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Research Questions

Discussion in 'Psychiatry' started by rgb, Dec 8, 2005.

  1. rgb

    rgb New Member

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    I'm a writer currently writing a novel that partly centers around the Crisis Triage Unit of a psychiatric hospital. While artistic license is a given, I would also like to be as accurate as possible.

    I'm interested to know:

    1. When and how a PET responds to a psychiatric emergency.

    2. The basic procedures for involuntary admittance to a crisis unit.

    3. The steps a doctor goes through when first examining a potentially dangerous and/or hostile patient.

    4. The role of a psychiatric nurse, including limitations of that role.

    I'd also like to know if there's a specific drug that can imediately cause someone to act irrationally and possibly violent.

    If there is anyone here who can give me some insight into these questions I would greatly appreciate your input here or, if you prefer, via private post.

    Thank you.

    rgb
     
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  3. Poety

    5+ Year Member

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    I've got some experience here but I'm sure others can add a bunch more since you've asked a lot of questions!

    Someone usually presents to the ER in a psych emergency because they have suicidal thoughts, or homicidal thoughts, or have been brought in by the police - now in my limited experience, you see a lot of these suicidal thoughts as malingerers looking for a place to stay and a meal when its cold outside, or when they are having major regrets over the coke binge they were on and now they're crashing. (I worked in an urban setting if you can't tell!)

    So you are consulted to see the patient that is c/o SI or HI - often times they are admitted for observation (usually voluntarily if they're looking for a place to stay) other times, its involuntary if they are a clear threat to themselves or anyone else - this is done by a 302 in Philly or whatever else which is a court ordered hold for observation up to 72 hours - at which point the patient will go before a judge, plead their case to stay or get out - and be switched to a 202 if voluntary or get their 302 status approved again. This goes on and on - during that time thye are admitted to an interdisciplinary team consisting of a social worker, nurse case manager, psychiatrist, and sometimes additional other people, I can't remmber them now - but each week the team will meet and discuss the patients progress, what the plan for discharge will be, and what social supports need to be in place before they are released.

    Meds are tweaked to keep the patient improving, they participate in group sessioins with other patients, and are assessed daily for mental status.

    Now, with a psychotic patient - they are often admitted for threatening harm to others or themselves by way of acting out in some extreme manner - often times they are UDS + for something, at which point they are admitted, cleaned up, possibly detoxed, with the same stuff going on as was said above.

    Thats all I can add for right now - I'm sure Sazi or OPD can add a lot more - or many of the other residents/attendings/students that frequent this forum - hope it helps a bit!
     
  4. Anasazi23

    Anasazi23 Your Digital Ruler
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    A pet...as in a cat or bird? You capitalized PET, which makes me think of Positron Emission Tomography (PET), which is a type of brain scan. Is that what you meant?
    I've seen on television how pets sometimes take the moods of their owners, becoming dysphoric or less active when the owner is depressed, for example. Some patients of mine have said how their dog or cat has seemed to give them more love when they're crying or seemingly upset.

    PETs, however, respond in a completely different manner. In one study, 5-HT1A receptors were decreased by about a third in panic disordered patients, some of whom were depressed. Most of the receptors were decreased in the anterior and posterior cingulate, and raphe nucleus.

    I have a feeling you were talking about birds, cats, and dogs, though.


    In NY:
    1. Interview the patient. Find that patient to be a danger to self, danger to others, or gravely disabled (unable to care for self).
    Assuming the patient doesn't sign in voluntarily, the physician will complete a 9.39 form from the ER called "Involuntary Application for admission." The form has a front and back which must be completed by the psychiatrist detailing the presenting problem, psychiatric and/or medical findings, and reason for involuntary admission. A copy of a form called "status and rights" is given to the patient, detailing their rights as an involuntarily committed patient.

    Depending on the circumstance, there is also a 2-PC form (2 Physician Certificate) which allows two doctors (with a third applicant doctor) to involuntarliy commit someone as well. From the ER, however, a 9.39 is performed.

    Depending on the acuity of the situation, the doctor will observe, then attempt to interview the patient. Often this is done with security close by, in case the patient becomes violent. If this does occur, the patient is usually placed in restraints and medicated with an IM injection.

    If the patient is calm enough to be interviewed, the psychiatrist will perform a standard yet focused psychiatric interview, focusing on the immediate cause of the patient's anger, paying special attention to any medical causes that may be contributing to the patient's agitated state. Many medical problems can masquerade as agitation. For this reason, the ER will attempt to draw blood, get a drug uring screen, a fingerstick glucose and other measures helpful in making a diagnosis.

