Psychosis in the Emergency room?

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Healthinfo104

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If a patient presents to the emergency room and is acutely psychotic and aggitated, do you have to just leave them and wait until a psychiatrist comes and evaluates them? Or can you go ahead and give IM's or medications to sedate them?
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Healthinfo104 said:
If a patient presents to the emergency room and is acutely psychotic and aggitated, do you have to just leave them and wait until a psychiatrist comes and evaluates them? Or can you go ahead and give IM's or medications to sedate them?
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Acutely psychotic patients who are a danger to themselves or others get a shot of haldol/ativan or a shot of ketamine until they are calm/unconscious. They can be evaluated by psych once they start to wake up. Every patient that enters the ED is your patient. While it is impossible to overstate the benefit that your consultants provide to you as an ED doc, they are consultants. It's still your patient. The idea of letting your patient potentially harm him/herself or others while waiting for another doc to weigh in isn't an acceptable practice anywhere.
 
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Healthinfo104 said:
If a patient presents to the emergency room and is acutely psychotic and aggitated, do you have to just leave them and wait until a psychiatrist comes and evaluates them? Or can you go ahead and give IM's or medications to sedate them?
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psychotic w/ a psych history gets B52'd (haldol/ativan/benadryl). Intox being an a-hole gets versed +/- ativan (quick take down + longer sedation) titrated to not being able to be an a-hole. Both get 4 pointed until they chill out. If they are totally out of control and i'm worried about them aspirating the booze and pills they get IM ketamine, rocuronium and a tube. An acutely psychotic/agitated pt is a danger to themselves and the staff, they are also a resource drain, you don't want 3/4 of the staff working on keeping one patient in line when you have a room full of other patients to care for and a door that could swing open with a code or trauma at any second.
 
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I'm trying to wrap my mind around this question. Where is it coming from?
 
deuist said:
A psychiatrist come to the ED?!?! Bwahahaha! That's funny
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Well don't most ER's have a psychiatrist within them to evalate psyvhiatric patients?
 
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Healthinfo104 said:
Well don't most ER's have a psychiatrist within them to evalate psyvhiatric patients?
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No.
We also don't have surgeons, neurosurgeons, GI, peds, ICU, Ortho, or pretty much anyone. Sometimes there's an IM or FM doc admitting patients. And every now and then a radiologist.
 
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Healthinfo104 said:
If a patient presents to the emergency room and is acutely psychotic and aggitated, do you have to just leave them and wait until a psychiatrist comes and evaluates them? Or can you go ahead and give IM's or medications to sedate them?
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We use a tranquilizer gun to sedate them.
 
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Even at my academic mothership with a psych residency... you never saw a psychiatrist in the ER. Buggered if we *ever* even saw a psychiatrist or a psych resident in the hospital.
 
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Oh man. I nearly aspirated I choked/laughed so hard when I read this.


Psychiatrist in the ED.



:rofl:
 
RustedFox said:
Even at my academic mothership with a psych residency... you never saw a psychiatrist in the ER. Buggered if we *ever* even saw a psychiatrist or a psych resident in the hospital.
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I've been to 3 shops with a "psych ED" "psych eval services" or whatever you want to call it. I've only seen a psychiatrist in one of them, and I'm pretty sure they were only there because they printed something off to the wrong printer.
 
GeneralVeers said:
We pump anesthazine gas through the life support systems.
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Have you already been given a hypo to prevent the gas from affecting you? Or do you just bring up a level 1 containment field around your doc box?

TNG was on back to back from 6p - 8p every weeknight for about 5 years of my childhood. Not so great for my popularity at the time. I have no regrets.
 
Dr.McNinja said:
I've been to 3 shops with a "psych ED" "psych eval services" or whatever you want to call it. I've only seen a psychiatrist in one of them, and I'm pretty sure they were only there because they printed something off to the wrong printer.
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We have a secure psych ED in our department with 24/7 in-house psychiatric coverage. God bless the ivory tower of academics....
 
Actually, now that I think about it, my residency did have psychiatrists who came to the ED. It didn't really change our practice significantly. Really, I only want to know one answer from them: "admit/transfer to psych unit" or "safe for discharge." If they (or a suitable surrogate) is not available, then I make that decision quite easily.

Theoretically, an in-house psychiatrist might reduce the rate of holds, but I didn't necessarily see that.

On an another but related note: I wish I could just say to most "suicidal" patients: "You're not really going to kill yourself, so I'll get your discharge paperwork and please follow up with a psychiatrist." I'd reserve holds just for the people I really think are gonna pull the trigger or at high risk for that.

