ER Psych Fishing

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clement

clement

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Shockingly, I’ve looked high and low and am having a hard time finding ER psych positions. This includes certain less typically appealing inland areas of SoCal. A handful I found most only offer odds and ends type scrap shifts their established psychiatrists don’t want (ie overnights covered by residents and low hourly pay). Some of these typically county hospital or crisis center roles seemed sourced out to third party companies like Vituity or Telecare Corp…Those are unappealing. I tried the American Association for Emergency Psychiatry and no real job leads there either (seems their site exports random jobs from indeed maybe). Does anyone have leads?
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This is because Psych EDs lose money. Hemorrhage money and need to be subsidized some how. Knowing that, you see why there aren't many of them. Secondly, why they then fill evening shifts with residents. In part, because some one like you who wanted to work psych ED were in short supply, so now they can risk losing their steady resident moonlighters for you... or stick with the cheaper and consist labor pool of moonlighters.

You may have more luck looking for, or trying to create a psych C/L position that covers floor / ED.
 
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yeah do you mean psych ED positions or just positions covering consults or doing evals for an ED? I'm also under the impression there are a lot more of the latter than the former. A lot of smaller hospitals make people do both roles as well (inpatient consults and ER evals) because there just isn't enough business to have two separate positions.

Psych is weird anyway in that a separate "ER eval" position even exists, for most other specialities it's someone on the inpatient units/floors or doing consults in the hospital who does the ER consults.
 
I'm not familiar with the psych ED options in SoCal, but assume there are limited full time, day shifts, and you probably just need to put you name in as an option to take the job when something opens up. In the meantime, as suggested above, maybe get a C/L or inpatient job at a hospital with a psych ED so you're already there when an opening comes available.

How many psych EDs even exist? I know there is one in Seattle at Harborview and it's the only psych ED in the whole of Washington state. I'm not sure if Portland, OR has one. Just saying I think they're a rarity.
 
These are not common positions. They indeed are horrific money losers. You're going to need to look at academic or county facilities, specifically facilities that are not private or otherwise trying to make money. They will not pay well. In general, most EDs have a social worker service on call available to involuntarily commit people and expect the ED physicians to be able to manage "psychiatric emergencies" otherwise. You might be able to find some C/L positions that have an ED rounding component, but I know that C/L is very different from emergency psych.
 
Would help to clarify what exactly OP is looking for. A stand-alone psych ER? Psych crisis/emergency services center? Working as the psychiatrist seeing consults in a primary ER or in the psych area of an ER?

Idk any stand-alone psych ERs near me but know of 3 places where I did residency that have walk-in emergency services/crisis intervention (2 are separate areas affiliated with CMHCs, one is separate area affiliated with a private inpatient psych hospital). If wanting to be in a medical ER you can try cold-calling or look at getting signed up through locums or telehealth. The last setting above was my previous positions which I proposed to the department chair of an academic center and was basically asked "when can you start" before I even laid out my proposition.
 
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Celexa said:
Do you care about the geographic area? Are you against academic jobs entirely or just the odds and ends type that you mention?
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I’m not terribly picky about geography. Not against academic either. I truly love ER psych (even more so after dabbling in outpatient work). Just never loved the ER hazing tradition where the newest psychiatrist tends to gets the left over undesirable shifts (i.e, “Dr So-and-So owns Tuesday AM shifts and only covers 1 weekend a year.”) He/She is invariably an 84-year-old sitting in his/her cave every Tuesday AM.
 
calvnandhobbs68 said:
yeah do you mean psych ED positions or just positions covering consults or doing evals for an ED? I'm also under the impression there are a lot more of the latter than the former. A lot of smaller hospitals make people do both roles as well (inpatient consults and ER evals) because there just isn't enough business to have two separate positions.

Psych is weird anyway in that a separate "ER eval" position even exists, for most other specialities it's someone on the inpatient units/floors or doing consults in the hospital who does the ER consults.
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I mean psych ED position, not the CL person or inpatient person covering the ED. I think the issue is I come from a state with state funded CPEPs and CA doesn’t work that way.
Ideally I’d want a stand alone psych ER. Second picks would be crisis center or psychiatrist doing med ER psych consults (but those are rife with CYA dispo calls). I’ve looked at 3 SoCal counties. One was horribly messy and pretended to hire me 2 times. The other two are either sourced out to Vituity (doubt I can get PSLF/student loan credit) or with all shifts being “spoken for” (we’re talking very large county hospitals).
 
