The scenario you are depicting is the one I tried to explain to medicine would need anesthesia to manage the airway. I am not the doc trying to arrange the transfer that doc is senior to me and says they cant find anyone to accept but Im not sure anesthesia has been asked.
So the way it works where I am is that psychiatry is consulted by medicine/neuro/etc., who comes to see the patient and establishes catatonia and works with medicine to make sure a medical caused is ruled out (verrrrrrrry carefully... more often than not, when we were consulted on inpatient medicine patients, it turned out to be a medical cause). The patient is also made sure that they're a decent candidate for ECT outside of the catatonia during the eval by the ECT psychiatrist. Once that is done, you go through the legal process, which will vary a lot by state, county, and facility. Hopefully a lot of the legwork is already done by the medical staff when the patient was unable to consent to medical treatment (e.g.: a power-of-attorney identified, etc.). After the legal stuff is taken care of, the patient is taken to ECT. The team usually consists of a psychiatrist and anesthesiologist/anesthesist. The psychiatrist is responsible for the ECT itself, but the anesthesist manages airway and vitals. After the procedure, the patient is observed in PACU and transferred back to the floor.
That said, my ECT stuff for inpatients is limited to
intra-facility transfers. I have no idea how it works if you are trying to transfer a patient to a different facility that has ECT. If I were in the ECT psychiatrist's shoes, I'd imagine that I would require that the patient be transferred medically from A to B and then work it out internally. I would also imagine that hospital B might smell a dump of a very tough case and instinctually want to refuse accepting transfer without a very compelling reason. It might be smooth sailing, but I could see how it would be tricky as well.
I recommended running ativan as tolerated until tachycardia subsides over the weekend but dont know how high they will push the dose. Hoping it will work first.
A usual ativan challenge in a catatonic patient is usually a gradual build of ativan from 2 mg TID up to 20-30mg/daily. They should have responded by 10 days. My experience with catatonic folks has always started prior to them reaching the intubated stage. Your case sounds interesting.
Bythe problem I mean if you have ECT in house how can you deny as easily as accepting from another facility?
It's not easy. ECT patients are evaluated and deemed appropriate only by psychiatrists on the ECT team. Even if a Hospital A psychiatrist recommends a patient for ECT, it isn't happening until the Hospital A ECT psychiatrist evaluates the patient and makes the determination, at least where I'm at. And in a non-consentable patient, due to the politics associated with ECT, the hurdles can be set higher than would be expected given risks v. benefits.
That said, I have no idea how it works for patients from another facility. The only thing I've seen is inter-facility transfers. When they are inpatient psych, they are transferred to our inpatient psych unit and then the ECT happens. If they are inpatient medicine, I can't see how they'd get to ECT unless they were transferred medically and I could visualize pushback for a lot of reasons unless they've done it a lot before (and if they're the only ECT show in town, they may very well have). Maybe they've got all the kinks worked out though. Let us know how it works.