Right now, I have to place a hold on anyone who says the magic words, even if they just want a sandwich.
 
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Angry Birds said:
Actually, now that I think about it, my residency did have psychiatrists who came to the ED. It didn't really change our practice significantly. Really, I only want to know one answer from them: "admit/transfer to psych unit" or "safe for discharge." If they (or a suitable surrogate) is not available, then I make that decision quite easily.

Theoretically, an in-house psychiatrist might reduce the rate of holds, but I didn't necessarily see that.

On an another but related note: I wish I could just say to most "suicidal" patients: "You're not really going to kill yourself, so I'll get your discharge paperwork and please follow up with a psychiatrist." I'd reserve holds just for the people I really think are gonna pull the trigger or at high risk for that.

Right now, I have to place a hold on anyone who says the magic words, even if they just want a sandwich.
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Lol funny... aside from the obvious med seeking or shelter seeking patients using suicide as means of getting what they want, how can you always tell who's serious or who is not?
 
Angry Birds said:
Right now, I have to place a hold on anyone who says the magic words, even if they just want a sandwich.
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"If you say you want to kill yourself, we aren't allowed to feed you because you might poison yourself. So, do you want to kill yourself?"
 
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I frequently discharge the meth-heads who claim suicidality in order for to gain a sandwich or a warm place to sleep. I document "Pt seen by psych services last week, cleared for discharge home" and then I discharge them.
 
Healthinfo104 said:
Lol funny... aside from the obvious med seeking or shelter seeking patients using suicide as means of getting what they want, how can you always tell who's serious or who is not?
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There are screening tools/decision rules to help. Just like chest pain. Now from everything I gather the data is not as solid for psych than say chest pain. So if your suicidal and intoxicated you get to sober then reeval. The drunks know this and abuse this. If someone tells me they are suicidal and not under the influence they get admitted I don't care if they just got out of the hospital. If psych balks I need a note and eval from them which means they need to come to the ED which means they then agree to admission. Just indefensible to send a suicidal patient home and then have them kill themselves.
 
EMDOC17 said:
If someone tells me they are suicidal and not under the influence they get admitted I don't care if they just got out of the hospital. If psych balks I need a note and eval from them which means they need to come to the ED which means they then agree to admission. Just indefensible to send a suicidal patient home and then have them kill themselves.
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What's everyone's experience with your psych service responding to ED requests to see a patient and leave a note? (for those patients claiming suicidality but probably malingering/attention-seeking or refuses to leave the ED without seeing a psychiatrist)

My last shift I had 3 psych sign outs all "pending psych eval" and psych never actually came to see the patients. I ended up discharging 2 and taking the hit/liability, and admitting 1 to psych after arguing with the psych attending over the phone for not seeing any patients and not returning my pages for 4+ hours.
 
plick said:
My last shift I had 3 psych sign outs all "pending psych eval" and psych never actually came to see the patients. I ended up discharging 2 and taking the hit/liability, and admitting 1 to psych after arguing with the psych attending over the phone for not seeing any patients and not returning my pages for 4+ hours.
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That sounds like a less than ideal situation. Do most places contract with a psychiatric group that provides evaluations for patients on holds? In California, there's county-by-county variation in who can place/release 5150 holds (any physician, psychiatrists only, etc.) and it was interesting to see the debate that came up at the California ACEP meeting regarding lobbying to change this. In my mind, I feel like I would like the "power" to place/lift 5150s (expediting discharge of malingering patients, placing holds when I thought it appropriate, etc) but most of the voices regarding that legislation opposed it -- e.g. they don't want the ability to place/remove 5150s because they feel like it comes with liability and PITA.

Any thoughts from people who have been in both situations? It seems like an important thing to figure out when looking at jobs.
 
plick said:
What's everyone's experience with your psych service responding to ED requests to see a patient and leave a note? (for those patients claiming suicidality but probably malingering/attention-seeking or refuses to leave the ED without seeing a psychiatrist)

My last shift I had 3 psych sign outs all "pending psych eval" and psych never actually came to see the patients. I ended up discharging 2 and taking the hit/liability, and admitting 1 to psych after arguing with the psych attending over the phone for not seeing any patients and not returning my pages for 4+ hours.
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That sounds terrible. I don't usually have an issue with psych. At most it is them telling me they just discharged the patient and they are using the system. I agree with them but tell them the patient is stating x. Most of the time they agree. Sometimes they don't and I request a note stating that they as the paychiatrist feels they are safe to D/C home. I have never had anyone refuse admission after that. I just don't feel you can send someone home that is telling you they are suicidal. I do send people home that feel suicidal but usually they have the insight of why they would not do it.
 
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