Psych or Criminal?

[docB]

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I had a guy that the police put on a psych hold and sent to the ER for threatening to kill his neighbor. The guy is not mentally ill in the usual sense. He's A&Ox4, no hallucinations, no delusions, not intoxicated, no psych history. He just had it with his neighbor over some long standing fued, told someone else that he was going to kill this guy and headed for the intended victim's haouse with a big chain. So my qusetion is why is this guy in my ER and not in jail? Does homicidal ideation necessarily mean you're mentally ill and not just a criminal? If this guy had actually killed the neighbor I'll gaurentee the cops wouldn't have dumped him on me. They would have arrested him. Why is it that someone who threatens to kill is insane and someone who actually kills is not? The basic answer is lazy cops. And people want to know why the ERs are overcrowded.

 

[mikecwru]

I had a guy that the police put on a psych hold and sent to the ER for threatening to kill his neighbor. The guy is not mentally ill in the usual sense. He's A&Ox4, no hallucinations, no delusions, not intoxicated, no psych history. He just had it with his neighbor over some long standing fued, told someone else that he was going to kill this guy and headed for the intended victim's haouse with a big chain. So my qusetion is why is this guy in my ER and not in jail? Does homicidal ideation necessarily mean you're mentally ill and not just a criminal? If this guy had actually killed the neighbor I'll gaurentee the cops wouldn't have dumped him on me. They would have arrested him. Why is it that someone who threatens to kill is insane and someone who actually kills is not? The basic answer is lazy cops. And people want to know why the ERs are overcrowded.

And the sad thing is, this guy may get a 72 hr hold on him, and because the cops don't want to foot the bill out of their funding, they'll release him from custody, it's a HIPAA violation to call them back when he's discharged, so these people are usually off scott free after 24hrs. (If you've found an accepting psych bed within 24 hrs.)

You're right... "dingus" is not directly in the DSM. Same thing goes for people committing an offense, then threatening to "kill themselves" to get out of jail. Well, the jails have suicide watch, don't they? Do what you want with the guy/girl, and if they're still "suicidal" on release, then bring them here.

mike

 

[doc05]

sounds like this guy has antisocial personality disorder. as it happens, this is one diagnosis that doesn't qualify for an insanity defense. just call your psych consult and don't worry about it too much.

 

[docB]

sounds like this guy has antisocial personality disorder. as it happens, this is one diagnosis that doesn't qualify for an insanity defense. just call your psych consult and don't worry about it too much.

Yeah... about that psych consult. In Vegas we don't have psych consult. We also have about a quarter the inpt psych beds a city our size needs. Many of you may not believe it but the "system" here in Vegas is that any nut that gets picked and even the ones who show up at the mental health office get sent to the ER for "medical clearance." Even if they have no medical complaint. Then, since we're stuck with them, we have to hold them here in the ER until a bed open up for them WHICH ROUTINELY TAKES 1-2 WEEKS. That's right, I have to hold psych pts in my ER for weeks on end. That's why I really don't need the cops dumping criminals on me in the guise of being mentally ill.

 

[FoughtFyr]

It's a HIPAA violation to call them back when he's discharged,

mike

Not if they brought him to you. You can call them back to state that Mr. Smith requires transportation from the ED. They brought him, so they already know he is there. If you do not tell tham anything except he requires a ride back to from whence he came, you are not providing them with additional information in violation of the HIPAA. The other way around the HIPAA is if your Police Officers are EMS trained at all. You can then call them to discuss their care of the patient legally. That discussion can include follow-up pertainent to EMS, things such as "this patient on medical exam did not require a medical hold". The trick is not to provide them with medical information that they did not already know or that is not pertainent to EMS QI/QA.

- H

 

[Sessamoid]

Then, since we're stuck with them, we have to hold them here in the ER until a bed open up for them WHICH ROUTINELY TAKES 1-2 WEEKS. That's right, I have to hold psych pts in my ER for weeks on end. That's why I really don't need the cops dumping criminals on me in the guise of being mentally ill.

