Psychiatric patients don’t fit the usual medical mold in the ED

The ED is a hectic place.

Sore throats. Heart attacks. Dog bites. Broken bones. Strokes. Major trauma. If you work in an ED, you see it all. And then some.

Is it any wonder then, with the potential for literally thousands of medical and surgical problems to stumble through the doors of an ED, that hospitals and the bodies that accredit them demand strict, regimented, standard, reproducible emergency assessments and the forms that document them? Of course not. This insures that all the basic questions are asked, that decision trees are followed, that diagnostic criteria are carefully applied, that correct diagnoses are made, and that treatment decisions are made based on evidenced based standards of care, both local and national.

There are (at least) two wild cards in this process. Health care providers and patients.

Oh, yeah, those. Real people. Stressed people. Tired people. Hurting people. People who are throwing up and having chest pain and screaming and threatening to sue. People who are seeing their hundredth patient at the end of a double shift while trying to focus their eyes on the paperwork in front of them at the same time. Exhausted, sick, frightened, smart, superstitious, trusting, paranoid people.

Mental health patients are people. Surprised by that, are you? Yeah. They’re people, just like you and me. They just happen to pull out guns to shoot themselves when they get really depressed, or take their clothes off and get hyper-sexual when they’re manic, or put black sheets and duct tape over the windows in their houses when they think the FBI has helicopters hovering outside their house. Other than those little details, they’re pretty normal people just like you and me.

These normal people with not so normal chief complaints (“I think the federal government has put a metal bug inside my brain, right back here at the base of my skull, look Doc”) come into the ED in all sorts of ways as we’ve already discussed. Here’s the rub. These folks don’t fit the usual medical mold. Not surprised at that either, are you? Good. You shouldn’t be. Why is this a problem?

  1. A one-size-fits-all assessment in the ED does not usually address psychiatric and mental health needs fully.
  2. Substandard psychiatric histories by health care providers unfamiliar with mental health presentations often lead to the report that “the patient has been fine” and lead to inadequate assessment, diagnosis and treatment.
  3. All that hallucinates is schizophrenia and all that is agitated is bipolar disorder. The problem with that level of reductionism? Hallucinations can come from drugs, brain tumors and iatrogenic medication interactions. Agitation can come from hypoxia, angina, and impending pulmonary embolism.
  4. Patients who hit the ED doors with previously diagnosed psychiatric illness may not get the same attention when they have somatic complaints.  My “live patient” for my psychiatric boards was a middle aged man with schizophrenia who was complaining of atypical chest pain. My examiners expected that I knew schizophrenia backwards and forwards (I did). They wanted to see if I would adequately address these potentially life threatening symptoms in a previously diagnosed psychiatric patient. If I had ignored these issues and focused only on his (relatively stable) delusions and hallucinations, they would have sent me packing. I passed the boards.

The ED is often the place that mental health patients, especially if they are indigent, come for both mental health and physical assessment and treatment. Both must be addressed.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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