Psych ED work

[erg923]

For a variety of reasons that I wont get into here, I provided psych coverage in the ER of our VAMC yesterday (yes, there was a back-up psychiatry attending on-call, although he was off site). The only thing I couldn't do was medical admission orders, I had to call a 3rd year resident at the med school to put in orders. So, yea. kinda on my own. Obviously, ER attending medically cleared folks.

1. I am wondering how common this is at other facilities?

2. I am wondering if I was bit too accommodating to the ER docs. Its a tough balance of being assertive and firm, but also forming good working relationships. Tough balance.

3. I am also curious how long a person has to not be endorsing SI/HI for a clinician really to "buy it," so to speak. Acute SI/HI with plans and prep that disappears suddenly within 1 hour is suspicious, of course. And alot of the VA guys are frequent flyers and alot of them know what to say and what not to say.

---

Members don't see this ad.

 

[PsyDr]

1) depends on the state. I have done this work in two different states, but do not currently due to state laws.

2) learning how to albe assertive when dealing with physicians is something that I have not found to be typical in training. Psychologists are trained to "back up" their opinions. Physicians are trained to make a diagnosis and treatment plan (and let the labs and H&p speak for themselves). It's a different way of operating, but since 84% of referral sources don't read np reports you may want to "speak their language".

3) I don't play around. You say it, you going in. Apa trust has a ce thing on this. You do not want the legal bs of a false negative. VA likely doesn't have this. That being said, you might want to educate medicine about the association with benzos, opiates, and suicide risk. Ask ed docs to rule out everything under the sun. Ask many many many questions. The people suffering will want to talk. Malingerers will try to be brief and get frustrated by the threats to internal reliability.

Division 12, section like 7 is the emergency psych section with some resources in this.

 

[erg923]

Thanks!

Yes, more questions is probably something I need to do. Obviously, tox, labs, vitals, BAL, history, legal is all stuff I ask on phone before I even go down. But once I am there I think it can be a little intimidating to pepper them with questions when I know damn well all they want me to do is see the person and move them out...somewhere.

 

[erg923]

3) I don't play around. You say it, you going in. Apa trust has a ce thing on this. You do not want the legal bs of a false negative. VA likely doesn't have this.

Regarding this, I get it, and I understand your point. However, what makes ER psych hard is the balance you are suppose to be doing between protecting the person and society and protecting/respecting individual rights and civil liberties. Whats the point of having ER psych evals if we simply admitted all who make ominous statements or threats? ER attending can do that. They wouldn't need us. Good psych ER is knowing how to balance those two...which carries inherent risk.

84%?! Reminds me of why I burnt on npsych in grad school. Ive done some a couple bariatric evals since being at VA, but I am happy that I haven't touched a WAIS since internship.