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clement said:
I mean psych ED position, not the CL person or inpatient person covering the ED. I think the issue is I come from a state with state funded CPEPs and CA doesn’t work that way.
Ideally I’d want a stand alone psych ER. Second picks would be crisis center or psychiatrist doing med ER psych consults (but those are rife with CYA dispo calls). I’ve looked at 3 SoCal counties. One was horribly messy and pretended to hire me 2 times. The other two are either sourced out to Vituity (doubt I can get PSLF/student loan credit) or with all shifts being “spoken for” (we’re talking very large county hospitals).
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Okay, you can't just say that and not tell us this story.
 
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clement said:
I’m not terribly picky about geography. Not against academic either. I truly love ER psych (even more so after dabbling in outpatient work). Just never loved the ER hazing tradition where the newest psychiatrist tends to gets the left over undesirable shifts (i.e, “Dr So-and-So owns Tuesday AM shifts and only covers 1 weekend a year.”) He/She is invariably an 84-year-old sitting in his/her cave every Tuesday AM.
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If you're that open geographically I'd just cold email academic dept chairs with the type of job you're looking for.

If you're willing to relocate to places with cold and grey winters, DM me and I can give you some thoughts on some of the depts I'm familiar with.
 
You are clearly the right person to be working in a psych ED. They do exist around the country. Some are a semi-seperated area from a regular ED that has different staff/policy but allows ED docs to swing by (I believe Asheville NC has a huge one like this). Freestanding psych EDs are more rare but do exist as above. Best of luck!
 
Celexa said:
If you're that open geographically I'd just cold email academic dept chairs with the type of job you're looking for.

If you're willing to relocate to places with cold and grey winters, DM me and I can give you some thoughts on some of the depts I'm familiar with.
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Thank you. I do have cold, grey backups and will keep your offer in mind…I should have said geographically open within CA for now-which isn’t doing me any favors. The closest hits are corrections areas that act as intermediary stabilizing settings between units. It used to be easier to find locums ER work here… but 98% of it is out and inpatient stuff naturally. Yes those are more plentiful in general but ER work is supposed to more undesirable too.
 
comp1 said:
Gotta appreciate loving ED psych so much you'd leave SoCal...
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See my other reply…But…Honestly at various times it’s afforded me a great lifestyle working 3 days a week, traveling, attending to family, setting my hours, not getting inundated by SW and RN emails from outpatient patient X who is upset after being kicked out of the house by her god cousin, etc.
 
Oh there we go, yes, "open within CA" I think is similar to a lot of people. 🙂 Reach out to the counties. You still might end up in Fresno.
 
clausewitz2 said:
Okay, you can't just say that and not tell us this story.
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Said county told me I was hired, pretending to start the medical staffing process…then called me to say they can’t do 0.75 FTEs and I should apply through their academic affiliate (which had a rigid contract and lower pay but allowed 0.75)….A few months later they pretended to hire me again through their “county route”…then in another twist, said I can only work 12-16 hour shifts (despite discussing with them all along that I’m looking for 8-10 with the occasional longer shifts). I was even willing to cover their weekends without multipliers. Now they’re desperately advertising for locums and formally rescinded their “offer” in a written Email …which I’ve never had happen- but it was for the better!
 
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I think that kind of interaction is going to be very common. These counties are disorganized. They don't bill per patient. They have a pot of money and they are always trying to find ways to maybe reduce the amount of that pot they spend. They're definitely willing to gamble that they might end up having to do locums and yes, asking for 0.75 FTE is going to make things loads harder. Some places would then need to find a provider who wanted 0.25 FTE or just always be short staffed and stress the remaining people out.
 
clement said:
Thank you. I do have cold, grey backups and will keep your offer in mind…I should have said geographically open within CA for now-which isn’t doing me any favors. The closest hits are corrections areas that act as intermediary stabilizing settings between units. It used to be easier to find locums ER work here… but 98% of it is out and inpatient stuff naturally. Yes those are more plentiful in general but ER work is supposed to more undesirable too.
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Haha now it makes sense the struggles you're running into, trying to stick to CA. As I look out my window into the cold and grey I definitely understand that! If you change your mind about geography, the northeast will be waiting for you .
 
