How do you assess suicidal ideation?

No Blue Zone shift is complete without seeing at least a handful of “Psych Eval” patients in the newly minted Blue Obs.

Until the department of Psychiatry starts up an intake process again at Grady we are left with the burden of screening these patients and making a decision as to whether the patient we are evaluating needs psychiatric evaluation and possibly a 1013 legal hold or if they would be more appropriately seen in an outpatient setting.

While there is no simple formula to apply in these scenarios, Michelle Lin (@M_lin), Associate Professor and Chair of Education at UCSF as well as the founder of the blog entitled Academic Life in Emergency Medicine presents her methodology in this post. ALIEM has a very unique and useful feature called Paucis Verbis which is intended to be digital versions of those index cards some of us used to stuff in our whitecoat pockets.

In her post she goes through Dr Orman’s mnemonics “TRAAPEDSILO” and “SAFE” which help identify risk factors for future suicide attempts. The high points are:

  • Rational thinking loss, specific ideation, and an organized/serious plan are red flags

  • Awareness, support and engagement are signs of decreased risk

  • In the end, physician judgement trumps all and truly we are at a crossroads or determining the patient’s risk as well as our own for “missing something”

These are high risk patients that often blend with the homeless and mentally ill which makes our jobs even more difficult.

Referenced post:

Do you like Rob Orman’s (@emergencypdx) mnemonic?

Will you use this on shift?


Leave comments or questions, we would love to hear from you!


~ Mene Demestihas, MD

@menelaosMD & @EmoryEM



  1. Mene, thank you for this great post. I’ll tell you my psych medical decision making usually ends something like this…”I think Mr. Jones is at low risk of harming himself or anyone else today and I think he is able to take care of himself. He is at low risk because he has insight to his situation, he has a current temporary stressor, his comorbid psych conditions are being treated, he is hopeful, he goes to church, he has family in the area and when I ask him what he would do if he got worse he answered: ‘call a help line or 911′”

    We see this so much we are a little jaded as to how high risk these patients truly are.

    • Tatiana on June 10, 2014 at 12:12 am
    • Reply

    It’s really helpful to read examples of documentation. Thanks!

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