway; when pious men
Were hunted like wild beasts if they should dare
To worship God in their own way; the way
Which they believed, in pure simplicity
To be acceptable to Him, whose eye
All seeing and all knowing, looks alone
At the intent and purpose of the heart.
With firm resolve they left their native land,
Their home, their own green fields, and shady lawns,
And o’er the pathless ocean took their course
To the wild shores of a far distant clime;
There, no proud king or haughty priest has power,
To mar their quiet peace and pious prayers.
Now, happy homes and fertile fields arose
On those far shores, and pointing to the heavens
The tall church spire reflected the bright sun;
The sons of God had gathered here, but, as
It was, in ancient time, when Satan came
Amidst their councils, and, with wily art
Laid schemes to tempt the holy man to sin,
So now, among the pious race, crept in
Some bad designing ones, whose cunning aim
Was to seduce the good and pious heart;
Or, failing this, to turn his holy zeal
To ridicule; to watch for some weak spot;
For, who, in this imperfect world of ours
Is free from imperfection; and, when found
With jeering mockery, to cause him shame,
In a small village dwelt a good old man
Beloved and honored for his kindly heart;
Zealous in prayer, in duty prompt and true;
With guileless life, and firm and holy faith,
The peaceful tenour of his life passed on;
The Sexton of the parish, his white hairs
Were reverenced by the simple pious flock,
To whom his services were duly paid,
Save by some graceless ones, who long had made
The kind old man the butt of many a joke;
But, as we often mark, the wicked jest
Would harmlessly rebound from its rude aim
And wound the miscreant who had sped the bolt.
’Twas on a windy, dark and stormy night
That the old sexton rose from his warm hearth
To brave the old and dreary autumn rain;
For, on each night, at nine, the old church bell
Was rung, with the intent that all should then
Go to their quiet rest; that peaceful sleep
Might be the portion of each weary frame
Till morn should rouse them to their daily toil.
Those were the days when superstition’s power
Was felt by all; none from its gloomy chains
Were free; the grave divine and the wise sage
Alike confessed its sway, its potent rule;
And, if dark fears of unknown ill had power
To shake the nerves of learned ministers,
We need not wonder if our worthy friend
Was not exempt from this besetting ill.
It was a night, he thought, when wicked fiends
Would triumph in the mischief they might cause;
And, though his faith in the Almighty power
To guard his steps, was all unshaken still,
Yet dismal fears and dark foreboding thought,
Would rush, unbidden, thro’ his beating heart.
The kind old dame shared in his fears of ill,
And, as with care, she wrapped about his neck
The warm and woolly comforter, with words
Of warning kind, she urged his quick return.
He sallied forth, and onward bent his way
To the lone church, which stood so near the shore
That the rude waves on such a night as this
Would almost dash their spray upon its side;
The wild wind roared amongst the woods, and seemed
Contending with the loud and deafening surge,
While the pale rays, which from his lantern gleamed
But served to show the black and muddy pools
That filled the road. Onward the good man strode,
And the same courage, summoned to his aid
Would have been lauded in the warrior bold.
Slowly the ponderous key turned in the bolt;
Through the broad aisle, he moved, with cautious tread,
Starting at the dull echo of his steps.
But, as he raised the light to seize the rope,
Its beams shone full upon the sacred desk;
What fearful sight appalled his shuddering gaze!
A Gorgon’s head usurped the holy place,
Which, to his terror-stricken mind appeared
The embodied form of Lucifer himself!
He stopped not to encounter the foul fiend,
But, rushing forth, stayed not his course, until
Safe landed at the reverened pastor’s door.
Great was the wonder, strong was the dismay
With which the pious man heard the dark tale;
But, with the conscious rectitude of truth,
He seized the Holy Book, with firm resolve
That the foul spirit should no longer hold
Usurped dominion o’er that hallowed spot.
Torrents of rain descending, seemed to warn
The zealous pair from the encounter rash,
Still, strong in faithful confidence, they gained
The fatal spot, when, with his talisman
Uplifted, uttering words of mighty power,
The pious pastor, with firm step and slow
Approached the dreaded form, though, strange to tell,
The wicked Tempter seemed to stand his ground,
Nearer and nearer they advance, and then
Ascend the stairs, armed for the conflict dire.
But, now, the shameless mockery unveiled
Shows but the head and horns of an old sheep,
A moment’s pause, and, then a pleasant smile
Illum’ed the good man’s face, as he addressed
The indignant sexton in a kindly tone.
“We have been weakly credulous, my friend,
“Our foolish fears have stolen our better sense,
“’Tis the vile trick of some rude infidel;
“But, we will turn his bad intent to good,
“And learn a lesson from this seeming ill.
“Henceforth, we will not suffer coward fear
“To thwart our judgment, or disturb our peace.”
So saying, with strong arm, he drew away
The unseemly object; and, with ready hand
The bell was rung by the old servitor;
And as they parted, each to his own home,
With mild and gentle tone, the pastor said,
“Do not forget, my good old friend, tonight,
“Ere you lie down upon your peaceful bed,
“To offer to our God, the prayer of faith,
“That He would turn the erring mind from sin.”
The morn arose, and the dark clouds dispersed,
Before the fresh and health inspiring gale,
When the malicious jester made his way
Towards the old church, to mark what the effect
Had been, of his vile mockery; whether
His trick had been discovered, or, unseen
By the old man, the foul caricature
Still occupied the holy preacher’s desk.
The beast he rode was vicious as himself,
For, as he turned the angle of the wall
From the highroad, upon the level green,
Scared by some object, which beset his path,
The fiery steed reared high, then plunging down
Threw his unwary master to the ground.
’Twas the grim object, which, with cunning skill,
He had prepared for the good Sexton’s harm,
And, which, on that dark night, the pious pair
Had drawn away, and thrown beside the wall.
With many a deep and heavy groan, he lay,
Till guided by the same wise Providence
The kind old man ’gainst whom the plot was laid,
Came to his rescue, and, with kindly care,
Soothed his distress, and brought him timely aid.
“I hope your memory is stored with many of these ‘legends of the

