When evaluating mental health patients, go beyond snap decisions

It is tempting to use our sense of sight to make snap judgments about people, places and things.

Think about it. When you walk into a restaurant, if you see a sparkling clean dining room, you probably assume that the kitchen looks the same and that the food will be prepared in a clean, safe environment. When you see a well-dressed pilot and crew walking onto an airplane that has been cleaned, fueled and prepped for flight, you assume that you are going to safely make it to your next destination.

The same thing happens when we meet people for the first time. It takes only a second, a small fraction of a second actually, to make a snap judgment about a person, whether you trust them or not, and whether you like them or not.

In the emergency room, I see all sorts of people for psychiatric consultations. I see little kids who are there with their parents, self-proclaimed drug addicts who are there to score their next fix, and elderly men who have lost their spouses and are contemplating suicide. Some of them have not bathed in weeks. Some of them wear tastefully applied makeup and have expensive haircuts. Some of them smile at me with straight, gleaming white teeth, while others have two teeth left in their head if that. Some people sit as far away from the camera as possible, face fixed in skepticism and arms tightly folded across chest in the universal “don’t bother me” sign. Others sit so close to the screen that I have a hard time seeing them at such an acute camera angle.

Before the camera comes on and my next patient is seated in front of me ready for the interview, I have had a chance to review the consultation request, vital signs, nursing notes, the doctor’s physical examination, lab reports, EKG printouts, CT scan interpretations, and a few data bases of medical information. I have a pretty good idea which direction my inquiry will take, what details I still need, and what disease processes I’m going to be looking for before I ever physically see the patient.

When the call comes in and I see the patient for the first time, the visual cues are very important. Someone who has a flat, expressionless face may be depressed, have Parkinson’s Disease, or have had a stroke. Someone who is in constant motion, fidgeting and not able to keep still may be in active alcohol withdrawal, have akathisia from antipsychotic medications, or simply be anxious about being in the emergency room. Someone who scans the room, fearful and paranoid, may have a primary psychotic illness like schizophrenia, or they may have snorted bath salts and be high as a kite.

In spite of my training in psychiatry and many years of clinical experience across a broad variety of settings, I do the same thing you would do when I see someone on camera for the first time. I make a snap judgment, not even a conscious one at times, about the person I see. It’s human nature.

The difference is, I have been trained to put that aside and to evaluate that person based on information given to me by the requesting emergency department, results of tests and studies that have been done or will be ordered, the clinical interview and mental status examination of the patient, and the synthesis of all that data to come up with a good, solid, working diagnosis that will then drive my recommendations to the requesting doctor.

That can make all the difference in the world. A blinking, staring, uncooperative “psychiatric” patient may be in untreated status epilepticus. A severely “anxious” patient who has been confined to a hospital bed for days may be getting ready to have a massive pulmonary embolism that will kill them. A wildly agitated, threatening, hostile patient that frightens the ED staff may be in fact so paranoid that he feels he must “kill or be killed”.

In the evaluation of mental health patients, as in life in general, you can’t always judge a book by its cover.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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  • Rob Burnside

    And let’s not forget the hyperglycemic diabetic–usually elderly, living alone, combative, and often thought to be drunk or demented, or, if unresponsive–a stroke patient. They were, and probably still are, some of the most challenging assessments EMS encounters in the field.

    • Guest

      That’s if they don’t get tased to death by police first.

      • Rob Burnside

        Good point. I hope it doesn’t happen but I’m willing to bet it has. In days of yore, these patients were routinely detained in drunk tanks, and sometimes died in custody.

    • Wvrosebud29

      This could also be a hypoglycemic patient who took his insulin but didn’t eat. Such a patient was shipped up to our acute psych unit because of his confusion. Someone remembered to test his blood sugar…it was 28. After treatment he was fine and no longer confused.

      • Rob Burnside

        Yes, you’re right, it can go this way too–often with drastic consequences. But, I saw many a hypoglycemic patient come rapidly around on-scene with 100 or so ccs of D5W on board. When we encountered this, we knew right away what we had, and usually followed with an amp of Glucagon. We’d transport to the ED and most of these patients would return home the same day–a happy ending. It’s slightly amazing to me that your patient wasn’t definitively treated prior to arriving at your unit. He could well have died along the way. Thanks for reminding us.

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