Psych Med Clearance

[thegenius]

Had a young psych patient the other day who we medically cleared. All the labs were normal however, the K+ was 3.2.

Ha! We got a call from the crisis facility saying they won't take the patient unless the K+ goes up, so the patient spent another 3-4 hours in the ED drinking K+, next lab test was 3.9, and everything was fine.

Got me thinking about the necessity of ordering any labs at all, or only ones that are actually needed. I'm fully aware that we, as ED physicians, order too many tests on psych patients overall for medical clearance and it is often easier to just order them for the sake of dispo, rather than spending 20-30 minutes on the phone during your shift arguing with the pinhead on the other end of the line about why you don't need certain lab tests done.

So instead of the common screening tests BMP, CBC, LFT, UA, Tox screen, EtOh, and +/- UPreg, the question really becomes whether any abnormal values from the above can cause psychosis, depression, acute anxiety, SI, HI...

I'm thinking the following can cause goofy, non-specific behavior mimicking acute psych disease...
- Sodium Level
- Cr/BUN
- Glucose Level
- WBC
- EtOH
- I'm +/- on tox screen (I often don't care if you are doing drugs)

I think the following are likely useless:
- K+, Cl-, Ca+, Mg+, Phos+
- Hg/Hct
- Platelets
- the diff on a CBC, even if you end up getting a CBC, don't get the diff!!! I had someone rejected once because the "RDW" was abnormal.
- LFTs

I think the following are situational only...
- Ammonia, TSH, UA, HCO3-

So is this entire concept just ridiculous, or is there possibly some merit?

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[GeneralVeers]

One place I work won't even evaluate a patient unless they have a mandatory CBC, CMP, Alcohol, UDS, Tylenol, and salicylate. It is so ridiculous, and they even apply it to 5-year-olds brought in by Mom for behavioral problems.

 

[thegenius]

One place I work won't even evaluate a patient unless they have a mandatory CBC, CMP, Alcohol, UDS, Tylenol, and salicylate. It is so ridiculous, and they even apply it to 5-year-olds brought in by Mom for behavioral problems.

F'ing terrible.

 

[GeneralVeers]

F'ing terrible.

Right because the major downside is that we find irrelevant abnormal labs, like a sodium of 132, or a potassium of 3.1 that delay definitive psychiatric care until "corrected".

 

[WilcoWorld]

Had a young psych patient the other day who we medically cleared. All the labs were normal however, the K+ was 3.2.

Ha! We got a call from the crisis facility saying they won't take the patient unless the K+ goes up, so the patient spent another 3-4 hours in the ED drinking K+, next lab test was 3.9, and everything was fine.

Got me thinking about the necessity of ordering any labs at all, or only ones that are actually needed. I'm fully aware that we, as ED physicians, order too many tests on psych patients overall for medical clearance and it is often easier to just order them for the sake of dispo, rather than spending 20-30 minutes on the phone during your shift arguing with the pinhead on the other end of the line about why you don't need certain lab tests done.

So instead of the common screening tests BMP, CBC, LFT, UA, Tox screen, EtOh, and +/- UPreg, the question really becomes whether any abnormal values from the above can cause psychosis, depression, acute anxiety, SI, HI...

I'm thinking the following can cause goofy, non-specific behavior mimicking acute psych disease...
- Sodium Level
- Cr/BUN
- Glucose Level
- WBC
- EtOH
- I'm +/- on tox screen (I often don't care if you are doing drugs)

I think the following are likely useless:
- K+, Cl-, Ca+, Mg+, Phos+
- Hg/Hct
- Platelets
- the diff on a CBC, even if you end up getting a CBC, don't get the diff!!! I had someone rejected once because the "RDW" was abnormal.
- LFTs

I think the following are situational only...
- Ammonia, TSH, UA, HCO3-

So is this entire concept just ridiculous, or is there possibly some merit?

You are correct. A good H&P has been shown to perform as well as or better than a battery of indiscriminate tests for Psych patients. If I can find the reference I'll post it.

 

[WilcoWorld]

Here's a meta analysis, Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%).

Ordering $1k worth of labs to detect conditions with an incidence <0.5% seems unwise, especially when you consider that in those patients the clinician probably already knew something was amiss.

 

[thegenius]

Here's a meta analysis, Across the three studies the prevalence of clinically significant results were low (0.0%-0.4%).

Ordering $1k worth of labs to detect conditions with an incidence <0.5% seems unwise, especially when you consider that in those patients the clinician probably already knew something was amiss.

I believe it. The problem arises on how much effort is one willing to put forth to win the fight with the psych / crisis people. Where I work, once people are medically cleared we transfer them to a county-approved "crisis facility" who then determines if they need inpatient psych admission and treatment. These folks are not bound by EMTALA. They can refuse anyone for any ridiculous reason. We looked at recent numbers and they have handled only like 8% of our 5150 patients over the past several months. Our ER and hospital administration is aware of this and trying to talk to them, trying to fix things, but it's a slow process and it's been like this (and getting worse) for the past several years and I don't see an end in sight.

