You don’t need to go to residency to prescribe Risperdal

[ridethecliche]

Sharing another story on here because well... why not?

Yesterday on the inpatient unit, I convinced two psychotic patients to start antipsychotics while playing jenga with them. The like.... 2-2.5 hrs I spent with them playing jenga and talking probably represent the longest I've ever played jenga while not under the influence.

It's also pretty hilarious when someone is straight up psychotic, internally preoccupied, responding to internal stimuli, etc etc etc... and you walk up to them and are like "hey dude, you wanna play some jenga and talk for a bit". He perked righttt up and goes, "man, I will crush you"!

Given that he has a history of violence and behavioral codes, I didn't quite know what to make it of it, but I think it worked out okay.

Probably the most stoked I've ever seen a patient on the unit tbh.

Who says play-therapy is just for kids.

But seriously though, it was a really interesting way to evaluate their attention span and cognitive processing. I had to remind him a few times that it was his turn but I didn't know what to make of that entirely because there were times when I was trying to talk to him where I forgot too so I didn't put that part in my note.

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[Attending1985]

Sharing another story on here because well... why not?

Yesterday on the inpatient unit, I convinced two psychotic patients to start antipsychotics while playing jenga with them. The like.... 2-2.5 hrs I spent with them playing jenga and talking probably represent the longest I've ever played jenga while not under the influence.

It's also pretty hilarious when someone is straight up psychotic, internally preoccupied, responding to internal stimuli, etc etc etc... and you walk up to them and are like "hey dude, you wanna play some jenga and talk for a bit". He perked righttt up and goes, "man, I will crush you"!

Given that he has a history of violence and behavioral codes, I didn't quite know what to make it of it, but I think it worked out okay.

Probably the most stoked I've ever seen a patient on the unit tbh.

Who says play-therapy is just for kids.

But seriously though, it was a really interesting way to evaluate their attention span and cognitive processing. I had to remind him a few times that it was his turn but I didn't know what to make of that entirely because there were times when I was trying to talk to him where I forgot too so I didn't put that part in my note.

What a nice and humane way to relate to your patient who is no doubt fearful and isolated. Wish this was a common thing. Update us on what this leads to. I predict less behavioral codes.

 

[Mad Jack]

Recently heard an attending psychiatrist telling med students that she believed nurses and PA’s provide equivalent care to physicians and snorted “You do don’t need to go to residency to be able to prescribe Risperdal!” She claimed that in her view the majority of our training was extraneous and that the ”literature” backed her claims of equivalency. She (the attending) is too high up in the food chain for me to critique face to face but I did feel pretty frustrated that she was trying to undermine her profession. In my mind since she’s close to retirement and holds some high positions in the hospital, I figure that her attitude is one of “I’m almost retired, to heck with the consequences of what I say!” and also heavily influenced by PC hospital politics.

If we follow her logic to its conclusion, wouldn’t a 3rd or 4th year medical student be superior to a PA in knowledge base? If she’s comfortable believing that a PA could replace us, would she be comfortable letting a med student run the service? I also find the reduction of what we do to simple brain dead prescribing a bit galling.

Thoughts?

Tell that to all the primary care physicians and hospitalists that panic when they hear their patients are having hallucinations. Ridiculous and sadly detached from reality she certainly is

 

[clausewitz2]

Tell that to all the primary care physicians and hospitalists that panic when they hear their patients are having hallucinations. Ridiculous and sadly detached from reality she certainly is

One of the banes of my existence on my C&L block was our system's mandatory suicidality screenings administered by not-especially-well-trained social workers on admission and the resulting stat consults for suicidal ideation. Roughly half the time it transpires that the patient has a prior BPD diagnosis, has done a lot of DBT work, is being admitted for some unrelated medical issue, and is actually doing pretty well in life. They just do think about suicide most days and answered honestly but can rattle off all the skills they can use if they need to and don't have any intention of acting on it and haven't in years.

Even just a -little- in terms of follow-up to screening questions could have saved everyone a lot of hassle.

 

[Mad Jack]

One of the banes of my existence on my C&L block was our system's mandatory suicidality screenings administered by not-especially-well-trained social workers on admission and the resulting stat consults for suicidal ideation. Roughly half the time it transpires that the patient has a prior BPD diagnosis, has done a lot of DBT work, is being admitted for some unrelated medical issue, and is actually doing pretty well in life. They just do think about suicide most days and answered honestly but can rattle off all the skills they can use if they need to and don't have any intention of acting on it and haven't in years.

Even just a -little- in terms of follow-up to screening questions could have saved everyone a lot of hassle.

