violent psych pts...

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krebse

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If you have a psych unit at your hospital, what's their approach towards violent psych pts? What qualifies as too violent for admission? Can a historically violent pt refuse medication while on involuntary commitment?

We had an awful pissing match with the crisis worker at my hospital last night about our floridly manic pt being too violent for admission. When asked why the cops and EMS brought him in 4-pointed he stated "I smoked some sick weed then went to 7-11 and **** went down". Other people describe the events as he got naked, physically assaulted 3 innocent people at the 7-11 stating he was a genius priest who knew what was best for them, then jumped on top of the squad when it pulled up and had to be tazed 3 times before he was subdued. Both accounts are probably accurate :). Anyhow, this all happened cause he needs in pt stabilization of his bipolar disorder. He doesn't belong in jail yet. Crisis refused him on the grounds that he's too violent. We said he's not violent after geodon. They said he can refuse his meds and they won't take him. He's uninsured so even if there is another unit/hospital that could take him there's no hope of getting him a bed. Long story short, multiple psychiatrists and supervisors were contacted by both us and the crisis worker and the whole ordeal ended with the chief of psychiatry re-evaluating the pt this morning for either medical clearance for jail or admission to our unit. We refused to medically clear him, he took up a bed in our ED all night, I left at 330 this morn and still don't know the final outcome. This was such a dissatisfying experience. I still need to do some reading about how this works in the eyes of the law and ability of pts to refuse meds here in my state, but I'm curious about others experiences with this.
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krebse said:
This was such a dissatisfying experience.
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Welcome to emergency medicine. There is no place in medicine where the extent of our system's breakdown is more evident. Psych care is the prime example.

The ED is now the default answer to all of society's social and psychological problems, even though we have almost nothing to offer.

Take care,
Jeff
 
We had a patient when I was in residency that lived in a room in the ER for two different week long periods. He was severely autistic. He could follow basic commands, but was non-verbal. Intermittently, he would start smacking his head into the wall. He would lean forward bending at the waist, almost doubled over and then, with all of his strength, slam his head into the wall. The first time he did it, the attending was so impressed that the guy got a CT of his brain to rule out a brain bleed. The problem was, that he would do it about a thousand times a day. He knocked so many holes in the ER wall in his room, that when he finally left, they had to come re-mud the wall, sand the whole thing down and re-paint it. He came in because they couldn't control this behavior at the long-term facility where he lived.

Guess what, we couldn't either.

He was on massive doses of sedative/anti-psychotic medications, but it didn't matter. Occasionally, he would get REALLY vigorous and some ER techs would tackle him and he would get IM meds.

I don't think that you could do a worse thing to an autistic guy... take him out of his normal routine, tell him he can't leave a 10 foot by 10 foot space, give him no peace or quiet, and constantly parade sick patients by his doorway, and make constant buzzers go off, and make him listen to over-head pages all day.

He liked to strip naked at night and walk around the ER... we let him, because, the alternative was physically assaulting him.

In-patient psychiatry was always magically full for him. The facility he came from was sick of dealing with him. Crappy situation, but come on people, ER stays are NOT therapeutic for true psychiatric pathology.

We used to have huge problems with psych borders, but the state got involved and by the end of residency, we didn't have any problems finding beds.

At one point, the state of Nevada declared a state of emergency because 1/3 of the ER beds were taken up by psychiatric patients awaiting psychiatry admission.

One day in residency, when we had several psych patients taking up space in the ER, I asked my attending what needed to change with modern psychiatry to improve throughput. I agree whole-heartedly with his opinion, "Emergency Departments need to be left out of the process."
 
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Psych can be absolutely abusive to the ED. The agency that deals with psych triage for the city refuses to send a social worker to evaluate the patient without a full medical w/u (cbc,bmp,uds,etoh,ekg,tylenol,asa) often on patients with known psych disease without medical issues. Because, as mentioned previously, nothing cures schizophrenia like a randomly beeping monitor.
 
I had been at a hospital where they had any person with a burn injury would bypass the ED and go straight to the burn unit (paramedics would deliver them up to the floor). Wonder why psych couldn't do something like that.
 
Part of the problem is that laws surrounding the dealing of psych patients varies widely from state to state. I've seen EDs that had great relations with their psych EDs, and ones where they don't. NY at least isn't so bad...those are scary horror stories :(
 
Last week we were holding 164 psych patients in the Vegas ERs, easily. 25% of the Er beds for the whole city.

Some patients actually present to LVMH (the county psych facility) and they transfer the patients to my hospital for "medical clearance" and then we are stuck with them for 3 days until they. Send an "evaluator'.
 