 

[Candidate2017]

Plaintiff's lawyer: Are you aware most psych meds can cause torsades?
Psych: Yes.
PL: Did you ask the ED to correct the pt's hypo K+?
P: No.
PL: Can you explain how hypo K+ can cause torsades? This is basic MS-1 stuff.
Psych: Um...
PL: Can you explain how Prozac can cause torsades?
Psych: Um...
PL: Do you even know how to dx torsades or tx it??!
Psych: Of course! It's that wavy thing on EKG. You can use Mg IV or defibrillate.
PL: Are there EKG machines, defibrillators or IVs at the psych facility?
Psych: No.
PL: So no way to monitor or treat torsades?
Psych: No.
PL: But it's safe to take this hypo K+ pt out the ED and give them Prozac? Without correcting the K+?
Psych: But... but the ED doc called me a pinhead!

 

[thegenius]

Plaintiff's lawyer: Are you aware most psych meds can cause torsades?
Psych: Yes.
PL: Did you ask the ED to correct the pt's hypo K+?
P: No.
PL: Can you explain how hypo K+ can cause torsades? This is basic MS-1 stuff.
Psych: Um...
PL: Can you explain how Prozac can cause torsades?
Psych: Um...
PL: Do you even know how to dx torsades or tx it??!
Psych: Of course! It's that wavy thing on EKG. You can use Mg IV or defibrillate.
PL: Are there EKG machines, defibrillators or IVs at the psych facility?
Psych: No.
PL: So no way to monitor or treat torsades?
Psych: No.
PL: But it's safe to take this hypo K+ pt out the ED and give them Prozac? Without correcting the K+?
Psych: But... but the ED doc called me a pinhead!

LOL
Even more reason why ED docs shouldn't be checking K+ or anything else for that matter unless it's strongly indicated.

Psych people can check K+, Mg++ and do whatever the hell they want with it. At the end of the day they just send them back to the ED, and they will refuse to take them back unless it's normalized, and there isn't a damn thing we can do at my facility.

 

[Candidate2017]

I believe it. The problem arises on how much effort is one willing to put forth to win the fight with the psych / crisis people. Where I work, once people are medically cleared we transfer them to a county-approved "crisis facility" who then determines if they need inpatient psych admission and treatment. These folks are not bound by EMTALA. They can refuse anyone for any ridiculous reason. We looked at recent numbers and they have handled only like 8% of our 5150 patients over the past several months. Our ER and hospital administration is aware of this and trying to talk to them, trying to fix things, but it's a slow process and it's been like this (and getting worse) for the past several years and I don't see an end in sight.

From my perspective, I want to make sure the patient's heart, kidneys, liver and marrow can take a pounding from the psych meds I will administer. They must also be healthy enough to not require IV meds because I ain't got no IVs. They must also be healthy enough to go 7-10 days without any medication because I can't force meds until the judge says so. If they need IVs or meds forced NOW, then it's an emergency. So back to the ED they go.

Rejections are also based on staffing level and unit acuity. If I have 5 violent, psychotic patients, who are not yet on a court order, beating up my staff of 5'2" RNs, and requiring security and me to come in q2h, then I will not fill the open bed with another psychotic patient from the ED. They have been safe in the ED for 12 days, they can wait another 12.

It would be interesting to require EM residents to work on the psych floor and do admits. I'd hazard their admittance rate would be similar.

 

[Janders]

In general, I'm not terribly interested in "useless" psych screening tests. Having been doing this a while, I give a couple of personal caveats-->

(1) I've seen more than one patient >55yo placed to psych (or medical rehab) with NO screening labs return with hypoNa in the 110s range and/or Hg in the 5 range. Also a uremic AKI... and one guy with a Ca+ >15.
(2) My "useless" Serum Box has found an APAP AND an ASA OD in patients who denied, vehemently taking an OD or even having acute SI.

I think the UDS is useless. I agree, LFTs, K+, Mg+, Phos+, and WBC are nearly useless. I think screening 25yo patients who have had labs or other screening in the past 1-2 years is nearly useless.

I get all the labs on older people. Low yield, but I guarantee not No yield.

 

[thegenius]

From my perspective, I want to make sure the patient's heart, kidneys, liver and marrow can take a pounding from the psych meds I will administer. They must also be healthy enough to not require IV meds because I ain't got no IVs. They must also be healthy enough to go 7-10 days without any medication because I can't force meds until the judge says so. If they need IVs or meds forced NOW, then it's an emergency. So back to the ED they go.

Rejections are also based on staffing level and unit acuity. If I have 5 violent, psychotic patients, who are not yet on a court order, beating up my staff of 5'2" RNs, and requiring security and me to come in q2h, then I will not fill the open bed with another psychotic patient from the ED. They have been safe in the ED for 12 days, they can wait another 12.

It would be interesting to require EM residents to work on the psych floor and do admits. I'd hazard their admittance rate would be similar.

It sound like there is a disagreement in what the role of the ER should be -- medical clearance does not indicate the absence of ongoing medical issues. medical clearance is defined as within reasonable medical certainty, there is no contributory medical condition causing the psychiatric complaints presented, there is no concern at present for a medical emergency, and the patient is medically stable for transfer to the facility.

I think it's fine and good medicine to make sure the medicines psych give do not damage the heart, kidneys, liver, and marrow. All doctors should know about the side effects of potential treatment options. However I would argue it's not the ER job to fine tune patients to be within a narrow spectrum of lab values prior to initiation of treatment, within reason.