Celexa said:
Haha now it makes sense the struggles you're running into, trying to stick to CA. As I look out my window into the cold and grey I definitely understand that! If you change your mind about geography, the northeast will be waiting for you .
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Why, thank you. The northeast is not unfamiliar terrain… And one that comes with a satisfactory ER psych clientele- although methier than it used to be.
 
clement said:
Why, thank you. The northeast is not unfamiliar terrain… And one that comes with a satisfactory ER psych clientele- although methier than it used to be.
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At least in the areas I've traversed, still not super meth-y. Right now of course fentanyl is standard and more and more issues with contaminated cocaine (often contaminated with fentanyl, but also unknown compounds we can't test for but the toxidromes don't look just like cocaine + fentanyl). Lotsa benzos (prescribed and illicit). Can't forget K2 and pcp and ye old standby, alcohol....
 
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I've always thought opiates were East Coast and meth was West Coast. Of course now the meth nearly always has fentanyl in it so it's more confusing. You have to pay attention to what the person thought they were buying, but that was always how I thought things generally worked geographically.
 
comp1 said:
I think that kind of interaction is going to be very common. These counties are disorganized. They don't bill per patient. They have a pot of money and they are always trying to find ways to maybe reduce the amount of that pot they spend. They're definitely willing to gamble that they might end up having to do locums and yes, asking for 0.75 FTE is going to make things loads harder. Some places would then need to find a provider who wanted 0.25 FTE or just always be short staffed and stress the remaining people out.
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Based on my short county career in another setting and various peripheral county interactions, I would agree that it’s sadly par for the course.

What was somewhat more atypical on a professional level was the hiring chief of psychiatry expecting me to sign a contract before being able to visit the ER or meet in person…Then telling me we’re moving forwards and ignoring a follow up voicemail….FWW said person would also manually time stamp text messages.
 
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comp1 said:
I've always thought opiates were East Coast and meth was West Coast. Of course now the meth nearly always has fentanyl in it so it's more confusing. You have to pay attention to what the person thought they were buying, but that was always how I thought things generally worked geographically.
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Back in the day, meth was indeed west and heroin east. Now it’s a mish mash with coke and pcp still veering toward the east. Meth would be too lowbrow for the Wolf of Wall Street… but definitely trickling into upstate NY and western Mass I presume. PCP is very DC.
 
Celexa said:
At least in the areas I've traversed, still not super meth-y. Right now of course fentanyl is standard and more and more issues with contaminated cocaine (often contaminated with fentanyl, but also unknown compounds we can't test for but the toxidromes don't look just like cocaine + fentanyl). Lotsa benzos (prescribed and illicit). Can't forget K2 and pcp and ye old standby, alcohol....
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K2/spice definitely hit the west first and at least my residency class did a fellowship in it at the VA (which back then was one of the fewer places testing). If I had a nickel for every young is this schiz or spice or the latter unmasking the former…
 
Sushirolls said:
This is because Psych EDs lose money. Hemorrhage money and need to be subsidized some how. Knowing that, you see why there aren't many of them. Secondly, why they then fill evening shifts with residents. In part, because some one like you who wanted to work psych ED were in short supply, so now they can risk losing their steady resident moonlighters for you... or stick with the cheaper and consist labor pool of moonlighters.

You may have more luck looking for, or trying to create a psych C/L position that covers floor / ED.
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Yea full-on bleeder… and now with calaims reimbursement billing reform crap on the west coast, I think it’ll just make more of a mess (but who knows if the third party entities like vituity will want these county psych EDs or crisis units?). I imagine east coast states fund and oversee more dedicated psych er’s because it saves money downstream… whereas out west it’s a revolving de institutionalization door both culturally and fiscally.
 
clement said:
Yea full-on bleeder… and now with calaims reimbursement billing reform crap on the west coast, I think it’ll just make more of a mess (but who knows if the third party entities like vituity will want these county psych EDs or crisis units?). I imagine east coast states fund and oversee more dedicated psych er’s because it saves money downstream… whereas out west it’s a revolving de institutionalization door both culturally and fiscally.
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This makes sense and aligns with my experience that blue state academic centers salivate at the prospect of a psychiatrist who actually *wants* all their clinical time there. I don't think anyone who primarily does the ED gets pulled anywhere else, ever. Pretty sure their base salary is higher than the rest of us too although I'm not certain.
 
Celexa said:
This makes sense and aligns with my experience that blue state academic centers salivate at the prospect of a psychiatrist who actually *wants* all their clinical time there. I don't think anyone who primarily does the ED gets pulled anywhere else, ever. Pretty sure their base salary is higher than the rest of us too although I'm not certain.
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Because these academic centers may hurt for CL and/or don’t want to lose inpatient coverage, they definitely work in CL, med er, weekends, overnights. Although much of it is just the cost of doing business in a psych ER unless free standing. Lots now trend w/ NP coverage which I refuse to staff over the phone…one place I don’t want to supervise np’s is in a psych er. The horror stories I could tell…

Free standing er’s without the cl or med ed component have the poor medical clearance and delays to a med er liability.
 
