Behavioral Emergency

[IAems]

So, was there an underlying medical cause?

Called to respond to a board & care for an involuntary psychiatric hold written prior to arrival for "danger to others" by a registered nurse (who is part of a local psychiatric evaluation team). I arrive on scene to find the patient ambulatory and wandering the hallways, with the RN assessing the patient behind a bulletproof glass screen (having made no actual patient contact). The patient is scared off by my uniform and wanders down to her room. RN dismissively gives a report which pretty much is summarized by, "Your patient's in room 24" (it was like trying to pull teeth to even get a med list which included only Prozac and Topamax).

Upon patient contact, patient exhibiting anxiety with severe dissociative speech (either conduction or jargon aphasia, e.g., "I have two stomachs but the moon can hardly be held responsible for a syllable. YOU HAVE NO FEET!! You have no feet.") The RN denies any immediate trauma. With a verbal GCS response of 3, I can't really obtain any sort of verbal assessment; this patient wouldn't even respond, "yes" or "no" or shake their head. Pupils are bilaterally dilated to about 6mm but equal and responsive to light. V/S as follows; HR: 136 W/R, RR: 20 (No accessory muscle use or increased effort of breathing, but seemingly increased tidal volume), BP 150/90, BGL 146. No facial droop. No slurred speech.

Now I'm aware that this sort of speech disorder is common of Schizophrenia, but the RN denies any such history, stating, "Patient only has Bipolar Disorder." To which, I ask about the Topamax which I believe is for Seizures and am told, "No, no, no." When I bring up the tachycardia and hypertension, I'm told, "She's just anxious." So, I transport the patient to the requested facility (12 minutes out) as I'm hoping that the patient's primary physician will be able to answer some of these questions, but instead of taking directly to the psychiatric ward as requested, I decide to clear the patient through the ER for a medical evaluation first.

Well, apparently, according to the doctor, I should have followed the nurse's orders and taken the patient directly up to the psychiatric floor, which I disagree with. The reason for this, I was told, was that ER departments are unable to deal with involuntary psychiatric patients without prior notice (on that note for US practitioners: Is there some sort of EMTLA exception for psychiatric patients that I'm unaware of). Anyway, my patient was apparently medically cleared in a very short period of time, suggesting my assessment was lacking.

Did I overreact? Was this simply undiagnosed schizophrenia masking the symptoms of an anxiety attack? Was I wrong in seeing the apparent S/S of a possible OD? What about postictal from a recent, unwitnessed seizure as the Topamax suggests? Let me know what you think or where to look to learn more. Thanks

 

[Aidey]

Topamax, along with a number of other seizure medications are commonly used for bipolar disorder. This includes Lamictal, Depakote, Tegretol, and Trileptal.

Both severe manic and depressive episodes can cause psychosis. Given the limited information available I doubt I would have taken the pt to the ED rather than the psych ward.

 

[Anjel]

sounds like a mental break to me and possibly onset of a new condition. Or one no one knew they had anyway.

I used to work in a psych office and what you described is pretty common.

I probably would of taken them straight to the psych ward.

 

[bigbaldguy]

We're told over and over again to always err on the side of caution. If the patient bumps his head use full C spine precautions. If the patient says their stomach hurts do a 12 lead ect. Then when we do, we get hammered for over reacting. It's just a tough call all around where you draw the line. I think it just comes down to experience (which I don't have) in making these desicions. Did you over react, maybe but if this patient was having a stroke or something and you didn't check your hunch you'd get hammered for that too, maybe more than hammered maybe sued fired ect. I guess all guys like you and me can do is keep looking like the occasional idiot who over reacts rather than run the risk of letting our inexperience kill someone because we're too proud to admit we just aren't sure about something.

 

[Farmer2DO]

I absolutely would have taken the patient to the ED. Only documented psych hx is bipolar, with an altered mental status not completely explained by the history. Also, a HR of 136 is pretty excessive. None of our psych departments here would even consider taking this patient.

As far as I know, there is no EMTALA exception for psych. I think the hospital was handing you a line of crap because they didn't want to deal with a psych. Also, I take orders from physicians, not nurses.

You were completely correct and appropriate in doing what you did.

 

[BandageBrigade]

How does emtala apply? Patient was a direct admit to the hospital, the hospital had accepted care. They were not refusing the patient in anyway. There had to be a doctors orders for the patient to be admitted; as far as I know a nurse cannot get a patient admitted without a physicians orders.