I have Bipolar 1 disorder but thankfully have never had to be hospitalized. My family manages to keep me "under control" when I start to go over the edge, which I don't do very often because I take my meds faithfully. Going to the ER would be a nightmare for me while in a mania and I would completely flip my ****. I don't understand why psych patients have to go through the ER first before they can be admitted to a psychiatric facility, but that's how it is in my state.
 
Nothing gets me to the radio faster than an ambulance requesting clearance to go straight to the psych facility.

And I agree that it's heartbreaking to have to confirm patients' persecutory delusions by restraining them & giving IM meds when they're becoming aggressive because they're in a very frightening situation. I did not go into medicine to torture the mentally ill.
 
krebse said:
Can a historically violent pt refuse medication while on involuntary commitment?
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I'm not an expert on the matter, but when you have a patient in your facility against their will (i.e. they want out and never signed any consent to treatment forms), the law for administering psychotropic medications varies from state to state, but it often requires that the provider obtain permission from the hospital's "patient wellbeing" board or committee before administering the med. In an acute incident, you can probably administer sedatives, provided you can defend that decision as a best available and justifiable course of action at a hearing.

IMHO, pharmacosedation should only be used in situations where you don't have the personel to physically restrain a pt and they're dangerous to themselves or others. If the pt goes TdP and you didn't have an EKG read, it may become that much harder to justify using the drug. Just my 2¢.
 
Dimoak said:
IMHO, pharmacosedation should only be used in situations where you don't have the personel to physically restrain a pt and they're dangerous to themselves or others. If the pt goes TdP and you didn't have an EKG read, it may become that much harder to justify using the drug. Just my 2¢.
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Should I ever become acutely psychotic to the point that I am a danger to self or others, and I find myself in the ED I beg you to sedate me rather than physically restrain me. I've never experienced either, so this is just speculation, but I think pharmacologic management is more humane.

And if you know an EKG tech who can get a decent EKG on a patient who needs to be restrained (which is a no-no word in Illinois, so be careful with your verbage) then let that tech know he/she has a job waiting at my shop.
 
WilcoWorld said:
Should I ever become acutely psychotic to the point that I am a danger to self or others, and I find myself in the ED I beg you to sedate me rather than physically restrain me. I've never experienced either, so this is just speculation, but I think pharmacologic management is more humane.
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I don't disagree with you, but there has been a decent amount of worms flying out of the pharmacologic route to the extent that there have been some lawsuits by people claiming that they were administered psychotropics for insufficient reason. I'm just saying that the feasibility of physical restraint to calm someone down (especially a smaller individual not on EtOH or drug rage) should be considered before drawing up the IM antipsychotics. If you have some huge drunk person fighting off two police officers, by all means give the offender a ride on a B-52. But I definitely see your point that sedating a pt as quickly as possible rather than having them endure an unnecessarily long physical struggle will almost always be better, as its not too likely that physical restraint will result in them calming down sufficiently all that often.
WilcoWorld said:
And if you know an EKG tech who can get a decent EKG on a patient who needs to be restrained (which is a no-no word in Illinois, so be careful with your verbage) then let that tech know he/she has a job waiting at my shop.
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I actually wasn't aware that the word restraint was a faux-pas; I thought that was what people's CPI training was for. I wasn't referring to the OP in the second paragraph. It was more so about using chemical restraint on a pt who was previously calm and the data was available, but then the individual became unruly later on. I doubt any court or committee would be able to demonstrate wrongdoing related to pharmaceutical sedation on an individual who was violent and potentially dangerous from the moment they came in (or were brought in).
 
Commanderzoom said:
I don't understand why psych patients have to go through the ER first before they can be admitted to a psychiatric facility, but that's how it is in my state.
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For the simple reason that we have to ensure that the patient's disorientation isn't due to a medical causes, especially a reversible one. That workup isn't going to happen in the psych hospital so they have to get medically cleared first. Having a psych history isn't enough, psychotics still have strokes, get low blood sugar, hypothyroid etc etc etc.
 
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Sorry, I didn't realize you were referencing that specific case.

As for the "chemical restraint" issue - I think it's a stupid documentation technicality, but apparently it's important to someone. It probably sprang from the same line of good intentions as HIPAA and suffered similar bureaucratic mutations.
 
Because of laws enacted on account of the "psychiatric survivor" lobby, at the jail we can't legally give anybody medications against their will. So the big guys usher violent psychotic individuals into small rooms, where they scream and kick and punch for hours, sometimes giving themselves fractures. IMV, a shot of vitamin H/lorazepam would be much more humane.

