Psi

It is time to address a large and often difficult aspect of emergency medicine, psychiatry. A little history may be helpful to understand the problem of psychiatric patients in the ER. Back in the 1960's, the first effective medications for schizophrenia became available. The dehumanizing treatments that had been applied prior to these medications is reminiscent of the Spanish inquisition. Patients were shocked with electricity, immersed in tubs of freezing cold water, given large doses of insulin to induce shock from low blood sugar, and subjected to psychosurgery. Prefrontal lobotomy was a well accepted treatment. Watch "One flew over the cuckoo's nest" for a taste of the "treatment" of schizophrenics.

The most common treatment involved storing these patients in large state psychiatric hospitals. Out of sight, out of mind. Having medications that could ameliorate the symptoms of psychosis made these human warehouses unnecessary. Plans were for community based out-patient treatment centers. Patients would get their medications, and counseling near to home. The drugs were prescribed but few of these psychiatric clinics were built.

The medictions had severe and disabling side effects. Long term use led to movement disorders such as tardive dyskinesia, a medication induced form of Parkinson's disease. Newer and supposedly better pharmaceuticals have been developed but they also have severe acute and chronic side effects. Weight gain, diabetes, elevated cholesterol are all known consequences of today's "atypical" anti-psychotics. One drug can even cause bone marrow damage that may be permanent.

A very eloquent paranoid schizophrenic, who I have known for 20 years, described his reaction to his medications most poetically. When asked why he continued to resist treatment by stopping his meds, he told me that they made him feel dead inside. He added that he would rather be crazy than be anesthetized.

Today the warehousing of psychiatric patients occurs in the ER. There is a revolving door from in-patient psychiatric hospitals to the community and this portal is the ER. When a psychiatric patient becomes a danger to the public or to themselves the police, EMS or their therapist sends them to the ER. The ER doc is supposed to "medically clear" the patient and then find an in-patient facility that will accept the patient.

Medical clearance is a mine field. The ER staff is responsible to diagnose and treat any and all medical conditions that the patient may have. The psychotic patient is often agitated, and even violent. Physical and chemical restraints are often necessary. Both the patient and the ER staff are at risk. This evaluation is frequently made more difficult because of a lack of medical records and the patient's inability to assist the ER staff.

The ER doc and nurses have examined, x-rayed, lab tested and sedated the psychotic patient. Only one task remains, disposition. Insurance or lack thereof, prexisting medical condtions, pregnancy, advanced age, and drug use all make this search difficult and long. Patients cannot be discharged back to the general community. The psychiatric hospitals hold all the cards. Patients have been stuck in the ER for days while a "bed search" continues. The patient gets fed, and has a bed but little actual treatment is given.

Finally a bed is found and the patient is sent to the psychiatric hospital by ambulance. I breath a sigh of relief as I sign the paper work for the transfer. The next week, or even just a few days later, the same patient is back in the ER. His meds were adjusted and he was discharged from the psyche hospital. He or she is still schizophrenic, bipolar, etc. One call to 911 and the cycle begins anew.

This is only the first of several postings concerning psychitric care in the ER. The vagaries of psychiatric diagnoses and specific conditions will be addressed in future blogs.