Consultations for Etoh Withdrawal

[firedoor]

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I have recently begun work as a hospital consultant. Several physicians are consulting and and expecting me to treat Etoh and benzodiazepine withdrawal.

Though I can handle uncomplicated cases, I don't feel that this is the appropriate domain of psychiatry (nor medico-legally sound).

Any suggestions on how to handle this, both logistically and politically?

 

[strangeglove]

Then whose domain is it? Where I trained, psychiatrists were the experts at this.

 

[firedoor]

Then whose domain is it? Where I trained, psychiatrists were the experts at this.

Medicine wiseass. These are medical emergencies.

 

[atsai3]

I have recently begun work as a hospital consultant. Several physicians are consulting and and expecting me to treat Etoh and benzodiazepine withdrawal.

Though I can handle uncomplicated cases, I don't feel that this is the appropriate domain of psychiatry (nor medico-legally sound).

Any suggestions on how to handle this, both logistically and politically?

In our ED, alcohol/drug intoxication/withdrawal cases are co-managed by the ED and by psych.

On the medicine ward, medicine manages their own unless the patient starts cussing or striking out at nurses; then they call psych consults.

On the psych ward, we manage our own unless the guy is rapidly headed for a medicine transfer; then we call medicine consults. The primary reason for transfers of "complicated" withdrawal cases is if the patient requires a level of care that psych nursing cannot provide.

 

[strangeglove]

Medicine wiseass. These are medical emergencies.

I am not suggesting that these patients be transferred to psych. However, as consultants we should be able to provide recommendations on how to manage alcohol and benzodiazepine withdrawal, even when it is "complicated." It's also worth noting that many detox units are run by psychiatrists.

 

[billypilgrim37]

Not really sure why you're cursing at strangelove. Typically I'd say we're similarly the "experts" at detox, save our toxicology service which basically just keeps adding valium until the patient falls asleep, and then let's them walk out the door the next morning to auto-taper. But they have their own service, they're not really a consult.

Typically medicine manages until it gets hard. We sweep in, clean up their nonsensical random benzo orders, teach the nurses how to use a CIWAS correctly instead of just giving two of ativan every time the guy says he wants some, and voila. We're also the only ones with the sense to say "yeah, last week it was benzo withdrawal, but now it's hepatic encephalopathy, quit giving him so much librium. i know he wants it. But his NH3 is 90 and he won't take his lactulose. Let's start there."

At some of the hospitals we work at we direct even the ICU, at the main university hospital the ICU consults us but have never once in the history of the hospital paid a lick of attention to anything we say. They just give more haldol and ativan drips until they have to intubate and sedate while we shake our heads.

So, yes, you should be the expert at this. But if you're not comfortable with it, don't do it. It's better you know what you're good at and what you don't feel as good about.

 

[whopper]

Several physicians are consulting and and expecting me to treat Etoh and benzodiazepine withdrawal.

Consultants are supposed to be consultants, not the actual treating physician. While in general I don't think consultants should actually be handling this, this is not going to apply to every single hospital in the world. The situation may be different in your hospital.

Just drop them a CIWA scale.

If they are really being a-holes, don't up that ante. Talk about it with their dept. head or your dept. head to sort it out with them. Clarify just what they expect you to do given that you're just a consultant.

I've seen several situations where the expectations of the consultants and the primary doctors differ. Better to clarify it now before it becomes a pissing match.

 

[Doc Samson]

Agree with SG - this is absolutely the bailiwick of psychiatry. Heck, addiction psychiatry is an ABMS subspecialty. At the Academy of Psychosomatic Medicine meetings, a bunch of sessions are usually dedicated to managing various substance withdrawal syndromes.

 

[billypilgrim37]

...bailiwick...

ah, how you expand my vocab... 😀

 

[jdh71]

Seems that this is very institutional and maybe regional in practice. Where I went to medical school, the psychiatrists handled almost all ETOH withdrawal, but they wouldn't touch withdrawal with a 10 foot pole where I did residency. Now in fellowship, I still see medicine doing the withdrawal, and doing it badly (we were much better with it at my old shop).

In my opinion, you can have them. If you guys want it, you should step up and take it.

 

[whopper]

In one of the hospitals I work at, one of my own patients was in ETOH withdrawal, I treated it and the administration flipped out telling me the IM doctors are supposed to handle it.

It certainly does vary per hospital....

 

[sunlioness]

Here it seems to be managed by whoever the admitting service is. If it's us, we do it. If it's medicine, they do it. We don't have a detox unit so anyone admitted to us will also be admitted for another psychiatric reason and not just withdrawal. When someone is admitted with withdrawal only, they go medical. We've been consulted for patients in withdrawal on medical floors when something funky or unexpected happens. Like recently I was consulted on a guy who was having hallucinations and they weren't entirely sure if they were entirely withdrawal related or not, so they asked me to weigh in.

 

[SuperSoccer19]

I have recently begun work as a hospital consultant. Several physicians are consulting and and expecting me to treat Etoh and benzodiazepine withdrawal.

Though I can handle uncomplicated cases, I don't feel that this is the appropriate domain of psychiatry (nor medico-legally sound).

Any suggestions on how to handle this, both logistically and politically?