Holy crap, and I thought it was bad in LA. We only get stuck with them for a day or two, usually. American health care at it's best!

 

[doc05]

Yeah... about that psych consult. In Vegas we don't have psych consult. We also have about a quarter the inpt psych beds a city our size needs. Many of you may not believe it but the "system" here in Vegas is that any nut that gets picked and even the ones who show up at the mental health office get sent to the ER for "medical clearance." Even if they have no medical complaint. Then, since we're stuck with them, we have to hold them here in the ER until a bed open up for them WHICH ROUTINELY TAKES 1-2 WEEKS. That's right, I have to hold psych pts in my ER for weeks on end. That's why I really don't need the cops dumping criminals on me in the guise of being mentally ill.

that is total b.s. that needs to be taken up with your ED and hospital administrators.

 

[Sessamoid]

that is total b.s. that needs to be taken up with your ED and hospital administrators.

This is not a problem that can be solved at the hospital or ED level. This is a system/public policy problem. Ever since the Reagan administration, we've put the mentally ill on the streets with little assistance and support. The common Joe likes to just put them out of his mind. This situation is just an extension of this problem. Nobody's going to admit the mental patients to the hospital, because if you have no psychiatrists in the hospital you don't have anybody to turn to. If there aren't enough psych beds in the city/county/state, there aren't enough beds. Harrassing the hospital administrator-of-the-day isn't going to change that simple fact.

 

[mikecwru]

Not if they brought him to you. You can call them back to state that Mr. Smith requires transportation from the ED. They brought him, so they already know he is there. If you do not tell tham anything except he requires a ride back to from whence he came, you are not providing them with additional information in violation of the HIPAA. The other way around the HIPAA is if your Police Officers are EMS trained at all. You can then call them to discuss their care of the patient legally. That discussion can include follow-up pertainent to EMS, things such as "this patient on medical exam did not require a medical hold". The trick is not to provide them with medical information that they did not already know or that is not pertainent to EMS QI/QA.

- H

Our legal dept regards this as a HIPAA violation and a violation of privacy in general once the person has been released from custody. There have been some public legal battles about this, including one where a guy was in the SICU for about a month and also had an attempted murder charge. The police would not charge the guy because they would have to foot his bill, so the police were thrown out of the SICU and not called when he was discharged.

Normal discharged prisoners in the ED have their medical information sealed in and envelope and addressed to the receiving nurse at the prison.

mike

 

[FoughtFyr]

Our legal dept regards this as a HIPAA violation and a violation of privacy in general once the person has been released from custody. There have been some public legal battles about this, including one where a guy was in the SICU for about a month and also had an attempted murder charge. The police would not charge the guy because they would have to foot his bill, so the police were thrown out of the SICU and not called when he was discharged.

Normal discharged prisoners in the ED have their medical information sealed in and envelope and addressed to the receiving nurse at the prison.

mike

Where I am at, the difference is in the content of the message. I can not say "Mr. Smith is being released with a discharge diagnosis of malingering". That is a HIPAA violation. Stating that Mr. Smith is being discharged is considered "public" information as anyone in the waiting room would know that. So I can say he is going, I can't say why.

- H

 

[mikecwru]

Where I am at, the difference is in the content of the message. I can not say "Mr. Smith is being released with a discharge diagnosis of malingering". That is a HIPAA violation. Stating that Mr. Smith is being discharged is considered "public" information as anyone in the waiting room would know that. So I can say he is going, I can't say why.

- H

I understood what you are saying. I'm saying that our legal department considers calling an unrelated party to let them know he's being discharge in an apparent effort to get him re-arrested.. is a violation of their privacy. We can't do it. Multiple lawyers have been arguing about this.