Celexa said:
At least in the areas I've traversed, still not super meth-y. Right now of course fentanyl is standard and more and more issues with contaminated cocaine (often contaminated with fentanyl, but also unknown compounds we can't test for but the toxidromes don't look just like cocaine + fentanyl). Lotsa benzos (prescribed and illicit). Can't forget K2 and pcp and ye old standby, alcohol....
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comp1 said:
I've always thought opiates were East Coast and meth was West Coast. Of course now the meth nearly always has fentanyl in it so it's more confusing. You have to pay attention to what the person thought they were buying, but that was always how I thought things generally worked geographically.
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clement said:
K2/spice definitely hit the west first and at least my residency class did a fellowship in it at the VA (which back then was one of the fewer places testing). If I had a nickel for every young is this schiz or spice or the latter unmasking the former…
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Lol, and here I am in the midwest seeing all of the above on a regular basis for 8+ years. I will say that K2 did seem to hit here a little later, but we also have a ton of PCP/wet here for 20+ years to the extent that med students during residency dinners would get super excited that we saw so much of it. I will say that other than PCP the other hallucinogens probably aren't as common as on the coasts, but we get a lot of weird stuff that doesn't show up on a common UDS too because there's a ton of labs in the states I've been in for the past several years.
 
Rectal ketamine or plugs seemed to favor the west too. MDMA and LSD in my experience were more east veering- but of course college towns toss in a selection wrench. Overall much more variety than meth out east including the ceremonial weekend respite visits from intellectual disability group home regulars and some severe bpd + npd usuals. Another difference I noticed was more er’s on the east where adult psychiatrists oversee children and teens. I do not miss the occasional abused 9-year-old getting IM’s and restraints.
 
Have you looked into Exodus? It’s kind of like what you are looking for and they have several locations in so cal……
 
ucsbgirl said:
Have you looked into Exodus? It’s kind of like what you are looking for and they have several locations in so cal……
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Indeed. Last I heard it involved covering 8 crisis clinics overnight x12 hours on weekends. With an additional perk being 70 check boxes in the EMR template (best guess, likely a lot of redundant cya).
 
Stagg737 said:
Lol, and here I am in the midwest seeing all of the above on a regular basis for 8+ years. I will say that K2 did seem to hit here a little later, but we also have a ton of PCP/wet here for 20+ years to the extent that med students during residency dinners would get super excited that we saw so much of it. I will say that other than PCP the other hallucinogens probably aren't as common as on the coasts, but we get a lot of weird stuff that doesn't show up on a common UDS too because there's a ton of labs in the states I've been in for the past several years.
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Can you tell me more what you mean by this? Labs that are making low quality knock off drugs that aren't showing on UDS?

My practice in adolescent addiction work (in an affluent area) is: high potency THC, high potency THC, high potency THC, a tiny bit of alcohol, tiny bit of shrooms/LSD, and a microscopic amount of cocaine, opioids, DXM, and ketamine.
 
We are getting hit with philly dope aka tranq dope here in the midwest. It's probably across the US already in the fentanyl supply chain. We've started getting it on UDS testing and finding it more than expected.
 
clement said:
NM would be a contender. Thank you.
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I trained at UNM. It's a high volume stand-alone psych ED (main ED elsewhere on the hospital campus). The service relies heavily on resident labor, which might make the job a bit easier (always 1, sometimes 3 residents are present depending on the time of day). Ancillary staff was good during my time, though not enough of them. PM me if you have questions.
 
theduderino said:
I trained at UNM. It's a high volume stand-alone psych ED (main ED elsewhere on the hospital campus). The service relies heavily on resident labor, which might make the job a bit easier (always 1, sometimes 3 residents are present depending on the time of day). Ancillary staff was good during my time, though not enough of them. PM me if you have questions.
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I am intrigued by UNM…I must say.

My view on trainees in the psych er, having simultaneously supervised residents and np’s in an insanely high volume county-type setting, is mixed.

A fair and understandably tired percentage despise psych ER rotations… Go through the motions of showing up and add to the competing fires (oh my, have you ever had to reverse the dispo on a Tolstoy novel write-up?)