If psych facilities want additional services, then I think they should pay for them and have some sort of agreement in place with ERs. Not that I think that would ever happen.

Another example is someone who comes in psychotic/suicidal and their vital signs are normal. Now, for the ER, I would argue that a toxicology screen is pointless in my decision on whether the patient is medically stable in this case. Assuming everything else is OK and this is not a trick question, the patient is medically stable. If they did methamphetamine and were not psychotic/suicidal, and they came into my ED with normal vital signs, I would discharge them because doing meth in-of-itself is not a medical emergency. Yet for some reason med clearance necessitates knowledge if they did drugs. While it's helpful knowledge for psych to know if they did drugs, why can't they test for it?

Lets say an outpatient psychiatrist wishes to start medication X and he wants a normal K+ prior to treatment. Something between 3.5-5.0. The psychiatrist orders labs and the K+ returns at 3.2. This is not a medical emergency. What does the psychiatrist do? Order PO KCl? Order a redraw?

 

[WilcoWorld]

Plaintiff's lawyer: Are you aware most psych meds can cause torsades?
Psych: Yes.
PL: Did you ask the ED to correct the pt's hypo K+?
P: No.
PL: Can you explain how hypo K+ can cause torsades? This is basic MS-1 stuff.
Psych: Um...
PL: Can you explain how Prozac can cause torsades?
Psych: Um...
PL: Do you even know how to dx torsades or tx it??!
Psych: Of course! It's that wavy thing on EKG. You can use Mg IV or defibrillate.
PL: Are there EKG machines, defibrillators or IVs at the psych facility?
Psych: No.
PL: So no way to monitor or treat torsades?
Psych: No.
PL: But it's safe to take this hypo K+ pt out the ED and give them Prozac? Without correcting the K+?
Psych: But... but the ED doc called me a pinhead!

Plausible though your dialogue may be, this rationale can be used to argue for any practice. I reject it.

 

[WilcoWorld]

Oh, and just to be clear - I'll order just about any non-send out lab if it means I'll get a Psych hold admitted.
Radiographs and invasive studies - I may put up a fight.

 

[deleted109597]

For the record, all of our local psych facilities require RPRs. You know, for all the neurosyphilis out there. Heaven forbid somebody Qui Tam them.

 

[GeneralVeers]

I've also had them request head CTs before when not clinically indicated. I refuse.

 

[Candidate2017]

It sound like there is a disagreement in what the role of the ER should be -- medical clearance does not indicate the absence of ongoing medical issues. medical clearance is defined as within reasonable medical certainty, there is no contributory medical condition causing the psychiatric complaints presented, there is no concern at present for a medical emergency, and the patient is medically stable for transfer to the facility.

I think it's fine and good medicine to make sure the medicines psych give do not damage the heart, kidneys, liver, and marrow. All doctors should know about the side effects of potential treatment options. However I would argue it's not the ER job to fine tune patients to be within a narrow spectrum of lab values prior to initiation of treatment, within reason.

I agree it’s not the ED’s job to optimize the pt but the ED doc’s job is to take all comers and dispo them. Optimizing them leads to faster dispo. The question I need to ask myself (and ED docs should ask by proxy): What labs can somewhat assure me this person won't die in the next 7-10 days if I locked them in an empty room on an island with no medical equipment, few medications and needed to pump a f*** ton of psychotropics into them? If you have your ducks lined up in a row, I can accept the pt. ​

If psych facilities want additional services, then I think they should pay for them and have some sort of agreement in place with ERs. Not that I think that would ever happen.

Psych facilities are heavily subsidized. Making psych facilities shoulder more costs would close them and cause the ED to become the de facto psych ward. That'd be the end of high hourly ED rates and/or 6 pph becoming standard.

Another example is someone who comes in psychotic/suicidal and their vital signs are normal. Now, for the ER, I would argue that a toxicology screen is pointless

This is the standard of care: Mental illness can never be diagnosed while a pt is intoxicated. Is the naked guy screaming he’s jesus psychotic or just on substances? A UDS/tox and a night in the ED will clarify. Alternatively you can skip the tox and sign a public, legal document attesting that it is your medical judgment that the pt needs to be deprived of his freedom due to a mental illness. When he sobers up in the AM, you’re on the hook for defamation, unlawful imprisonment AND malpractice. Only one of those 3 is covered by your malpractice insurance.

Yet for some reason med clearance necessitates knowledge if they did drugs. While it's helpful knowledge for psych to know if they did drugs, why can't they test for it?

I can do UDS/tox. But that requires me to admit them and risk it being a substance induced issue. Insurance will not reimburse a psych ward because it is not a substance abuse unit and the hospital suits get mad. Not that ED docs care about it but it is a matter of financial survival.

Lets say an outpatient psychiatrist wishes to start medication X and he wants a normal K+ prior to treatment. Something between 3.5-5.0. The psychiatrist orders labs and the K+ returns at 3.2. This is not a medical emergency. What does the psychiatrist do? Order PO KCl? Order a redraw?