 

[Farmer2DO]

How does emtala apply? Patient was a direct admit to the hospital, the hospital had accepted care. They were not refusing the patient in anyway. There had to be a doctors orders for the patient to be admitted; as far as I know a nurse cannot get a patient admitted without a physicians orders.

EMTALA applies because it mandates an appropriate medical screening examination. Where I am, that doesn't happen in psych. A patient with a HR of 136 and unexplained AMS needs to be examined medically.

The doctors order most likely came over the phone, from the nurse sitting behind to bullet proof glass that hadn't assessed the patient. That doesn't count as a medical screening evaluation. If this patient went to psych with a HR of 136 and later had a bad outcome (let's say PE) and was unable to verbalize their complaints, for whatever reason, everyone involved would have their a$$ in the frying pan. IAems assured that he wouldn't be part of the campfire, and tried to ensure appropriate care for his patient at the same time. I still say, good choice to go to the ED.

 

[8jimi8]

Direct admits are usually MD to MD phone consults. Having an MD order lretty much clears you to bypass the ED, no? I have directly interfered with a discharge (for direct admit) to a psych facility by using the words uncontrolled chest pain second to pulmonary hTN. The receiving MD refused the pt upon hearing my assessment. So possibly the answer was calling med control? What do you think?

 

[IAems]

If only . . .

So possibly the answer was calling med control? What do you think?

In LA, BLS does not make contact with med-control (which for us is base hospital contact), only ALS does. No kidding. I have brought this problem up to the County on multiple occacions only to be dismissed. I wish I and my fellow basics could contact med-control for orders in these unusual circumstances, but you're kind of on your own. Also, since I'm not directly hearing the order from the physician, I can't assume that a physician made any such order, especially at a board and care which may or may not have physician oversight. If this was hospital to hospital that would be one thing, but we're talking about a board and care where patients wander hallways left to their own devices and come and go as they please. For all I know this could have been controlled substances. . . It wouldn't be the first time I've seen it at a board and care.

 

[Seaglass]

I don't think your choice was unreasonable, but I would've taken the pt straight to the psych floor. My reasons:

-There's nothing there that strongly indicates a non-psych emergency to me. Misdiagnosis, maybe--this could be the first presentation of schizoaffective disorder--but not a head injury or something similar. Those vitals are worth another look, but may not be all that scary, depending on the patient. For someone young, out of shape, and agitated, I wouldn't be too worried.

-The psych floor may actually be more likely to recognize a non-psych emergency. In my experience, a lot of providers outside that specialty will chalk up everything they see to the psych issue, no matter how poorly it fits.

All that being said, I'm used to good psych facilities. If I didn't have those, or I knew the ED staff was good with psych pts, I'd have gone there. Regardless, I would've called med control. CYA.

 

[jccilm]

I don't think your choice was unreasonable, but I would've taken the pt straight to the psych floor. My reasons:

-The psych floor may actually be more likely to recognize a non-psych emergency. In my experience, a lot of providers outside that specialty will chalk up everything they see to the psych issue, no matter how poorly it fits.

So you're saying that because the psych department was definitive care that they would do a better job at treating the patient than the ED?

 

[firetender]

This involves a common problem with calls like this; TRUST.

I really don't trust the RN's at the facility either. They had negligible patient contact, therefore no real physical evaluation went on. Compound that with not really trusting the patient to provide accurate data to work with and you have a reason to have a more thorough evaluation of the patient done at an ER prior to admission in the Psych ward. You were between a rock and a hard place and acted appropriately.

 

[socalmedic]

@IA, yes you can contact medcontrol just call the hospital ED and ask to speak with an MICN she will tell you their recorded number. then go from there, you will have to tell them a few times that you are BLS and need a destination decision, they will be confused, the RN, this is usual just roll with it.

 

[Aidey]

Out of curiosity how do we know for sure that the RN never directly assessed the patient? Is there any indication that the RN hadn't done a more extensive assessment prior to EMS arriving on scene?

 

[IAems]

Good question, depressing answer

Out of curiosity how do we know for sure that the RN never directly assessed the patient? Is there any indication that the RN hadn't done a more extensive assessment prior to EMS arriving on scene?

I've worked with this particular RN for two years now and I can guarantee she didn't conduct a physical assessment. Sometimes a psych hold is written before patient contact, but that's a whole other issue.

 

[Aidey]

There are times when psych holds here are written before the practitioner has seen the patient and I understand why. Most of these cases are patients who are court ordered to do certain things like take their meds, not drink/do drugs, or attend weekly counseling sessions. When they violate the court order the psych hold is automatically issued.

