Take your suicidal patient to psych! We're done with them.

[heyjack70]

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I imagine this is a common consult situation, where a post overdose, or otherwise sick patient, often with psych history, is admitted to the ICU or medicine floor for monitoring and care and gets delirium. Then the medicine team essentially "fixes" the patient, eg their labs are good, no more infection, and the nomogram time course is sufficient to believe they are past any acute risk from ingested substances. But they are still delirious. You get the inevitable call requesting to "take the patient to psychiatry." Sometimes, this is very inappropriate because the patient is hallucinating/delusional due to their delirium, and they don't even have a diagnosis of psychotic d/o. But sometimes, the patient has a history of depression, and when they presented they were suicidal, and may still be saying they are suicidal during lucid moments, and the medicine team feels they are doing nothing for the person except giving them the haldol that you ordered for delirium, so why not admit them to psych for their SI.

Of course the delirium should be resolved before transferring to psych, right? I mean it's a medical emergency. They may not have an acute process underlying the delirium in this moment because the medicine team has fixed it, but the delirium is somewhat protracted. But they should stay on medicine until they clear up, right?

Do you folks have any experience or advice for dealing with aggressive medicine/ICU teams/attendings, in situations where the patient may need psych, but they aren't past their delirium yet?

 

[Doc Samson]

I imagine this is a common consult situation, where a post overdose, or otherwise sick patient, often with psych history, is admitted to the ICU or medicine floor for monitoring and care and gets delirium. Then the medicine team essentially "fixes" the patient, eg their labs are good, no more infection, and the nomogram time course is sufficient to believe they are past any acute risk from ingested substances. But they are still delirious. You get the inevitable call requesting to "take the patient to psychiatry." Sometimes, this is very inappropriate because the patient is hallucinating/delusional due to their delirium, and they don't even have a diagnosis of psychotic d/o. But sometimes, the patient has a history of depression, and when they presented they were suicidal, and may still be saying they are suicidal during lucid moments, and the medicine team feels they are doing nothing for the person except giving them the haldol that you ordered for delirium, so why not admit them to psych for their SI.

Of course the delirium should be resolved before transferring to psych, right? I mean it's a medical emergency. They may not have an acute process underlying the delirium in this moment because the medicine team has fixed it, but the delirium is somewhat protracted. But they should stay on medicine until they clear up, right?

Do you folks have any experience or advice for dealing with aggressive medicine/ICU teams/attendings, in situations where the patient may need psych, but they aren't past their delirium yet?

Be equally aggressive. Delirious patients are by definition acutely medically ill. If the jackass on the other side starts saying "they're asymptomatic" (and they often do), then you can point out all their symptoms. Call it an acute encephalopathy if you have to rather than a delirium. Get an EEG - delirious patients will have theta-delta slowing. Psychotic/manic/depressed patients won't. Use that as objective evidence that there is an untreated somatic process in play and the patient is not medically cleared.

 

[Manicsleep]

I lot of these patients in delirium are often not treated well in the ICU setting with lights constantly on, staff coming in at all hours of the night and incessant beeping of the equipment.

I agree that caution is needed but education is as well. Perhaps a step down/tele unit for 48 hours? Ask them to open the curtains in the morning, stay away from sedating drugs during the day, ask family/staff to walk the patient/keep them engaged, keep it quiet at night. Sometimes its amazing how much faster the delirium lifts with small changes like that.

 

[nitemagi]

What I hear a lot is the "well they're asymptomatic [except for their delirium]."

What I try to hammer over and over and over again, is that delirium indicates a person is having end-organ damage, and that organ is the brain.

Research currently suggests that unlike the old myth that after resolution a person returns to their baseline, the longer a person with delirium goes untreated, the less close to baseline they will ever get back to. Meaning permanent deficits. So at times when ignored I will document (somewhat heavy-handedly) that this is clearly delirium, indicating end-organ damage to the brain, and failure to hospitalize and treat the underlying medical etiology could result in permanent disability and death...

It kind of puts them in a medico-legal corner, so I don't recommend doing it often. But I've done it when I was honestly scared for the outcome of a patient if left untreated, and I've seen some patients with severe problems after untreated delirium (such as blindness), etc. I'll also all too often see internists do a basic screening panel and then give up because they couldn't find a cause. And they're right - If you don't look for it, you won't find it. That doesn't mean there is no cause.