Pts who require psych hospitalization are seriously ill even if all labs are normal. They have less reserve and elevated rates of death from all causes. Outpatients are more stable. Or else they'd be sent to... the ED. With a 3.2, I'll document absence of CP or palpitations, risks/benefits, reorder lytes, EKG, with F/U to PCP (all labs go to PCP) and the ubiquitous "go to ED if symptomatic." Of course PCPs sometimes send otherwise healthy 3.2s to... the ED. I've had those whilst doing time rotating through the ED.

 

[Candidate2017]

Oh, and just to be clear - I'll order just about any non-send out lab if it means I'll get a Psych hold admitted.
Radiographs and invasive studies - I may put up a fight.

Psych pts tend to punch and kick brick walls. The ED is often the last shot some psych patients get to have ortho come see them.

 

[thegenius]

Psych pts tend to punch and kick brick walls. The ED is often the last shot some psych patients get to have ortho come see them.

My guess is the poster meant someone reading the chart and believing they need an xray from a chart review. Some trust has to be given to us ED docs, we are not going to be knowingly sending untreated orthopedic emergencies to the psych ward. I'll occasionally get admitted psych patients transferred to the ED who hit the wall or whatever, and I'll get the xray. I've gotten an admitted psych patient sent to the ED requesting that I "get a Neurology consult to r/o dementia." The ER doesn't work that way, for any patients whether they are psych or non-psych.

 

[OneTwoThreeFour]

Plausible though your dialogue may be, this rationale can be used to argue for any practice. I reject it.

I believe this was specifically meant to address why OP was asked to replete K. Once the test is resulted the cat is out of the bag-you're giving arrhythmogenic meds to someone in an arhythmogenic state and choosing not to correct an abnormality. From all the liability stuff I've learned, seems like a very lose-able/settle-able case.

 

[thegenius]

I agree it’s not the ED’s job to optimize the pt but the ED doc’s job is to take all comers and dispo them. Optimizing them leads to faster dispo. The question I need to ask myself (and ED docs should ask by proxy): What labs can somewhat assure me this person won't die in the next 7-10 days if I locked them in an empty room on an island with no medical equipment, few medications and needed to pump a f*** ton of psychotropics into them? If you have your ducks lined up in a row, I can accept the pt. ​

At the end of the day there is nothing I can to assure you the patient won't die. You know...maybe psych hospitals aren't set up right then. Aren't there medical doctors at these places to help out the psychiatrists? I think the problem is that ER docs know just enough about risk, treatment side effects, pathology, etc. to know that an isolated WBC of 12, or K+ 3.2, or other kinds of similar things doesn't put the patient at increased risk of torsades from psychotropic drugs. Or any other common side effect from psychotropic drugs. And if you are giving a **** ton of drugs, that stuff will have to be monitored.

A big problem for us are diabetics who have fluctuating sugars. We had a Type 1 DM patient come to the ER 4 consecutive days from the psych facility for elevated blood sugars, and their criteria is anything > 160 comes to the ER (why 160 you ask? I have no clue). One time it was 165. LOL. The other times like 220, 260, once was 410. It is so frustrating because ER doctors are not trained, nor qualified, to medically treat chronic medical conditions, and these patients cannot be admitted. But for some reason the onus is on us to go beyond our training to do this. We are forced to do this because the psych facility "won't take the patient back."​

This is the standard of care: Mental illness can never be diagnosed while a pt is intoxicated. Is the naked guy screaming he’s jesus psychotic or just on substances? A UDS/tox and a night in the ED will clarify. Alternatively you can skip the tox and sign a public, legal document attesting that it is your medical judgment that the pt needs to be deprived of his freedom due to a mental illness. When he sobers up in the AM, you’re on the hook for defamation, unlawful imprisonment AND malpractice. Only one of those 3 is covered by your malpractice insurance.

Does a positive drug urine screen prove intoxication? (it does not). I guess I don't understand your sentence(s) beginning with "Alternatively". I think I do...

Pts who require psych hospitalization are seriously ill even if all labs are normal. They have less reserve and elevated rates of death from all causes. Outpatients are more stable. Or else they'd be sent to... the ED. With a 3.2, I'll document absence of CP or palpitations, risks/benefits, reorder lytes, EKG, with F/U to PCP (all labs go to PCP) and the ubiquitous "go to ED if symptomatic." Of course PCPs sometimes send otherwise healthy 3.2s to... the ED. I've had those whilst doing time rotating through the ED.

Well I don't think I've had a PCP send for a 3.2, but I get your point.

Very interesting and thoughtful discussion I appreciate it. The overall impression I get is that there is a broader definition of "medical clearance" by the psychiatric community. It should NOT be called medical clearance, and my impression is that there is a greater or higher expectation of making sure someone is not going to deteriorate under your care than the standard patient we discharge.

The problem I see is that we cannot "optimize" some of these patients, with the K+ 3.2, or the Type 1 DM that has a baseline Cr 2.4, and on Xarelto for a DVT with fluctuating sugars. There is a delay in psychiatric treatment as a result of this.

 

[Rendar5]

A few points:
1. UDS will not tell you if a behavior is substance-induced or not (unless a patient admits to using when confronted with results) as they are not always accurate and do not tell you what is actively in their system at the time of testing. There is a reason they are not admissible in a court of law generally. If you want something accurate you will need to send for confirmatory testing using mass spectroscopy or gas chromatography which is not doable in the ED and are send out labs.