I tell people when they bring them to the ED, either put them under arrest or you're going to have to leave.

mike

 

[wook]

I had a guy that the police put on a psych hold and sent to the ER for threatening to kill his neighbor. The guy is not mentally ill in the usual sense. He's A&Ox4, no hallucinations, no delusions, not intoxicated, no psych history. He just had it with his neighbor over some long standing fued, told someone else that he was going to kill this guy and headed for the intended victim's haouse with a big chain. So my qusetion is why is this guy in my ER and not in jail? Does homicidal ideation necessarily mean you're mentally ill and not just a criminal? If this guy had actually killed the neighbor I'll gaurentee the cops wouldn't have dumped him on me. They would have arrested him. Why is it that someone who threatens to kill is insane and someone who actually kills is not? The basic answer is lazy cops. And people want to know why the ERs are overcrowded.

Depending on the state, the police may not have enough probable cause to place the person in custody. If they did not witness his threatening behavior and a breach of the peace, they may not have been able to lock him up. They may be able to summons him to court for threatening to commit a crime (depending on the state), but not take him into custody. The officers involved MAY have been lazy, but also may have been hindered by what they observed directly (to fulfill the element for an arrest where they observed a breach of peace in progress) and the statutes laws for the specific state.

Wook

 

[docB]

Depending on the state, the police may not have enough probable cause to place the person in custody. If they did not witness his threatening behavior and a breach of the peace, they may not have been able to lock him up. They may be able to summons him to court for threatening to commit a crime (depending on the state), but not take him into custody. The officers involved MAY have been lazy, but also may have been hindered by what they observed directly (to fulfill the element for an arrest where they observed a breach of peace in progress) and the statutes laws for the specific state.

Wook

OK, fine. But if the police can't do anything should the guy be dumped on the ER? We're approaching the point where we are inappropriately forced to try to be all things to all people. I'm already PMD, EP, social worker, drug dealer, hotel manager, bus token vendor and many other things. Now I have to be cop and corrections officer too?

 

[ERMudPhud]

that is total b.s. that needs to be taken up with your ED and hospital administrators.

Ah the luxury of being a student in an academic medical center....

What doc05 doesn't realize is that most hospitals don't have a psychiatry department, they don't have inpatient psychiatrists, there is no psych consult. We are it.

I have the luxury of working next door to a big psych hospital so I can usually transfer people there and there is a public detox facillity down the street so I rarely have to keep the drunk or crazy around for very long.

One possible solution for docB: It varies from state to state but where I work the police can put you on a mental health hold but any physician(not just a psychiatrist) can drop one. So when the police show up with someone like that I will sometime quickly see them and examine them and drop the hold before the police leave. At that point I explain to the police that he might be homicidal but he is medically and psychiatrically clear. Of course the police can always just dump him and run or even have EMS bring him in. My attitude is if he is still expressing the urge to kill his neighbor I will call the police and say Mr. so-and-so is hanging out in our hospital lobby saying he is going to kill his neighbor and he is about to leave to go do just that. I think my civic duty to protect the community outweighs my HIPAA duty to protect the patients privacy and I'd take my chances on that one in court.

 

[docB]

One possible solution for docB: It varies from state to state but where I work the police can put you on a mental health hold but any physician(not just a psychiatrist) can drop one. So when the police show up with someone like that I will sometime quickly see them and examine them and drop the hold before the police leave. At that point I explain to the police that he might be homicidal but he is medically and psychiatrically clear. Of course the police can always just dump him and run or even have EMS bring him in. My attitude is if he is still expressing the urge to kill his neighbor I will call the police and say Mr. so-and-so is hanging out in our hospital lobby saying he is going to kill his neighbor and he is about to leave to go do just that. I think my civic duty to protect the community outweighs my HIPAA duty to protect the patients privacy and I'd take my chances on that one in court.

That's a pretty good idea. It addresses the Tarasoff issue and the mental illness issue and dumps the problem back on the cops where it belongs. And I agree, I'll take my chances in HIPPA court on that one. Thanks.