Or they get furious that psychiatry was brought in in the first place

 

[ridethecliche]

Or they get furious that psychiatry was brought in in the first place

I had one patient that was pissed off that he had us consulted when he said he wanted to jump out the window because he was stuck in the hospital.
He goes "I'm so frustrated. I don't want to kill myself or I would have done it years ago. I just want to go home. I can't even jump out of the windows because I know they're locked and I can't open them. I've just been here for two weeks and I'm sick of it."

I responded: "Man, if I was in your place I'd be pissed too. Why don't we just chat for a few minutes so we can figure out how we can make this less painful for ya".
-Proceed to do a full suicide screening anyway.

 

[Mad Jack]

I had one patient that was pissed off that he had us consulted when he said he wanted to jump out the window because he was stuck in the hospital.
He goes "I'm so frustrated. I don't want to kill myself or I would have done it years ago. I just want to go home. I can't even jump out of the windows because I know they're locked and I can't open them. I've just been here for two weeks and I'm sick of it."

I responded: "Man, if I was in your place I'd be pissed too. Why don't we just chat for a few minutes so we can figure out how we can make this less painful for ya".
-Proceed to do a full suicide screening anyway.

God I'm having consult flashbacks. Not a week would go by that I wouldn't stumble into something like that. And I'd always have to be the one to play damage control and still get the job done

 

[clausewitz2]

Gentleman s/p CABG has been stuck in hospital for a week after surgery and wants to go home. Team tells him it's not going to be today and he says, 'well maybe I'll just go smoke until my heart explodes.'

consult psych for SI

 

[Stagg737]

Gentleman s/p CABG has been stuck in hospital for a week after surgery and wants to go home. Team tells him it's not going to be today and he says, 'well maybe I'll just go smoke until my heart explodes.'

consult psych for SI

I had a similar situation but it was a stat consult overnight (around midnight) and I'd literally just pulled in my driveway after a swing shift. Only stat consult I ever got from our VA on overnight call there:

Surgical NP placed stat consult to psychiatrically clear a patient without any psych history for an urgent appendectomy the following morning. He was supposedly suicidal, so I expected him to be ripping out IVs or something that would make safety during surgery a concern. Turned out that he said that before going to the ER "the pain was so bad I felt like I could die" and NP felt like a stat consult was necessary. No PHQ-2 or Columbia performed. Went back to the hospital and patient was in his room with wife and mom laughing (at nearly 1 in the morning, which was weird) and they were all very confused to see me. Did a quick screen and proceeded to page the on-call surgeon to report that we had psychiatrically cleared their stat consult for surgery the following morning as he wasn't suicidal and never was. Also wrote the most passive-aggressive note I've ever written which made my attending laugh the next day. Never got a stat consult overnight from that VA again. The big kicker was that the consult was placed just before midnight and the NP ended her shift at midnight and couldn't be contacted for details about the consult.

This is one of the dumbest consult situations I've been in and crap like this that makes me so frustrated about the mindset of the attending in the OP.

 

[Old&InTheWay]

The best (worst) consult I've heard about was from the trauma service for a teenager who was injured as a passenger in an MVC driven by another teen. The urgent question was whether the crash was actually the product of a "suicide pact" between the teenagers. Turns out there was no objective evidence of any such thing and was based solely on a "hunch" of the trauma provider. The idea just "popped into their head" and they felt compelled to involve the CL team.

We probably should have just told them, "you don't have to be a psychiatrist to prescribe Risperdol."

 

[calvnandhobbs68]

The best (worst) consult I've heard about was from the trauma service for a teenager who was injured as a passenger in an MVC driven by another teen. The urgent question was whether the crash was actually the product of a "suicide pact" between the teenagers. Turns out there was no objective evidence of any such thing and was based solely on a "hunch" of the trauma provider. The idea just "popped into their head" and they felt compelled to involve the CL team.

We probably should have just told them, "you don't have to be a psychiatrist to prescribe Risperdol."

 

[Mad Jack]

The best (worst) consult I've heard about was from the trauma service for a teenager who was injured as a passenger in an MVC driven by another teen. The urgent question was whether the crash was actually the product of a "suicide pact" between the teenagers. Turns out there was no objective evidence of any such thing and was based solely on a "hunch" of the trauma provider. The idea just "popped into their head" and they felt compelled to involve the CL team.

We probably should have just told them, "you don't have to be a psychiatrist to prescribe Risperdol."

Sounds like the trauma provider is the one that needed the psych consult

 

[pisekar]

maybe

but more importantly, you need to go to residency to learn when you shouldn't prescribe risperidone

 

[Matthew9Thirtyfive]

Apparently you have to go to residency to remember to give it. Nursing forgot to give my acutely psychotic patient his risperidone and it got caught by the overnight resident. Kind of a big deal lol.