My program has emergency psychiatry- in fact several months of it.
During the first 2 years of residency, the resident will spend about 4 months doing it and all calls are done on the emergency psyche unit (we call it PIP-Psychiatric Intervention Program).
It has its pros & cons.
-Diagnosis is easier because you often times do not have time to give the most specific dx because you only see the patient for a few hours tops--e.g. depressive do nos, psychosis nos--this could be good or bad depending on how you see it--easier but less satisfying.
-You won't see patients for days, only hours-again can be good or bad depending on how you see it.
-You get a lot of turfing dump jobs from the ER doctor. Of course this in general is bad. About 2-5 times a week we'd get a pt that was medically cleard that clearly should not have been. Some of the ER docs are looking to find any psyche sx and should they find anything, immediate dump to PIP, even if the patient is in the ER for a chief complaint of a medical (not psychiatric) problem.
some brief examples
-pt hung himself, was medically cleared with no x-rays or CT scan of the neck
-pt jumped off the 2nd floor of a building, had 2 broken legs, was medically cleared with no treatment on his legs & the ER doc reported a complely normal physical exam.
-pt with delirium 2ndary to hepatic encephalopathy (clearly--had asterexis, ascities, hx of Hep C), dumped to PIP wth no serum ammonia levels and no previous psyche hx. ER doc when asked denied pt had asterexis & refused to order a serum ammonia. (Turned out it was through the roof--I ordered it and when the ER doc found that out he was very upset with me).
The above are the worst case scenarios I've seen, but they happen, though usually on a more mild level very often. Some of the ER docs, when you bring this to your attention, well some of them are apologetic & work cooperatively, some of them blow up in anger and start screaming. As a resident, that actually made life easy for me because then I'd just tell them to talk to my attending, then the attending had to deal with an irate ER doc, not me. (of course I will be an attending soon...)
-you get a lot of dumping from other branches of services. A lot of cops dump patients onto you that clearly should be in jail, but once you got them, they refuse to pick them up. E.g. a guy who attacked someone (he's a gangbanger and thought it would give him more street-cred) but once in handcuffs he starts claiming he'll kill himself. Then he's brought to PIP and you can clearly tell he's malingering. Then you call the cops and they say he's your problem, not theirs.
If admit the guy to an inpatient unit, you're admiting a guy who clearly has no Axis I, you discharge the guy & he attacks someone, you may be cited for releasing someone not safe.
-Other places do a lot of dumps. Some nursing/group homes will drop off someone because that person did something completely understandable such as ******ed patient screamed because water in the bath was burning hot, but after hours of observation was fine. You write down for the patient to be discharged back to the home and now the home refuses to take them back (which may have been their plan all along). In that situation you can't discharge the person to the street but you got no where to put them and on weekends DDD is closed, social workers aren't available aon weekends and you can only keep them in the psyche ER for 24 hrs tops (per NJ state law)....a very difficult situation to be in.
While this make ER psyche sound unattractive, this type of turfing happens a lot in medicine in general. I'm just pointing out how it works in ER psyche. You're going to get it in inpatient & outpatient psyche quite a bit.
-On the flipside, some inpatient units may refuse to take a patient because they do not feel the pt is medically stable even though the pt clearly is stable. This can be interesting (in the bad sense of the word) especially when you got a 24 time limit and need to admit the patient somewhere and no one will take that patient.
There are days where almost nothing happens. There are days where its all heck (e.g. there's a acid-rock band concert in town, lots of people end up in the ER during those nights)
It can at times require a lot of improvisation. E.g. the ******ed patient I mentioned, you have to start thinking of every solution you can come up with & you got limited time to come up with it. There are often times where every inpatient unit you call up is full, there are times where the inpatient unit will put pressure on you to fill them up because their census is too low and you got no one who wants to be admitted or is commitable at the moment.
You will do a lot of civil commitments...a lot of them. I would do on average 3 a day. When I was applying for a forensic fellow position, some of the fellowships had you work ER psyche for that purpose.
Psychologically, theres more uncertainty in the air with this job because much of what you can do depends on others' (inpatient units, police, ER docs etc) decision. This can cause some anxiety--> frustration--> anger ---> hate (sound like Yoda now). However others tend to thrive under this type of stress.
Our PIP unit has very good relations with the local rescue mission and this adds some appeal to the job. The people running the rescue mission in Atlantic City are some of the most devoted, empathic & caring people I've seen, and they're trying to help people try to help themselves. Occasionally its good to see some success stories happen from our referral from PIP to the mission. When working inpatient you don't hear what goes on at the mission much but in PIP, contact with them is quire often. Best story was a guy who was homeless with OCD, and after we got him started at the mission, he was eventually able to get control of his OCD and get a decent job.
Overall IMHO a good experience in residency. Personally I wouldn't want to do it as an attending but everyone's taste varies.
