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Emergency medicine clinical excellence series: PEM #1 – the difficult teenage years


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I was lucky enough to be given study leave to attend the Royal Society of Medicine Paediatric Emergency Medicine study day. I learnt a lot from the day, and wrote some notes as we went along. The speakers were all excellent, and any errors in my note taking will be my errors in interpretation, rather than theirs.

Here is a summary of the first talk:

The difficult teenage years – adolescent mental health in the emergency department

Dr Louise Morgansetein, Child and Adolescent Psychiatrist

This was a really interesting overview of the CAMHS mental health perspective with some useful analogies and statistics:

  • 2/3 self harm presentations are out of hours
  • There is no difference in the severity of the presentation whether it is in or out of hours


On assessment:

  • Take a thorough history covering everything you would normally – including whether they are actively suicidal.
  • Remember to ask where they got the idea from – lots of copy cat attempts. Some schools have a “scoring system” for what happens when you get to A&E.



If you need to sedate a child, try and start with oral sedatives first as per your departmental policy.

Don’t bargain with them e.g. “take this pill or I’ll have to give you an injection”.

Once children have been successfully sedated try and keep the balance between keeping them calm, and taking observations – observations every 15 minutes was recommended.

As much as we don’t like it because of bed problems, the NICE guidelines for self harm do say people need to stay in hospital over night to be assessed by CAMHS in the morning. Before patients go to the ward, remember to check they have no more paracetamol/implements with them to self – harm again. If you haven’t been able to check this, make sure it is handed over to the ward staff that they will need to.



Two effective analogies were used to try and help us to understand why people self harm.

The first is that people are either dandelions or orchids. The dandelions will grow and flourish what ever you do to them, in what ever conditions, what ever you throw at. They take a lot to be damaged. The orchids need a lot of TLC, and even a small insult will damage them. A young person presenting with self harm is most likely to be an orchid (but not exclusively – everyone has their breaking point, even dandelions). Having survived medical school, most of us are dandelions, and struggle to see why the orchids can’t cope with insults that seem trivial or even every day occurrences to us. In the ED we can give the orchids some TLC, and then they might be able to grow properly again.

The next analogy was used to explain why some people find self- harming pleasurable. Think of a stiletto. Some people (like me, and the presenter!) think they’re horrible – uncomfortable. To them, a stiletto represents agony and discomfort. There’s nothing good about them. On the other hand, some people love them, save all their extra pennies to buy them and for them they are pure delight – even if they hurt a bit to wear. It’s the same with self harm – pain may be pleasure.



Technical report—pediatric and adolescent mental health emergencies in the emergency medical services system, 2011, Pediatrics, 127(5) e1356 -e1366.

NICE guidelines on self-harm.

Kaplan, T.  Emergency Department Handbook.

About the authors

  • Charlotte Davies is an Emergency Medicine trainee in South East London She is very interested in education, and #FOAMEd. She also writes for


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