There are also times where a friend/family member gives them enough information to warrant a psych hold. The practitioner has the ability to decide NOT to have the patient transported if the clinical picture doesn't meet what was described.

Considering the potential for things to go wrong when confronting someone in their home, I understand getting the hold paperwork ahead of time.

 

[CAOX3]

Did I overreact? Was this simply undiagnosed schizophrenia masking the symptoms of an anxiety attack?

Could be, but I dont think it changes anything.

Was I wrong in seeing the apparent S/S of a possible OD?

No you werent wrong? Its a likely avenue to explore.

What about postictal from a recent, unwitnessed seizure as the Topamax suggests?

Could be but again Im not sure it makes this an emergency, people with a seizure hx, well they have seizures.

Let me know what you think or where to look to learn more. Thanks

I think you did fine, you relayed your suspicions, thats all you can do. Im not going to come unglued because I believe the patient needs to go to the ER rather then a floor, You fullfilled your obligations, choose your battles wisely and if you plan on spending any amount of time in EMS your going to need thick skin this field is full of second guessing Monday morning quarterbacks.

 

[Seaglass]

So you're saying that because the psych department was definitive care that they would do a better job at treating the patient than the ED?

Not really. Just that I'm more likely to trust them not to be distracted by the patient's most obvious signs. (Again, this only really applies to the ones I know.)

 

[IAems]

Absolutely right, but . . .

There are times when psych holds here are written before the practitioner has seen the patient and I understand why. Most of these cases are patients who are court ordered to do certain things like take their meds, not drink/do drugs, or attend weekly counseling sessions. When they violate the court order the psych hold is automatically issued.

There are also times where a friend/family member gives them enough information to warrant a psych hold. The practitioner has the ability to decide NOT to have the patient transported if the clinical picture doesn't meet what was described.

Considering the potential for things to go wrong when confronting someone in their home, I understand getting the hold paperwork ahead of time.

I will completely agree that there should be occasional cases where a practitioner doesn't physically assess a patient prior to writing a psych hold, but when that's the rule more often than the exception, I do have a little bit of a problem. For example, I shouldn't be telling the RN about abnormal vital signs or dilated pupils, or have them completely dismiss me when I'm simply asking for clarity regarding medications. Honestly, with this particular nurse I'm lucky to (A) know where the patient is, (B) receive any sort of report, and (C) find myself in any semblance of a controlled environment. I'm not complaining, really, that's what I love about EMS, but it is nice when our fellow health care providers make some attempt . . .

 

[Journey]

I will completely agree that there should be occasional cases where a practitioner doesn't physically assess a patient prior to writing a psych hold, but when that's the rule more often than the exception, I do have a little bit of a problem. For example, I shouldn't be telling the RN about abnormal vital signs or dilated pupils, or have them completely dismiss me when I'm simply asking for clarity regarding medications. Honestly, with this particular nurse I'm lucky to (A) know where the patient is, (B) receive any sort of report, and (C) find myself in any semblance of a controlled environment. I'm not complaining, really, that's what I love about EMS, but it is nice when our fellow health care providers make some attempt . . .

Was the psych ward located in or attached to a hospital?

By stating earlier that you worked with this RN, in what capacity? Are you trained as a Mental Health professional? What psych training did your EMT training give you to make a list of differentials as they pertain to mental health issues?

Do you know how long this patient was with the RN or if there was a court or other medical professionals involved? The patient has prescription medications so some history was at least known and probably played a role in the assessment.

Psych patients benefit from getting to an environment where they can be unrestrained even if in a locked room. Being tied down in an ED in full public view with Security Guards is not an effective initiation of good treatment. Not only is it traumatic for this patient but also for the toddler who might be in the bed next to them.

If this was a hospital based or even a free standing psych unit, their admission workup normally requires an ECG and labwork.

This sounds more like you just don't like this nurse for whatever reason and as an EMT, you want to prove her wrong every chance you get. Your agrument is sounding more personal than professional with each post you make. What you are doing is proving is you may have limited knowledge of the system you work in for mental health admissions. Learn about what others actually do first before going off on an RN whom you only see for a few minutes.

And, the RN may be giving a report what she believe is appropriate for your level of training. It is not uncommon for facilities to only give limited information knowing the level of EMT. Why go indepth with medications and advanced procedures done when that report has already been given to the other facility and whatever else is in the paperwork or easily accessible on some computer systems. No physician or RN should even rely just on the information relayed to them about medications from an entry level provider who has not had any pharmacology in their training. Of course there will be exceptions but most EMTs are still just held to the knowledge in a 110 hour course.