2. Medical clearance is medical stability for inpatient treatment or incarceration depending on what you’re doing it for. It’s not just declaring that there is no medical condition causing the situation and no danger in transferring. I need to feel comfortable with them being ok for a week or so. Not just comfy with them for 12-24 hours. I always found the term medical clearance to be misleading but don’t know if there’s a better simple term. On my charts I usually write the more drawn out version I wrote above.

3.Sometimes you need labs. Sometimes you don’t. Demanding labs regardless of my evaluation is dumb and goes against ACEP guidelines and I’m pretty sure also goes against psych society guidelines. I do agree that older folks warrant further work up and those without established psych illnesses often warrant it. That said I won’t often fight it because it’s just not worth the aggravation of dealing with someone not as informed as you. Every now and then I can convince a psych place to take without labs. Fortunately I can often do just this for detox facilities and rehabs which send folks out to my ED a lot (I live in a major rehab area of the country).

4. I do understand the need for baseline labs and EKG’s when patients are going to receive various medications. I often order them for patients going to the psych facility at my hospital. Just realize this is not part of medical clearance and are done purely as a matter of courtesy.

5. Having worked at various places in Florida a K of 3.2 this is quite close to normal for our population as the great majority have K’s between 3.3 and 3.5 for some reason. I don’t usually replete until 3.1 and don’t usually get worried until like 2.7.

 

[hamstergang]

I'm a psychiatrist.

I did most of my residency at a free standing psych facility. There, we couldn't get an EKG except during certain hours (mostly morning I think) and otherwise had to call 911 if we were concerned about something. Labs also couldn't be drawn at any time and weren't processed on site. So I understood the idea of this most stringent "medical clearance."

Still, as residents we reviewed the evidence which seemed to strongly suggest a good H&P was better (maybe only just as good?) than blindly ordering all these labs and imaging, but administration couldn't be convinced. Part of the resistance was that if we evaluated the patient and needed to send them to another psych facility, they'd reject the patient without that stuff. The whole system needs to change at once, it seems.

But my job now has the psych inpatient embedded in the hospital. If we need any lab, any imaging, any consult, we could get it right away. I believe this issue exists now more due to inertia than any reasoned argument.

 

[rbnsafsadgf]

At least the ACEP policy backs this up.
Psychiatric Patient

That said I have diagnosed both neurosyphilis and hyperthyroidism who presented as psych this year.

 

[GeneralVeers]

I'm a psychiatrist.

I did most of my residency at a free standing psych facility. There, we couldn't get an EKG except during certain hours (mostly morning I think) and otherwise had to call 911 if we were concerned about something. Labs also couldn't be drawn at any time and weren't processed on site. So I understood the idea of this most stringent "medical clearance."

Our point is to let us do our job. You want us to medically clear a patient? That means we will assess and treat for any emergent, life-threatening condition. Please let us do it, and don't second-guess our tests over the phone, or try to make us do nonsense labs. If by some miracle I was able to get a psychiatrist to come in and do "psychiatric screening" I wouldn't second-guess their findings.

 

[thegenius]

At least the ACEP policy backs this up.
Psychiatric Patient

That said I have diagnosed both neurosyphilis and hyperthyroidism who presented as psych this year.

LOL
How did you diagnose neurosyphilis? I know/presume you need an LP, what made you do an LP?

Also....ACEP New Jersey chapter on protocols for medically clearing psych patients in that state. Thoughtful, but at the end of the day they recommend labs (with some caveats)
http://www.njha.com/media/33107/ClearanceProtocolsforAcutePsyPatients.pdf

 

[Stagg737]

Our point is to let us do our job. You want us to medically clear a patient? That means we will assess and treat for any emergent, life-threatening condition. Please let us do it, and don't second-guess our tests over the phone, or try to make us do nonsense labs. If by some miracle I was able to get a psychiatrist to come in and do "psychiatric screening" I wouldn't second-guess their findings.

The issue, as far as I've seen, isn't with psychiatrists not wanting to let you do your jobs. The issue is that when a patient comes to the psych unit and has a medical issue rear it's head that wasn't caught in the ED, it's not you who gets skewered by the admins. Where I've rotated/t's the psychiatrists who allowed the admission without the "proper" testing who take the heat. I've got no problem ordering lab tests myself (as a psychiatrist), but the patient will still hang out in your ED until I get the results back unless I want admins screaming that I wrongly admitted a medical patient to the psych unit.

Yea, there are some ridiculous policies out there (sending the patient to the ED for glucose of 165? Lol, wut?) but on many psych units, especially stand-alone hospitals/units, there isn't a non-psychiatrist available 24/7 or even 95% of the time if a patient has a medical need. So the labs will be a legal CYA move anyway for those few patients that do develop a medical issue and have to be transferred out or weren't properly medically cleared in the first place.

 

[rbnsafsadgf]

LOL
How did you diagnose neurosyphilis? I know/presume you need an LP, what made you do an LP?

Also....ACEP New Jersey chapter on protocols for medically clearing psych patients in that state. Thoughtful, but at the end of the day they recommend labs (with some caveats)
http://www.njha.com/media/33107/ClearanceProtocolsforAcutePsyPatients.pdf

LOL
How did you diagnose neurosyphilis? I know/presume you need an LP, what made you do an LP?