days of yore,’” said Mary, “and that you will find leisure to arrange
them in the same interesting form.” “It will be a powerful inducement
to attempt it, my dear cousin, if it will interest you.”
Chapter XV
On the succeeding evening Herbert proceeded to read to the

assembled listeners the continuation of the reminiscences of the
times of the American Revolution.
While the heart of many a patriotic American was throbbing with
indignation and anxiety, and the countenances of many a mother,
wife, daughter or sister was pale with watching and tears, the face of
nature was delightful and undisturbed. The soft breezes were rich
with the perfume of flowers and shrubs, the verdant fields glittered
with the dew, the sweet melody of birds and hum of insects
enlivened the scene, while the cattle, with measured steps, were
pacing the accustomed path, toward their green pasture. With the
early dawn the old marketman had returned, and brought stirring
news. The roads, he said, were filled with soldiers, and tents were
pitched in every convenient place; they would permit no provisions to
be carried into Boston, and had even succeeded in carrying off the
cattle which were pastured on the islands in the harbor, so that it was
supposed that the British troops were likely to have much difficulty in
procuring food. “Our troops are ready and brave enough,” said he, “if
they be not trained for service, and, what if their muskets be of all
sizes and shapes, the main thing is to know how to use them, which,
I’ll warrant they do.” They had proceeded without any interruption, he
said, until they had crossed Malden Bridge, when they were stopped
by a small party of soldiers, who, after some questions, permitted
him to go on, but refused to let the gentleman pass until they
received further orders from their commander; that he had waited
until they applied to him, who “luckily,” said the old man, “proved to
be General Knox, and you may be sure that he would see that any
friend of Captain B.’s had his rights, so, after some talk apart, he not
only allowed him to proceed, but sent a man with him, that he might
not be again stopped, and I saw him depart, after he had shaken
hands with me, and left this piece of money with me, like a
gentleman as he is.” He proceeded to say, that as it was late before
he concluded his business, he had stopped at the house of an old

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Acute Psychiatric Emergencies 1st

Edition Advanced Life Support Group

Acute Psychiatric Emergencies 1st Edition Advanced Life

Advanced Paediatric Life Support A Practical Approach

Advanced Paediatric Life Support A Practical Approach

Advanced Life Support European Resuscitation Council

Pediatric Advanced Life Support Provider Handbook 1st

Acute Care Nursing: Recognising and Responding to

The Menopause Support Group 1st Edition Heather Wardell

The Final Girl Support Group Grady Hendrix

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Cover image: © Purestock/Getty Images (Negative Space 2002 Diana Ong)

Set in 10/12pt Myriad Light by SPi Global, Pondicherry, India

1 Structured approach to acute psychiatric emergencies 1

2 Primary unified assessment and immediate psychiatric management 5

3 Secondary physical and psychosocial assessment 13

4 The patient who has harmed themselves 19

5 The apparently drunk patient 37

6 The patient behaving strangely 51

7 The acutely confused patient 63

8 The aggressive patient 75

9 Legal aspects of emergency psychiatry 91

11 The patient experience 107

Sue Wieteska CEO, Advanced Life Support Group

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Structured approach to acute

●● Recognise the importance of good communication

●● Identify a structured approach to managing psychiatric emergencies

This text seeks to provide a safe, practical system for practitioners.

1.3 Close working between emergency and psychiatry staff

1.6 A structured approach

Figure 1.1 shows the structured approach in diagrammatic form.

Prepare to see patient

VERY VERY Rapid

SECONDARY Focused physical history Focused conversational psychosocial

Figure 1.1 The structured approach

Primary unified assessment

Key factors to note are:

2.3 Primary assessment – the unified assessment

Prepare to see patient

P VERY VERY Rapid

Figure 2.1 Structured approach: primary assessment

2.4 Primary physical risk assessment

A Airway – patency and security

Go on to ask the following:

2.5 Primary psychiatric risk assessment

Box 2.1 Level of arousal or agitation

Box 2.2 Standards for place of safety rooms

A Alarm – is there a panic alarm in the room?

Make an assessment of the environmental risk (Box 2.3).

Box 2.3 Environmental risk

Current thoughts of harming self

Current thoughts of harm to others

Make an assessment of intent (Box 2.4).

Box 2.4 Intent assessment

Box 2.5 Risk from objects

LOW – no potentially harmful objects

2.6 Unified assessment and immediate treatment

• Current environment in which they are being contained

1 Structured approach to acute psychiatric emergencies 1

2 Primary unified assessment and immediate psychiatric management 5

3 Secondary physical and psychosocial assessment 13

4 The patient who has harmed themselves 19

5 The apparently drunk patient 37

6 The patient behaving strangely 51

7 The acutely confused patient 63

8 The aggressive patient 75

9 Legal aspects of emergency psychiatry 91

11 The patient experience 107