Others are stellar and go right up to the flames. Some depends on systems restraints—like in the northeast state regulated cpep’s would not allow trainees to see patients in triage—-but np’s who couldn’t discern delirium from sick sick or manage the most menial degree of agitation could triage patients. I never understood that.
 
Merovinge said:
Can you tell me more what you mean by this? Labs that are making low quality knock off drugs that aren't showing on UDS?

My practice in adolescent addiction work (in an affluent area) is: high potency THC, high potency THC, high potency THC, a tiny bit of alcohol, tiny bit of shrooms/LSD, and a microscopic amount of cocaine, opioids, DXM, and ketamine.
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Labs that are cutting other substances into the drugs or just using household products at some point from production to the buyer. I don't know a lot of what is used, but there will be weeks where we'll get a dozen of our typical frequent flyers with SUDs all come in with similar atypical symptoms ("bad batch"). Here's an article that used GC-MS with samples to identify potential cutting agents. Patients have straight up told me that they spray hexanes or other inhalants on some drugs to alter the effects. I've even had a patient who made and sold Wet tell me they actually used formaldehyde as the dipping liquid. Apparently you can just buy formaldehyde off of Amazon, which shouldn't surprise me as much as it did.


On a more familiar front, Kratom and Delta-9 are also legal in my state, which has been an absolute nightmare as a lot of the people that come in for psychosis from "just marijuana" later tell us they were using Delta-9 waxes or oils and vaping. I've seen people have bizarre amnesia (one kid forgot his whole family other than his mom) or die from these.
 
Stagg737 said:
Labs that are cutting other substances into the drugs or just using household products at some point from production to the buyer. I don't know a lot of what is used, but there will be weeks where we'll get a dozen of our typical frequent flyers with SUDs all come in with similar atypical symptoms ("bad batch"). Here's an article that used GC-MS with samples to identify potential cutting agents. Patients have straight up told me that they spray hexanes or other inhalants on some drugs to alter the effects. I've even had a patient who made and sold Wet tell me they actually used formaldehyde as the dipping liquid. Apparently you can just buy formaldehyde off of Amazon, which shouldn't surprise me as much as it did.


On a more familiar front, Kratom and Delta-9 are also legal in my state, which has been an absolute nightmare as a lot of the people that come in for psychosis from "just marijuana" later tell us they were using Delta-9 waxes or oils and vaping. I've seen people have bizarre amnesia (one kid forgot his whole family other than his mom) or die from these.
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I'm sure you mean delta-8 or delta-10 as delta-9 is the major intoxicant people think of with THC. The problem with the other psychoactive components from my understanding is usually related to a lack of regulation/adulterants like you mentioned above rather than either component causing more psychosis. Are you aware of literature supporting these being more harmful than delta9 already in generating psychosis?
 
Merovinge said:
I'm sure you mean delta-8 or delta-10 as delta-9 is the major intoxicant people think of with THC. The problem with the other psychoactive components from my understanding is usually related to a lack of regulation/adulterants like you mentioned above rather than either component causing more psychosis. Are you aware of literature supporting these being more harmful than delta9 already in generating psychosis?
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Nope, I'm talking about delta-9, I've had several patients/families show me the packages. I get a lot of patients who buy/use delta-9 and end up in our ER because they think they're getting legal Delta-9 (from hemp which is supposed to be <0.3% THC) when they're actually getting stuff with 80%+ THC or synthetics. We recently had a grand rounds presentation from one of our addiction psych docs about cannabis use in our state and cannabis-induced psychosis is getting more common here. I saw at least 2-3 cases a month when I was working only in the ER.
 
Stagg737 said:
Nope, I'm talking about delta-9, I've had several patients/families show me the packages. I get a lot of patients who buy/use delta-9 and end up in our ER because they think they're getting legal Delta-9 (from hemp which is supposed to be <0.3% THC) when they're actually getting stuff with 80%+ THC or synthetics. We recently had a grand rounds presentation from one of our addiction psych docs about cannabis use in our state and cannabis-induced psychosis is getting more common here. I saw at least 2-3 cases a month when I was working only in the ER.
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Oh gotcha, yeah I've dealt with it for so long that it's not novel but I can see how that would be wild for people thinking they are getting hemp. Of course regular ole 90-100% THC will be generating plenty of psychosis going forward. We routinely are seeing adolescents with THC levels >5000 (which is the max Quest will go to on GC-MS) which raises the risks of everything: hyperemesis, psychosis, withdrawal, SI, etc.
 
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