Our psychiatric nurse, who should be canonized, sometimes manages to talk them into taking a Zyprexa Zydis. Even if they spit it out right away, there's enough buccal absorption that often they settle down within 1/2 an hour or so.
 
Pharmavixen said:
Because of laws enacted on account of the "psychiatric survivor" lobby, at the jail we can't legally give anybody medications against their will. So the big guys usher violent psychotic individuals into small rooms, where they scream and kick and punch for hours, sometimes giving themselves fractures. IMV, a shot of vitamin H/lorazepam would be much more humane.

Our psychiatric nurse, who should be canonized, sometimes manages to talk them into taking a Zyprexa Zydis. Even if they spit it out right away, there's enough buccal absorption that often they settle down within 1/2 an hour or so.
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thought the whole point of chemical restraint was they aren't in the right mindset to make decisions for themsleves. that being said how do they know if they truely want the meds or not? :smuggrin:
 
DoctorMedic said:
thought the whole point of chemical restraint was they aren't in the right mindset to make decisions for themsleves. that being said how do they know if they truely want the meds or not? :smuggrin:
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Yes; who are we to interfere with people's democratic right to give themselves boxer's fractures in both hands?
 
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I don't worry about the bureaucratic law. If the psych patient is violent, loud, swearing, or threatening to leave, they are going to get the B-52. No negotiation, no nice talking, I want them down and quiet. If I have to suffer the consequences, so be it.
 
Pharmavixen said:
Because of laws enacted on account of the "psychiatric survivor" lobby, at the jail we can't legally give anybody medications against their will.
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This is a HUGE problem for my job. I work at a forensic psychiatric hospital with people who are incompetent to stand trial. Many of them require involuntary meds to be stabilized to become competent. Once they are competent, they go back to jail to await the criminal proceedings....and they start refusing their meds and decompensate and end up back with us and can bounce back and forth repeatedly because of this.
 
GeneralVeers said:
I don't worry about the bureaucratic law. If the psych patient is violent, loud, swearing, or threatening to leave, they are going to get the B-52. No negotiation, no nice talking, I want them down and quiet. If I have to suffer the consequences, so be it.
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Political differences aside, I could totally work with you.

Better to ask forgiveness than ask permission.
This is a HUGE problem for my job. I work at a forensic psychiatric hospital with people who are incompetent to stand trial. Many of them require involuntary meds to be stabilized to become competent. Once they are competent, they go back to jail to await the criminal proceedings....and they start refusing their meds and decompensate and end up back with us and can bounce back and forth repeatedly because of this.
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Two words: Risperdal Consta.
 
Pharmavixen said:
Political differences aside, I could totally work with you.

Better to ask forgiveness than ask permission.

Two words: Risperdal Consta.
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Thanks, for the words of kindness.

The nurses love working with me on psych patients because I don't negotiate, I don't have a conversation: "Hey Mister crazy schizo, why are you yelling, crazy and spitting? Does it have to do with your childhood?"

If they endanger staff, disturb other patients, or make it difficult for nursing staff to take care of their patients then I'm going to give you them the sedatives, repeated doses if necessary.
 
I agree with the later posts. Agitated psych patients, regardless of its it because its drug or alcohol or underlying psych, gets put down.

I prefer IV haldol and ativan (I do alot of education on how to properly physically restrain patients to put in IV's)

Haven't ever had psych say someone was to violent.
 
roja said:
I agree with the later posts. Agitated psych patients, regardless of its it because its drug or alcohol or underlying psych, gets put down.

I prefer IV haldol and ativan (I do alot of education on how to properly physically restrain patients to put in IV's)

Haven't ever had psych say someone was to violent.
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This post got me thinking about IV Haloperidol - I was taught never to give it IV, but I see a lot of people doing it in my new ED. My lit search yielded plenty of case reports of IV vitamin H leading to torsades, but it looks like these almost uniformly occur in people getting repeat doses, and in total doses more than 10 times what I usually need to use in the ED.

So, Roja - you're a thoughtful doc - what do you have to say on the issue of IV Haloperidol? Is the danger of this practice overblown?
 
How easy is it to give something IV to an agitated pt?
 
roja said:
I agree with the later posts. Agitated psych patients, regardless of its it because its drug or alcohol or underlying psych, gets put down.

I prefer IV haldol and ativan (I do alot of education on how to properly physically restrain patients to put in IV's)

Haven't ever had psych say someone was to violent.
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Roja, always the voice of reason. As I discussed this with a psychiatrist, he agreed - no matter how violent, put 'em on ice overnight, and they can be seen in the morning. Whether it's Geodon or the B-52 (or the "10-4, good buddy!"), it works.
 
