When every minute counts: What workup is sufficient for diagnosis under pressure?
Determining an exact diagnosis in the ED is less important than establishing a diagnostic category to guide emergency psychiatric treatment.
Police officers bring Mr. A, age 25, to the emergency department (ED) in handcuffs after an alleged assault at work. He is calm but will provide no information about himself. ED staff don’t know if he has been using illicit substances, is on medications, or has any medical conditions.
Mr. A says the FBI is after him, but he makes no threats to ED staff. He talks about milking cows on a farm and of hearing animal sounds, though he lives in the city. After about 30 minutes, he consents to a lab draw and provides a urine sample.
Because no charges are pending and Mr. A is semi-cooperative, police remove his handcuffs and leave him in the care of two ED security officers. He is given something to eat and drink and seems fairly content. He asks how long he will need to stay in the room but does not demand to leave.
In a fast-paced ED, physicians might not notice signs of psychiatric illness, such as Mr. A’s paranoid and delusional thinking. By being familiar with techniques to manage patients’ psychiatric emergencies, you can help your ED colleagues:
- establish working psychiatric diagnoses and medical causes of psychiatric symptoms in the fast-paced ED
- maintain a safe ED environment for patients and clinicians.
What ed patients want
To understand how ED patients feel, put yourself in Mr. A’s shoes. You were at work and began to hallucinate. You believed your boss was out to harm you, and in fear you made comments perceived as threatening.
The next thing you know, you’re in a police car with handcuffs on. All of your coworkers witnessed your embarrassment. Now you are in a small ED room, wondering what’s going to happen next. Are you going to be put in a straight jacket and a padded room?
Patients may experience anxiety-provoking thoughts whether they come to the ED voluntarily or involuntarily. Fear and confusion can affect their behavior in the ED, and how providers respond to patients in crisis can escalate or de-escalate an already-difficult situation.
Psychiatric illness in the ed
Mr. A may have a psychiatric disorder, as do at least 3% of patients seen in EDs.1 This figure may be low, however:
- Kunen et al2 asserted that EDs are underdiagnosing psychiatric disorders, given a U.S. Department of Health and Human Services 1999 estimate that 20% to 28% of Americans have psychiatric illnesses. Using ED discharge records across 6 months in three emergency departments, the authors found the psychiatric diagnosis rate to be 5.27% in 33,000 ED visits.
- Another study, done in a university teaching hospital ED, showed that ED physicians trained to focus on patients’ presenting problems often missed comorbid medical or psychiatric illnesses.
In the randomized, controlled trial by Schriger et al,3 218 patients with nonspecific complaints suggesting occult psychiatric illness (such as chronic headache, abdominal pain, or back pain) completed the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire. This 27-item self-report asks questions about mood, alcohol use, obsessive-compulsive symptoms, phobias, and somatoform symptoms.
Participants were then randomly assigned to “report” or “nonreport” groups, depending on whether or not ED physicians received their PRIME-MD scores. Even when informed of patients’ psychiatric symptoms, ED physicians rarely diagnosed or treated psychiatric disorders. Lack of mental status documentation and psychiatric interviews was apparent, the authors noted.
Case continued: a toxic cocktail
Mr. A’s urine drug screen and lab results are positive for benzodiazepines, methamphetamines, and cannabis. The staff decide Mr. A will require further observation and detoxification, and he is told this. A bed is not available at the hospital, however, and calls to nearby facilities find no empty beds.
As time passes, Mr. A shows signs of agitation and arousal. He paces the examination room—his jaw clenched and his face flushed—and begins raising his voice, asking to be discharged.
Recommendations. Unpleasantness is sometimes unavoidable, but no one in the ED has tried to create an alliance with Mr. A (Box). Try to make patients’ ED experiences as positive as possible. Make it clear that you share a common goal: to help the patient feel better. In fact, psychiatric patients and emergency psychiatrists have similar ideas about what constitutes quality ED care. When surveyed,4 ED patients said they preferred:
- verbal interventions compared with medications
- a collaborative approach with ED physicians
- having medications selected for their specific problems, medication experiences, and choices
- benzodiazepines rather than conventional antipsychotics such as haloperidol.