In the hospitals I have worked at or rotated in, the internal medicine or ICU team always does the actual management of withdrawal if the patient is on their ward, but will often consult psych for consideration of transfer at some point or to assist with recommendations after discharge--going to substance treatment vs psych follow up if comorbidity, etc. Unless the patient is on a psych ward, we do not give recommendations on how to appropriately detox patients, but will medically manage them if they are on our ward (tend to be lower risk).

I agree with you that this should be managed medically and that IM/ICU docs should be the one's making these recommendations, as sometimes they need to be hit with such a high benzo load or are so delerious and hemodynamically unstable that intubation, management of medical conditions, etc. needs to be forefront. Also, sometimes its not as clear cut as to whether there isnt a comorbid medical condition going on that is being blamed on etoh withdrawal. However, I also feel that psych should at least be able to make recommendations in mild/moderate withdrawal.

Edit: of note, patients at my current hospital can get admitted to the psych unit for detox--its the higher risk patients that go to the medicine ward and managed by IM

 

[Sneezing]

Agree with SG - this is absolutely the bailiwick of psychiatry. Heck, addiction psychiatry is an ABMS subspecialty. At the Academy of Psychosomatic Medicine meetings, a bunch of sessions are usually dedicated to managing various substance withdrawal syndromes.

My program has an addiction/chemical dependency unit that will get the majority of admits from outpatient or the ED. Now if some one is discovered to be in withdrawals on the floor the internists will start random doses of benzos and consult psych. Psych will manage the withdrawal as a consultant and more importantly for dispo recommendations of addiction. If a person has true DTs and not just withdrawal with hallucinosis they'll likely find their way to the unit.

 

[masterofmonkeys]

The problem here is that I have never yet met a medicine doc (even some with several decades of practice) who can manage or even always spot severe w/d as well as psych can. A big part of our consult service at the County hospital was determining drip amounts, scheduled doses, etc and putting together the algorithm for txing agitation (benzo first, THEN haldol you spazzes) for the patients whose w/d was so bad they needed the ICU.

 

[BobA]

To the OP:
There are a number of protocols for this - and if your hospital doesn't already have protocols they probably should implement some. Sometimes the protocol needs to be tinkered with (for instance, CIWA alone is usually insufficient for someone with h/o complicated withdrawawl and needs added standing benzo's, etc). See up-to-date for more info.

It's always a good idea to telephone the consulting physician and ask what specifically it is that they want help with - that is, do they really not know how to pick a withdrawal protocol? or do they need help with other issues? If you're not comfortable managing the benzo regimen, you may be able to still be helpful to the medical service by addressing these other issues.

Often times, it seems like the medicine team needs help with these cases because (1) they treat addicts like subhumans and don't take the time to get important history about past complicated withdrawals, etc or (2) they can't deal with the affect that withdrawing people can sometimes stir up. So you may be able to avoid recommending specific benzo protocols and focus more on these issues - helping nurses and physicians deal with difficult patients, assist with dispo, etc.

For what it's worth, Etoh/benzo withdrawal - esp complicated withdrawal - are bread and butter consult psychiatry issues where I'm currently training.

 

[mo1ly]

No offense but who would you expect to deal with eto/benzo cases I'm kinda confused🙄 plus usually physicians in other fields don't take benzo addiction that serious

 

[firedoor]

No offense but who would you expect to deal with eto/benzo cases I'm kinda confused🙄 plus usually physicians in other fields don't take benzo addiction that serious

No offense taken.

I expect medicine to handle alcohol/sedative-hypnotic withdrawal. Just as an overdose is a medical emergency/urgency, so is withdrawal (the exception being treatment in a dedicated inpatient addiction psychiatry unit because that's a whole different ballgame). Whether other physicians fail to take benzodiazepine dependence seriously is beside the point. Psychiatrists should treat the long-term dependence and comorbid psychiatric issues. I'm not saying that psychiatrists should never be involved in the care of withdrawing patients, just not as the primary managers of acute withdrawal.

If psychiatry were consulted for every case of alcohol or benzodiazepine withdrawal in a mid-to-large sized hospital...well let's just say there aren't enough hours in the day.

 

[DrGoHuskies]

At both of the massive teaching hospitals we cover as Psych residents, consults to the C-L service are probably ~40% complicated ETOH/benzo withdrawal and ~40% delirium. Yes, it seems like IM should be able to manage these patients appropriately, given that they are in fact urgent medical issues, and it does astound me at how poorly trained IM residents seem when it comes to managing something potentially life-threatening like ETOH w/d. My experience has been most consistent with billypilgrim's: pop in and streamline the benzo dosing, minimize the damn PRN's, and "encourage" the medical team to continue looking for other causes to explain the delirium if it persists.

Often it seems that Psych is consulted because the medical teams freak if there's even a hint of a psychiatric symptom--agitation, hallucinations, odd affect (or just crying, even), or non-adherence (refusing to allow blood draws at 3AM?! Madness!). It's absurd how many consults we get for "Rule out new onset schizophrenia in a 60 y/o man with alcoholic cirrhosis, severe CHF, and s/p CVA," for instance. It seems strange to me that the internists can't recognize the differences between major mental illness and delirium, given both are so common...but that's the reality, at least 'round these parts.