Wilcoworld- I think one has to be careful when making broad practice changes based on case reports. They certainly give us something we should think about, however, causal relationships do not make something true. I had never really heard of the no IV haldol until the last year. I did a lit search and basically found what you did. Some case reports that reported torsades after repeated doses. Maybe it was from the haldol. Maybe it was from other things. Agitated psych patients can be on many things. Prescribed and illegal. However, I think when you weigh those case studies against the vast volumes of IV haldol given across the country and world, I think that there were probably other things going on. And that the risk/benefit leads towards giving it. (IE, if you could come up with a theoretical NNT and NNH, the NNT is going to FAR outweigh the NNH of using IV haldol in highly agitated, combative patients.) To put it in context, *if* you accept the NNT (sketchy at best given the combined outcomes used to calculate this number for stroke patients) for lytics of 16 and the NNH of 18, and we jump on this like no one's business, it kind of puts it in a different light. (I would imagine if you could get a NNH on IV haldol it would be on the order of 7-800)

Pharma- the problem with IM medications is that they take upwards of an hour to have an effect and repeat dosing can be tricky and lead to oversedation. I have on many occasions seen IM meds given and patients agitated enough to break out of physical restraints. The key to getting an IV into an agitated patient is coordinated, appropriate physically restraining the patient. You have to have several people and you have to hold them down in a way that is SAFE and effective for both the patient and those involved. Basically placing the pressure on the shoulder joints and knee joints so that they can not move. They you put the IV in. The meds need to be ready when you do this. The IV meds act much quicker. The reason for the need for quickness is multifold: the patients are a danger to themselves, staff and other patients. They take up huge resources which also affects the ability of the ED to care for other, sicker patients.
 
I wasn't promoting IM meds; was just curious about the logistics of getting an IV into someone who violently doesn't want one.

Totally blue-skying here, but I wonder if TdP associated with IV haldol is related to cocaine abuse. The haldol/ativan combo was standard for years for psychotic pts whatever the etiology, and given cocaine's potential for psychosis & cardiotoxicity, maybe the haldol in those specific pts is a greater TdP risk.
 
Didn't think you were. it is not uncommon for people to try and use these meds IM. I just find it pretty useless. Getting an IV in is really no harder than getting IM meds in. :)

I think it is very possible that IV haldol has become 'dangerous' much like phenergan, reglan and droperidol became 'dangerous' when expensive new drugs have come out.....

I did have a psychiatrist (who never manages acutely psychotic patients) try and tell me that I should use po meds in acutely psychotic patients. Now, I can get an extremity down and and IV in it, but I am not (nor asking anyone else) to try and shove pills (even ODT) into someones mouth!
 
roja said:
I did have a psychiatrist (who never manages acutely psychotic patients) try and tell me that I should use po meds in acutely psychotic patients. Now, I can get an extremity down and and IV in it, but I am not (nor asking anyone else) to try and shove pills (even ODT) into someones mouth!
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They keep rejecting my suggestion of an Ativan/Haldol dart gun for acutely agitated patients (or nurses).
 
I find that only a really small segment of my psych patients are good candidates (by my own criteria) for ODT zyprexa. The people who have insight into their disease but are nonetheless being driven even more crazy or suicidal by it often respond pretty well. Obviously, these aren't the droids we're discussing, just made me think about how infrequently I have a psych patient that the oral stuff might help.

Totally agree with the above IV placement advice - once you are at the point in your psych rodeo that you could put something in IM, you could probably just start a line.
 
roja said:
I think it is very possible that IV haldol has become 'dangerous' much like phenergan, reglan and droperidol became 'dangerous' when expensive new drugs have come out.....
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:thumbup:

roja said:
I did have a psychiatrist (who never manages acutely psychotic patients) try and tell me that I should use po meds in acutely psychotic patients. Now, I can get an extremity down and and IV in it, but I am not (nor asking anyone else) to try and shove pills (even ODT) into someones mouth!
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Well, our psychiatric nurse has had some luck in getting pts to take Zyprexa Zydis, and when she's successful, it works fast as IV. But we do that because we don't have other options.

Not to bash psychiatrists, but I've had a couple of incidents where a methadone pt who missed his methadone for a couple of days while in police custody is in WD and vomiting, and a psychiatrist happens to be around so I ask if he wouldn't mind giving some IM gravol (not legal for me to give injections) so that the pt can keep down his methadone. And these psychiatrists look at me in astonishment before saying, "I NEVER give injections!!!"
 
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