Also....ACEP New Jersey chapter on protocols for medically clearing psych patients in that state. Thoughtful, but at the end of the day they recommend labs (with some caveats)
http://www.njha.com/media/33107/ClearanceProtocolsforAcutePsyPatients.pdf

By actually taking a history and talking to the patient and family.... made the LP a no brainer.

It is interesting that the NJ policy endorses CMP, EKG, CXR... I have never gotten that I somebody I plan on admitting to psych.

 

[WilcoWorld]

By actually taking a history and talking to the patient and family.... made the LP a no brainer.

That's my point - do an H&P and order appropriate tests. It's not the "screening labs" that catch the diagnosis, it's the H&P. One of my main issues with "screening labs" is that they provide a false sense of security, and get used as a substitute for a good H&P. As such, they may put patients at an increased risk of missed Dx.

 

[Siggy]

From my perspective, I want to make sure the patient's heart, kidneys, liver and marrow can take a pounding from the psych meds I will administer. They must also be healthy enough to not require IV meds because I ain't got no IVs. They must also be healthy enough to go 7-10 days without any medication because I can't force meds until the judge says so. If they need IVs or meds forced NOW, then it's an emergency. So back to the ED they go.

Rejections are also based on staffing level and unit acuity. If I have 5 violent, psychotic patients, who are not yet on a court order, beating up my staff of 5'2" RNs, and requiring security and me to come in q2h, then I will not fill the open bed with another psychotic patient from the ED. They have been safe in the ED for 12 days, they can wait another 12.

It would be interesting to require EM residents to work on the psych floor and do admits. I'd hazard their admittance rate would be similar.

"This patient is medically cleared. Why are you delaying patient care because you don't want to spend money for more nurses and techs?"

Strangely enough, this tends to grease the wheels when trying to discharge patients from the floor to a psych unit.

 

[deleted109597]

Medically cleared=medically stable.
Thus, if I would discharge them home to take care of themselves with this medical problem, presumably the psychiatrist could also take care of it as well as a layperson. At least, as long as they gave them their meds. I've learned that diabetes can go wrong if the psychiatry ward feeds the patient but does not provide insulin. The patient knew they needed it, but nobody gave it. It turns out psychiatric illness does not make you immune to medical problems.

 

[Groove]

K 3.2? Slap a tourniquet on the pt's arm for 90 secs...redraw. K 4.9, voila. Done.

 

[Candidate2017]

Medically cleared=medically stable.
Thus, if I would discharge them home to take care of themselves with this medical problem, presumably the psychiatrist could also take care of it as well as a layperson. At least, as long as they gave them their meds. I've learned that diabetes can go wrong if the psychiatry ward feeds the patient but does not provide insulin. The patient knew they needed it, but nobody gave it. It turns out psychiatric illness does not make you immune to medical problems.

I'm not fixated with the term "medically cleared." I'm concerned whether the pt is "appropriate" for the psych ward, not that EM docs care about what that entails.

Sending psych pts to the ED for sugars in the 160s or for a neuro consult to R/O dementia is inappropriate and abusive in the above example. That's not the norm though. Also, you'd be surprised at how many psych pts refuse insulin, which we cannot force. So... off to the ED.

 

[Candidate2017]

Our point is to let us do our job. You want us to medically clear a patient?

I didn't ask you to medically clear YOUR pt. You can keep YOUR pt and treat as you see fit.

 

[Candidate2017]

K 3.2? Slap a tourniquet on the pt's arm for 90 secs...redraw. K 4.9, voila. Done.

I've had more than one EM doc tell me the tips and tricks they use to slip inappropriate pts on to the psych ward. They either can't read "psychiatry" on my white coat or lack insight to give a f***. But they wonder why their word isn't taken.

 

[thegenius]

By actually taking a history and talking to the patient and family.... made the LP a no brainer.

Well not particularly helpful, but that's OK. LPs are pretty rare in the ED, and adding a VRDL or whatever the test is to CSF is extremely rare and doesn't come back in time for the ED to make a diagnosis. I'm looking a neurosyphilis on UTD and lots of non-specific symptoms, especially in those who don't have confirmed exposure to syphilis.

 

[thegenius]

I'm not fixated with the term "medically cleared." I'm concerned whether the pt is "appropriate" for the psych ward, not that EM docs care about what that entails.

Actually I do care about what that entails, and I appreciate your comments on that matter.

Sending psych pts to the ED for sugars in the 160s or for a neuro consult to R/O dementia is inappropriate and abusive in the above example. That's not the norm though. Also, you'd be surprised at how many psych pts refuse insulin, which we cannot force. So... off to the ED.

I, as an ED doc, do have the right to do things to people in the proper scenario. If I feel they cannot make an informed medical decision then I can temporarily force interventions to save their life.

However it's not clear to me that I can do anything about the patient who has acute psychosis and is refusing their insulin. Presumably these patients first came to the ER, placed on an involuntary psychiatric hold (5150 in CA), we eventually transferred them to you medically stable, and then they come back because they refuse their insulin. I don't know if I can force them to take their insulin, or force it upon them.

ER docs, want to chime in on this? A patient could be on a perpetual hold in the ED for weeks by refusing their medicine.