    Details on the psychiatric interview can be found by doing a quick google search. Here is a basic article from a psychiatry journal/magazine to get you started.

    The psychiatric nurse, depending on the setting, may obtain blood samples, assist in restraining the patient, or administer medication. They do not conduct the psychiatric interview or make clinical decisions in most cases.
    They will record their observations of the patient for the doctor to review, when considering the discontinuation of restraints, watch for adverse medication effects and relay their findings to the doctor, who will remedy the complications, if they arise.

    There are quite a few, including those in the steroidal class (prednisone, cortisone), amphetamines and amphetamine like drugs (Ritalin, Cylert, Dexadrine, Adderal and other amphetamine salts), and illegal drugs such as PCP and cocaine to name a few. Alcohol of course is another common culprit.
     
  5. Poety

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    Sazi, did he mean PET - psychiatric emergency team? :p
     
  6. Anasazi23

    Anasazi23 Your Digital Ruler
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    Ohh,

    LOL
    We have a different term for it here. Usually CPEP (comprehensive psychiatrc emergency program, or some such iteration.

    If I wasn't post-call, I probably would have figured that out.

    I like my interpretation better....pets reacting to acute psychiatric illness. Much more interesting.
    :laugh:
     
  7. Poety

    5+ Year Member

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    Your interpretation was WAY more colorful than mine, and I'm not sure mine is right!
     
  8. rgb

    rgb New Member

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    Thank you very much for the replies. They're a great help.

    And, yes, by PET, I mean Psychiatric Emergency Team. Let me explain the situation a bit:

    A woman is nearly hit by a cab driver. She's naked, has blood on her hands and face and when the cabbie tries to help her, she attacks him with a pair of scissors. He manages to knock her cold before she can do any damage.

    The police are called. I would assume that a psychiatric emergency team would be consulted as well -- but obviously that's where the details get a bit fuzzy. I have no idea what procedures would be followed to get this woman from the street into a psychiatric hospital -- as quickly as possible. Who would make the determination that she needs to be committed, etc.

    Forgive my complete ignorance. I'm here to learn. :)
     
  9. Anasazi23

    Anasazi23 Your Digital Ruler
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    An ambulance would be called either by a passer-by or the police on the scene. The woman would be transported to a nearby hospital by paramedics or EMTs where she would undergo medical clearance and psychiatry would be called. Since the woman has blood on her, she would more likely go to a medical ER first to rule out injury and control exposure risk. If/when she was cleared, and depending on the hospital facilities, she would most likely be consulted by psychiatry in the medical ER, or transported to the psychiatric ER for a full evaluation and agitation management, if it were possible.
     
  10. Poety

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    don't ruin the story Sazi :laugh: i wanna see how it pans out dammit :p
     
  11. rgb

    rgb New Member

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    You'll have to wait until 2008. Sorry. :D
     
  12. Anasazi23

    Anasazi23 Your Digital Ruler
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    Oh, I already read the book...

    Turns out that the woman was a psychiatrist herself and was evaluated in the ER after she murdered her abusive daughter's husband in a fit of rage.

    She knew that in order to hide from the police, she must remain in a hidden place, where her confidentiality would be respected. She told the psychiatrists that she was suicidal and had been hearing voices, in addition to other buzzwords, in order to get herself admitted.

    She used believable phrases like, "my doctor put me on some pills that start with a "D," I took them twice a day and he would make me get some blood taken every month or so.

    The psychiatrists bought her story, admitted her under her pseudoname, and she was able to eventually secure a release and even get on SSD in the process. She eventually was able to secure a plane ticket and flee the country, writing to her daughter from New Zealand under her pseudoname, "Anna Freud."
     
  13. rgb

    rgb New Member

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    LOL. Great story.

    Thanks for the info and the link to articles, by the way. You've been a GREAT help.
     
  14. Poety

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    Wow Sazi, and the psychiatrists daughter was abusing who? HAHAHAHAHA :laugh:
     
  15. Doc Samson

    Doc Samson gamma irradiated
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    The basic formula from street to inpatient is pretty standard (EMTs/police-> ED-> emergency psych eval -> inpatient unit). However, the details (especially legal) vary widely from state to state. Here we have the Section 12 (commonly known as a pink paper) whereby a single psychiatrist can involuntarily commit someone for up to 3 days. Alternatively, if the police had arrested the patient, then they would need to be seen by a designated forensic provider (DFP) at a forensic facility, and would then be hospitalized under a section 18a.
    Either way, you'd probably want to figure out which state your story is taking place in before embarking on further research.
     
  16. Poety

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    Massachusetts ROCKS, I'm from Mass :) :thumbup: :horns:
     

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