For a safer ED, take steps to build trust
Treat patients with respect, and preserve their sense of dignity
Offer patients choices when reasonable to help them feel they have some control
Strongly (and early) encourage smokers to accept nicotine replacement to avoid withdrawal and heightened arousal
Offer food, beverages, a blanket, or other comfort measures that would not compromise safety (do not give hot coffee, in case the patient throws the cup at someone)
Allow patients to call a loved one, friend, or pastor (offer a cordless phone to avoid strangulation attempts)
Allow relatives or friends to sit and talk with the patient if this would not compromise safety
Keep patients informed on what is going on and why
Answer questions asked by the patient and family or friends
Offer oral medications first
Get to know your security staff well
A pragmatic workup
Medical illnesses such as delirium, stroke, drug toxicity, or urinary tract infections can trigger or worsen psychiatric illness (Table 1).5 Comorbidities such as diabetes, hypertension, obesity, and heart disease are common in patients with psychiatric disorders, and psychotropics can cause or exacerbate these conditions.
In the high-pressure ED, a sufficient workup for complicated medical conditions lies somewhere between extensive/unnecessary and inadequate. Thus, determining an exact diagnosis is not as important as establishing a diagnostic category to guide emergency treatment.
Think of psychiatric disorders as they are organized in DSM-IV-TR—mood, anxiety, psychotic, substance use/withdrawal/intoxication, cognitive, adjustment, somatoform, and personality disorders—and whether they are primary or secondary to a general medical condition or substance use. For example:
- Anxiety disorder secondary to a general medical condition means the history, physical exam, or lab reports suggest a medical condition is the direct physiologic cause of the mood disturbance.
- Methamphetamine-induced psychotic disorder would be the diagnosis if methamphetamines are presumed to be causing a patient’s psychotic symptoms.
Hospitalization. ED staff often develop a treatment plan based on a patient’s clinical picture and a working diagnosis. The plan hinges on deciding if the patient needs to be admitted to the hospital. Admission may be warranted for life-threatening medical conditions or safety issues, such as threats to self or others or inability to care for oneself at home. Other issues come into play—such as starting or changing medications and follow-up to ensure continuity of care—if you decide to discharge the patient.
Medical disorders that can cause psychiatric symptoms
Alcohol and drugs of abuse
Amphetamines (including methamphetamine), cocaine, heroin, Jimson weed, ketamine, marijuana, MDMA (‘Ecstasy’), LSD, PCP
Antibiotics, anticholinergics, anticonvulsants, antihypertensives, benzodiazepines, chemotherapeutic agents, cimetidine, corticosteroids, digitalis, narcotics, propranolol, sleep medications, tricyclic antidepressants
Hypertensive encephalopathy, intracranial aneurysm, metastases, normal pressure hydrocephalus, postictal nonconvulsive status, primary CNS infection, seizure disorders, stroke, subdural hematoma, tumor
Acute rheumatic fever, diphtheria, malaria, Legionnaires’ disease, pneumonia, Rocky Mountain spotted fever, sepsis, syphilis, typhoid fever, urinary tract infection
Adrenal disease, diabetic ketoacidosis, hepatic encephalopathy, hypoglycemia, pituitary dysfunction, renal disease, serum electrolyte imbalances (sodium, potassium, calcium), thyroid disease, vitamin deficiencies, Wilson’s disease
Arrhythmias, congestive heart failure, COPD/asthma, myocardial infarction, pulmonary embolism
Anemia, lupus, multiple sclerosis, temporal arteritis, vasculitis
Source: Reprinted with permission from Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000;18(2):185-90. Copyright 2000, Elsevier.