Ultimately I see a conundrum whereby a patient does not have a medical emergency, does have a psychiatric emergency, but is not appropriate for the psych ward.

 

[thegenius]

I didn't ask you to medically clear YOUR pt. You can keep YOUR pt and treat as you see fit.

No no no, we are not going there. We need your help - you guys are integral in our health care system. For what it's worth, I have had very positive experiences with our Telepsychatrists at my hospital, especially when it comes to older people presenting with hallucinations. These patients need help and it was provided.

 

[Groove]

I've had more than one EM doc tell me the tips and tricks they use to slip inappropriate pts on to the psych ward. They either can't read "psychiatry" on my white coat or lack insight to give a f***. But they wonder why their word isn't taken.

They told you our closely guarded tourniquet K repletion technique eh? Suuuure they did. What other tips and tricks have the crafty EM docs told you in your vast and expansive experiences as a PGY-2 psych resident 3 months out of your intern year?

 

[Rendar5]

Do you mind sharing these special techniques because I’ve been an EM attending for 7 years and don’t know any tricks to put inappropriate patients on the psych wards nor understand why I would even want to do such a thing since it would just come back for me to take care of on my next shift.

 

[Rendar5]

Actually I do care about what that entails, and I appreciate your comments on that matter.



I, as an ED doc, do have the right to do things to people in the proper scenario. If I feel they cannot make an informed medical decision then I can temporarily force interventions to save their life.

However it's not clear to me that I can do anything about the patient who has acute psychosis and is refusing their insulin. Presumably these patients first came to the ER, placed on an involuntary psychiatric hold (5150 in CA), we eventually transferred them to you medically stable, and then they come back because they refuse their insulin. I don't know if I can force them to take their insulin, or force it upon them.

ER docs, want to chime in on this? A patient could be on a perpetual hold in the ED for weeks by refusing their medicine.

Ultimately I see a conundrum whereby a patient does not have a medical emergency, does have a psychiatric emergency, but is not appropriate for the psych ward.

If psychiatry determines patient has medical capacity to refuse insulin, then the patient can go home having refused care. And can come to the ED when they change their mind on getting medical care or have a diabetic complication and need stabilization no longer being able to refuse care. An acutely psychotic patient cannot refuse life saving treatment, but may be able to refuse less emergent treatment depending on the situation. It has to be determined on a case by case basis.

I don’t see many scenarios where a patient has to live in the ED. If a patient is being involuntarily held and has a medical issue preventing admission to psych (maybe they have certain lab values the medical director for the psych unit refuses to accept WRITTEN DOWN IN OFFICIAL REGULATIONS WHICH THEY CAN SHOW ME), he can be admitted to the medicine service and then medicine and psych can argue about this later on. I’ve had this happen on rare occasions, such as moderately abnormal Labs. Medicine gives a little push back. It it’s no different from various social admits we sometimes have to push through

 

[n2b8me]

Sometimes I roll my eyes, but I can accept another facility requesting an extra lab test, or a blood pressure to be lowered in order for them to accept my patient.
It is all about liability for them and following the regulations...
It is no big deal to me if I think it is important or indicated. We do so many tests and procedures especially in the ER that a lot of others would consider not indicated.
I appreciate the comments from Psych, AND that they are willing to take care of these people. VERY APPRECIATED!
A lot of times these patient's are for the most part ignored in the ER for hours on end, held in captivity, until they shout out for something; then they get tranquilized (again) and restrained (again).
Whatever test or treatment you want just ask... if it helps get them out of my ER dungeon - I'm all for it.

 

[d2305]

I've never seen a type 1 DM schizophrenic.

 

[BoardingDoc]

I've never seen a type 1 DM schizophrenic.

Thats because the well controlled ones don't seem schizophrenic and the poorly controlled ones are already dead from DKA.

 

[Candidate2017]

What other tips and tricks have the crafty EM docs told you in your vast and expansive experiences as a PGY-2 psych resident 3 months out of your intern year?

Glad you can count. That’s 8.25 months working the psych wards if you’re keeping track. Guess which colleague the ED docs call and ask to admit their pt to the psych ward? Hint: it ain't the sr residents or the faculty.

If you must go there and mock my training:
What % of your ED pts have a chief psych complaint? Have a psych hx? Are on psych meds? Have a personality disorder?
And your EM program required you to work how many months on the psych ward?
Our psych interns spend time functioning as EM interns (because it's important for us to understand ED flow, sick vs not sick, handling acute issues), so surely your EM residency had you spend a couple of months on the psych wards?

What'd you say, my man? ZERO months of psych?

There are a minority of callous ED docs like you who just move meat, but there are many wonderful, kind, patient, ED docs who treat even the most marginalized pts with respect. I appreciate their hard work and the predicament they are in.

 

[Rendar5]

Glad you can count. That’s 8.25 months working the psych wards if you’re keeping track. Guess which colleague the ED docs call and ask to admit their pt to the psych ward? Hint: it ain't the sr residents or the faculty.

If you must go there and mock my training:
What % of your ED pts have a chief psych complaint? Have a psych hx? Are on psych meds? Have a personality disorder?
And your EM program required you to work how many months on the psych ward?
Our psych interns spend time functioning as EM interns (because it's important for us to understand ED flow, sick vs not sick, handling acute issues), so surely your EM residency had you spend a couple of months on the psych wards?

