you know it's july.......

[vistaril]

when the inpatient units are filled with detox pts, borderlines, and shelter seekers......

Not sure how you guys programs do it, but here it's mostly second years who cover the ER overnight, when a lot of the admissions come in. Many dont have a lot of experience in the ER, and so the above admissions seem to slip in pretty frequently in July and August....

fortunately, I start my acting attending inpt month tommorrow and the attending has already told me he is going to let me do anything I want as he knows Im solid clinically.

The intern on service I talked to earlier this afternoon, and he gave me a rundown of the 8 pts on his team currently on the service: 2 detox pts who dont sound suicidal, 2 pts who were admitted last night and are known malingerers, and two borderlines in the middle of their usual hospitalization.......

I told him to have their discharge stuff all prepared for tommorrow morning, because after I lay eyes on them I dont anticipate they will be there by lunchtime.

and thats going to be my strategy all month....if the ER wants to admit people who are malingering, or seeking detox, or whatever....that's fine but I'll meet them once they get up to the unit, quickly assess them, and dc them before they even get settled......

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[DD214_DOC]

How do you manage to prevent admitting borderlines who will not recant their statements of suicidality? I send them out if they reconstitute or do something stupid as an attempt, such as scratching their wrists with a twig, but otherwise I often feel trapped. It's also not easy convincing an attending to not admit a borderline who is chronically suicidal.

 

[toothless rufus]

It's also not easy convincing an attending to not admit a borderline who is chronically suicidal.

I find it ironic that attendings, those with the most (usually) knowledge and experience want to keep borderlines, while residents, with the least (usuallly) want to discharge them.

Is it b/c they just figure why bother putting their license at risk? Easier/safer to keep than to street?

 

[nitemagi]

I find it ironic that attendings, those with the most (usually) knowledge and experience want to keep borderlines, while residents, with the least (usuallly) want to discharge them.

Is it b/c they just figure why bother putting their license at risk? Easier/safer to keep than to street?

This has been addressed elsewhere. Not all attendings feel that way. You're also asking an attending to trust YOUR assessment of the patient, often without doing their own independent evaluation, which is risky. Some thus play it conservative. Some have also never figured out alternative approaches to risk mgmt and suicidality, and the idea of chronic vs. acute risk. Chronic (years of suicidality) isn't much of a risk factor IMHO that should weigh into choice of hospitalization, unless they have many real SA's. Acute SI is a bigger deal.

I saw a guy once on consult who had SI chronically for 40 years. No one had asked that at first, of course. They thought SI=hospitalization. We dug up his records and he had travelled all over the country complaining of SI, always wanting to get hospitalized. Guess how many SA's he had? Zero. That one didn't take much to figure out. With less information though sometimes it's safer to hospitalize and figure it out once they're on the unit. The cost of miscalculating the risk and not admitting is a LOT higher than an improper admission. Potentially irreversible.

 

[splik]

I find it ironic that attendings, those with the most (usually) knowledge and experience want to keep borderlines, while residents, with the least (usuallly) want to discharge them.

Is it b/c they just figure why bother putting their license at risk? Easier/safer to keep than to street?

It's not ironic at all...attendings usually have been round long enough to know that borderlines even with pathetic histories of attempting suicide often go on to do so and succeed in ending their life, deliberately or accidentally. Of course it is a delicate balance because hospitalization can make many borderlines much worse (had one this week who attempted suicide on the unit to 'prove' he was serious), but it is not black and white to think that hospitalization is never indicated for a borderline. I am lucky in that where I am we have i/p DBT groups and all the nursing staff are trained in the management of borderline pts...which of course does not stop these patients splitting the team and lo an behold nurses are almost always on the bad side of the split! I love borderline pts...so wonder if I don't have some narcissistic traits..!