Reasonable medical assessment in psychiatric emergencies
Obtain a medical history, the best determinant of medical need
Listen to patients. If they say they have a medical condition, believe them; if they say they don’t, try to believe them
Thoroughly check vital signs
Conduct a focused physical examination
Maintain a high index of suspicion
Be selective with laboratory testing. Check:
Order blanket laboratory screening
Order an ECG in healthy young patients in the absence of clinical findings
Order chest radiography in the absence of known disease/exposure/symptoms
Source: Reprinted from Currier GW. Medical assessment on the psychiatric emergency service. Psychiatric Issues in Emergency Care Settings 2004;3(July):17, with permission from Cliggott Publishing Group of CMP Healthcare Media. Copyright 2004.
In the study of ED patient preferences,4 one-fifth of patients said they went to the ED because they lacked access to routine mental health care. Therefore, besides psychiatric conditions caused by medical illnesses, ED physicians can see patients with any primary psychiatric diagnosis, including mood and anxiety disorders and psychosis.
Under pressures of time and limited collateral information, ED staff must:
- individualize psychiatric treatment
- consider use of medications and/or restraints
- rule out life-threatening causes for psychiatric symptoms
- stabilize patients and prevent injury to self and others.
These tasks are becoming increasingly difficult as more and more patients present to emergency rooms. Nationally, ED visits increased from 19 million in 1992 to 108 million in 2000, according to the U.S. Department of Health and Human Services.1
Psychiatric patients are seeking ED care in greater numbers, and the number of those staying longer than anticipated (“boarding”) also has increased, according to a 2004 survey of 340 physicians by the American College of Emergency Physicians, American Psychiatric Association, National Mental Health Association, and National Alliance for the Mentally Ill. Surveyed physicians blamed inadequate Medicaid funding and bed shortages for the increasing ED visits.7
In crowded emergency rooms, where patients wait longer and longer to be seen, the influx of acutely ill psychiatric patients increases the risks of agitation, violence, and injury, as well as litigation.8
Case continued: going up in smoke
Recognizing Mr. A’s arousal, ED staff tries to reassure him and offers him food, something to drink, a phone Call, and a magazine. When these attempts fail to de-escalate his agitation, staff offers to make him more comfortable by giving oral lorazepam, which he adamantly refuses. He is told again that he must stay until a transfer facility is found for him.
Mr. A then demands to go outside “for a smoke.” When he is told ED patients cannot leave to smoke and is offered nicotine replacement, he begins to scream and lunges at one of the security officers. He is extremely strong, and additional officers are summoned. He retreats inside the room, slams the door, shatters the door window with a chair, and begins punching the broken glass. He slides to the floor in a vasovagal reaction at the sight of his bleeding hands but soon becomes combative again.
Staff give Mr. A IM haloperidol, 10 mg, and lorazepam, 2 mg, to manage his extreme agitation and place him in physical restraints to protect him and others. Within 25 to 30 minutes he is calm, and a safe environment has been re-established. The lacerations on his hands are sutured, and he is admitted to an inpatient psychiatric hospital for further stabilization and treatment.
No place for complacency
Mr. A’s experience illustrates how situations can become dangerous when precautions are not taken. Five steps can help you prepare and protect yourself when evaluating patients in the ED:
- seek the patient history
- evaluate the context in which the patient is being assessed
- identify arousal states (fear, anger, confusion, and humiliation)
- structure the interview for safety
- keep your guard up during the clinical encounter.9
Risk is high when law enforcement officers bring a patient to the ED. Be on guard, even if the patient is 80 years old and in a wheelchair. Complacency has no place in the ED; prepare as much as you can before interviewing the patient.
When restraints are needed. Involuntary medication and/or restraints may be necessary when reasonable interventions have failed, the patient will not cooperate, and he or she is exhibiting behavior/symptoms that could result in injury. Approximately 10% to 20% of psychiatric patients require physical or chemical restraint in the ED.10