What'd you say, my man? ZERO months of psych?

There are a minority of callous ED docs like you who just move meat, but there are many wonderful, kind, patient, ED docs who treat even the most marginalized pts with respect. I appreciate their hard work and the predicament they are in.

Glad you can count. That’s 8.25 months working the psych wards if you’re keeping track. Guess which colleague the ED docs call and ask to admit their pt to the psych ward? Hint: it ain't the sr residents or the faculty.

If you must go there and mock my training:
What % of your ED pts have a chief psych complaint? Have a psych hx? Are on psych meds? Have a personality disorder?
And your EM program required you to work how many months on the psych ward?
Our psych interns spend time functioning as EM interns (because it's important for us to understand ED flow, sick vs not sick, handling acute issues), so surely your EM residency had you spend a couple of months on the psych wards?

What'd you say, my man? ZERO months of psych?

There are a minority of callous ED docs like you who just move meat, but there are many wonderful, kind, patient, ED docs who treat even the most marginalized pts with respect. I appreciate their hard work and the predicament they are in.

He’s not callous. He’s posting a snarky response in response to your snarky response insinuating that EM docs are manipulating the system to get you to accept bogus cases and challenging you to provide examples of the tricks they supposedly let slip.
That said I do appreciate your realization that we try to treat people to the best of our abilities and toolsets available to us.

Btw some programs do have residents do some time working in a psychiatric ED. I did 2-3 months between residency and sub internship on emergency psych.

 

[NITRAS]

From my perspective, I want to make sure the patient's heart, kidneys, liver and marrow can take a pounding from the psych meds I will administer. They must also be healthy enough to not require IV meds because I ain't got no IVs. They must also be healthy enough to go 7-10 days without any medication because I can't force meds until the judge says so. If they need IVs or meds forced NOW, then it's an emergency. So back to the ED they go.
.

There isn't anyone who can ensure patients won't decompensate if they don't take their medication. That is kind of silly.

And EM docs don't get much if any medicine ward experience, either. Nor outpatient medicine. It doesn't mean they can't do it, they get plenty of experience managing chronic medical problems by people using them as their PCP. (and that is coming from an internist).

 

[Shufflin]

Inpatient psychiatrist here. The conversation has become a little lively here. Good for eating popcorn.

The ED doctors are saving our butts from the front lines of psychiatric madness. So they are 100% truly appreciated in every way. If a patient needs to come to the behavioral health unit, and they passed through the gates of the ED, I feel assured they are medically stable enough to come on in. A low lab value here and there doesn't phase me. First, I'm a very competent doctor and know how to treat basic issues, and when to ask help from the hospitalist. Second, we have access to a hospitalist. Third, the ED has never sent up someone with a dangerously high or low lab value. A marginally low potassium should not cause a block to the psych unit. We (a good psychiatrist with hospitalist as backup) should know how to take care of that or at least turn to help on the unit for guidance or a consult. That's my two cents.

Our colleagues in the ED see psych issues on every shift, and over time become proficient at telling whether a patient needs to be admitted or not. That's all I care about. Doing that really well and discharging the riff raff will help both teams out.

 

[Groove]

Glad you can count. That’s 8.25 months working the psych wards if you’re keeping track. Guess which colleague the ED docs call and ask to admit their pt to the psych ward? Hint: it ain't the sr residents or the faculty.

If you must go there and mock my training:
What % of your ED pts have a chief psych complaint? Have a psych hx? Are on psych meds? Have a personality disorder?
And your EM program required you to work how many months on the psych ward?
Our psych interns spend time functioning as EM interns (because it's important for us to understand ED flow, sick vs not sick, handling acute issues), so surely your EM residency had you spend a couple of months on the psych wards?

What'd you say, my man? ZERO months of psych?

There are a minority of callous ED docs like you who just move meat, but there are many wonderful, kind, patient, ED docs who treat even the most marginalized pts with respect. I appreciate their hard work and the predicament they are in.

Looks like I struck a nerve?

I'm not mocking your training, I'm mocking your lack of training. Distinct difference. You are a baby resident a few months outside your intern year and haven't even mastered your craft, yet feel the need to climb in this forum and critique a bunch of seasoned EM docs that have been practicing medicine much longer than you. You see, it's a pet peeve of mine when I see posters with overinflated egos, feeling big for their britches, arrogating authoritative opinions like they've been doing this for 30 years and low and behold...it's a green behind the ears resident with too much time on their hands, stirring the pot and activating their blowhard SDN alter egos. (No offense towards residents, just this one.) You're calling me callous? You don't even know me dude, LOL. I've made one post on this thread and it was a joke about fixing a low potassium value. You were just too naive and inexperienced to recognize it as a joke. Get back to your books and patients and I hope to God you come out of residency with a better attitude than you've shown in here or you're in for a world of pain out in private practice.

Good grief, why are people paying attention to this clown. I'd much rather hear from the psych attendings and appreciate THEIR posts at least.

 

[deleted109597]

Thats because the well controlled ones don't seem schizophrenic and the poorly controlled ones are already dead from DKA.

I've seen a ESRD one that was a train wreck. Fired from every dialysis clinic in town. Medicine wouldn't admit him because he would punch. Welp, guess we just let him die then.