All that being said, some people do recover on their own. But you can never know. Unless someone has a paper to refute this.

 

[Manicsleep]

Also, if 2 other organs are involved the chances of death within one year is huge if the patient develops delirium.

This should be discussed with the family....I also need to find the data on this again.

 

[nitemagi]

Also, if 2 other organs are involved the chances of death within one year is huge if the patient develops delirium.

This should be discussed with the family....I also need to find the data on this again.

Sadly there's a lot of data out there. But other services are grossly undertaught, and most of this is in the critical care literature!

http://www.ncbi.nlm.nih.gov/pubmed/21371353
http://www.ncbi.nlm.nih.gov/pubmed/21309472
http://www.ncbi.nlm.nih.gov/pubmed/21092264
http://www.ncbi.nlm.nih.gov/pubmed/20664045

 

[Doc Samson]

After doing this for a while I've come to the sad conclusion that other services typically just do not care. The goal is to get the patient off their rounds list. It is a remarkable breath of fresh air when a colleague from another specialty really wants to be educated about delirium and starts to independently evaluate and appropriately manage delirious patients, but it happens pretty infrequently. Ah well, job security, I suppose.

There's also data that patients with prior psychiatric history are far more likely to have their delirium missed/misdiagnosed b the primary team. That tends to get me irate since it's just straight up discrimination. In the words of one of my mentors "What were you expecting their schizophrenia to inoculate them against?"

 

[Majesty]

A little off topic but psychosomatics is no longer on psychiatryonline. Very useful articles.

 

[nitemagi]

A little off topic but psychosomatics is no longer on psychiatryonline. Very useful articles.

I think I read somewhere they were changing publishers.

You should still get it if you're an APM member, I think.

 

[Doc Samson]

A little off topic but psychosomatics is no longer on psychiatryonline. Very useful articles.

Yes, we're now published by Elsevier instead of APPI. APM members still get online access, with additional free access to the other 3 Elsevier CL journals including General Hospital Psychiatry (a very nice membership perk). The journal is now also a very pretty blue instead of the traditional crimson.

 

[whopper]

Be equally aggressive

Agree with Doc Samson whose expertise in this area is above my own, but....

Be careful in fighting back. Do not go toe-to-toe with an attending if you're a resident. Fighting back against an attending is like David. v. Goliath without a sling. You may also be fighting back when your attending doesn't give a damn. I often encountered this problem as a resident, and brought it up to the psychiatry attending, who in-turn, didn't care about it just like the other dept. trying to dump a patient becuase that doctor wasn't in charge of inpatient and was doing something else such as C/L or was on-call. It was simply easier for the psych attending to dump the patient to inpatient psychiatry than actually question the IM or surgery doctor. (And on top of that the psychiatry attending in my program who did this didn't remember his damn IM or surgery at all. Significant drop in Hgb or Hct in the past 6 hours and the patient just got out of surgery 2 days ago? I had to point these things out to him.)

Of coursem when the inpatient unit got these dumps, they were all ticked-off, but it was out of my control. The psychiatry attending on the unit knew I was caught in the middle because I was usually one of the only guys trying to stop these dumps.

If you are in a malignant program, have an idiot attending supervising you, or don't exactly know what you're possibly getting into, try to be diplomatic. I've often felt when interacting with other residents from other depts, we were able to figure it out together without animosity. When it was an attending or staff member, it was often IMHO a dump job with the other end not giving a damn other than to lighten their load.

I have too many stories such as the time I asked the attending if the patient had asterexis, he tells me "no" and the patient is showing it in front of both of our eyes but the attending continues to deny it.

 

[Mattchiavelli]

yes, call neurology, we will be happy to further complicate matters 😀

Kidding aside I think there is a documentation aspect that goes along with "if you don't look for it you won't find it," if the Internists/ICU docs are looking at it through their usual view they might be documenting what looks like a healthy patient ON PAPER but who obviously still needs evaluation and treatment, and depending on what hospital you're in someone may be breathing down their necks (administration) to lower level of care or discharge from the floor. Just a little devil's advocate.

Sometimes people get atrophy in the parts of their brain that stored their behavioral training (if they were paying attention). There are a lot of people that don't know how to properly document behavioral issues/cognitive deficits that warrant addressing, they get scared, and call psych.

And I know it's really rough dealing with people that flat out REFUSE to know anything outside of their area of expertise. Fight for minds!

EDIT: PS thanks to nitemagi for the articles