Behavioral Emergency

[exodus]

Easy answer: Call the recieving hospital, let them know what you found and ask if THEY want you to continue to their facility or go through the ER first. Many times they won't mind the pt being cleared by an ER, especially if it's an off-site location.

 

[Journey]

Easy answer: Call the recieving hospital, let them know what you found and ask if THEY want you to continue to their facility or go through the ER first. Many times they won't mind the pt being cleared by an ER, especially if it's an off-site location.

Several factors may be involved here especially if it is a hospital based unit.

The hold in the ED may cancel out the direct admit which may then mean another evaluation which will require the patient to be tied up in the ED longer and not getting the necessary treatment. The patient may also lose his bed at that facility and will have to wait longer until another doctor or someone can arrange for transfer to another facility. In the meantime a bed is being occupied for a physical exam which could have been done in the psych unit especially if hospital based. Another ambulance will then have to be called to transfer the patient to another facility and possibly one where his doctor does not have privileges. Thus, the initial ambulance crew may have created a problem which so many in EMS complain about. In this example the Wake County APP makes sense but that is designed for those who do not already have a direct admit established. Although in this case the APP could have been called to talk at a more informed level with the RN and have a better understanding for the basis of the admission...hopefuilly.

 

[CAOX3]

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 . . .

See your worrying about things you have no control over, you made an attempt to obtain a report she didn't comply or didn't care. Your not going to change the work ethic of an incompetent nurse so don't even bother attempting it.

Your job now is to address the needs of the patient with or without the nurses help.

I think you did that. You fought for what you believed to be in the best interest of the patient, sometimes we don't get the results we're looking for, the point is you made the attempt and at times your just going to have to be satisfied with that.

 

[Journey]

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.

This is one problem with anonymous forums. It is very easy to seek out sympathetic advice and opinions from people who don't know you and are more than willing to support one of their own instead of seeking out more information and getting alittle education in the process from those in your immediate area like the doctor. You want everyone, and many will, to agree the RN is an idiot according to your version of the story and you also want to prove the doctor wrong. Yet, you have not shown where your assessment indicates a specific knowledge of psych patients. You also may not be aware of which EDs are better equipped to handle involuntary psych holds. There are many precautions that facility must take when these patients are in their ED. So instead of trying to justify your actions, get more informed about the protocols, facilities and laws governing your area. You can only expect others to justify your actions solely based on your story. I would like to know the RN's and doctor's side.

We can all pat you on the back in the internet way but it really does not help you with the next psych patient. Your attitude towards the RN and now this doctor may also influence your judgement for the next patient. You may keep making the same mistakes over and over because you have not looked for reliable information based on your area and your resources. I think that is a good argument for an EMT to advance their education rather than getting years of experience at a Basic level without knowing more about the many disease processes including the psych situations.

 

[IAems]

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?

This nurse works with a Local PET and refers calls to us. We work with several hospital PET groups and I have nothing but the best to say for most of them. I will admit EMT specific training was brief, and I only have an A.S. in Psychology (might as well be nothing), but any EMS provider is trained in behavioral emergencies.

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.

Couldn't agree with you more. I have actually been involved in changing local policies regarding mandatory restraint placement on non-combative, non-violent psychiatric patients and, at my own company, through the oversight of multiple mental health professionals and medical direction, instituted a psychiatric / behavioral emergency in-service involving orientation to various warning signs and symptoms of behavioral emergencies, as well as orientation to the DSM-IV-TR, and even very basic self-defense with a strong emphasis on minimizing potential harm to both the health care provider and the patient.

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

This facility's work-up does not require either or, at the very least, does not require it at intake.

This sounds more like you just don't like this nurse . . .[and] want to prove her wrong every chance you get. Your argument is sounding more personal than professional with each post you make. Learn about what others actually do first before going off on an RN whom you only see for a few minutes.

I will admit that her attitude toward patients is a little disconcerting to me. I've seen passionate nurses and they are worth their weight in gold, and I've seen burned-out providers while always trying to remember to give people the benefit of the doubt because this industry (and psychology in particular) is tough. I agree, the previous posts have been more personal than professional, but, psychology is what brought me into the industry and I sometimes get a little too worked up about it. You have given me some more things to consider, but as an EMS provider, should I be considering an admission process? And is it always best to trust someone's word just because they have letters after their name?

 

[Journey]

I will admit that her attitude toward patients is a little disconcerting to me. I've seen passionate nurses and they are worth their weight in gold, and I've seen burned-out providers while always trying to remember to give people the benefit of the doubt because this industry (and psychology in particular) is tough. I agree, the previous posts have been more personal than professional, but, psychology is what brought me into the industry and I sometimes get a little too worked up about it. You have given me some more things to consider, but as an EMS provider, should I be considering an admission process? And is it always best to trust someone's word just because they have letters after their name?

Just because another professional is not openly passionate does not mean they do not care. Some have learned to no wear their emotions on their sleeve for all to see including the patient. RNs and other health care workers may have grave info about patients that they must not show for it not being the appropriate time. They may also have worked a couple of suicide attempts or successful along with doing a few involuntary psych holds. This RN may have had to place an 8 y/o into involuntary custody who displayed anything but human behavior. In the ED one RN may work a couple of pedi codes and maybe two or 3 adult codes in a slow day. They may have had to be present to console a patient who miscarried after multiple pregnancy attempts. All of the emergencies that each ambulance brings in may land on the RN's plate. When they are caring for 10 patients at any given time, they have to adjust and not get weepy or constantly getting upset when the system is not perfect and neither are the care givers or patients. When you keep that in perspective, you can see why on the nursing forums there are not endless threads about the stupid things EMS providers do everyday when bringing or picking up patients. Yeah the nursing forums are full of ramblings but rarely do they point out the faults of other professions such as the way those in EMS do. Maybe that comes with education and more experience from working as a multidisciplinary team with many patients in your care at one time. Those in the hospital are also quick to realize their errors as the statistics show for medication. Somebody is always looking and believe me when I say if that RN sent an unstable patient to a psych unit, the incident would be noted formally and she would be expected to answer for her actions which may include the nursing board's involvement.

 

[Journey]

And is it always best to trust someone's word just because they have letters after their name?

Just like the midwife thread, if someone has higher education than you and more experience in a particular speciality, do not kick them to the curb. Use them and learn from them. EMT school specialize in very little and the even includes emergency medicine. I do respect education and experience. What might appear wrong to me might actually be correct.

Let me give you a recent practical example. In the ED, due to all the uproar about an oxygen article (and a poorly written one at that), I had an EMS crew screaming at me that I was going to kill the patient because I put them on a NRB while setting up for a BiPAP trial knowing we would probably be intubating anyway. What they didn't understand, even after myself and the physcian tried to explain, was while the SpO2 was 98%, the A-a gradient was 400 mmHg with a lactate of 7 0mmol/L in a patient who already has renal insufficiency. Until the oxygenation/ventilation and BP MAP could be stabilized to obtain a decent ScvO2, a higher level of oxygen was going to have to stay in place until other rescue measures are achieved. Thus, the EMS crew went away in anger and frustration that they couldn't "save" the patient from the idiots in the ED. I'm sure on some EMS forum, maybe even this one, they vented their frustrations about how the ED staff was harming the patient and got all to agree with them.