Episode 10: Psychiatric Emergencies

Seeking psychiatric care isn't easy. How does it work Inside the ER? Let's break it down.

If you need help please call 988 the Suicide and Crisis Lifeline.

Email us at insidetheer@gmail.com.
Visit our website at insidetheer.buzzsprout.com (episode scripts available there).

Transcript

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

Today you’re joining us for our tenth episode, entitled “Psychiatric Emergencies.” Just like our last episode about code status, this is not the funniest topic I could pick…soooooo…be forgiving if I keep a somber tone. Also I think it’s important to remind everyone that if you are having thoughts of hurting yourself please call the Suicide and Crisis Lifeline at 988.

Before I get into it, remember that you can listen to all of our episodes at our website, insidetheer.buzzsprout.com. Then maybe afterwards you’ll wanna email us at insidetheer@gmail.com with a question you’d like to hear answered on the show.

Ok so today we’re going to talk about mental health related ER visits, as in when patients come in for a potential psychiatric emergency. We’ll go over what these patients complain of, what constitutes a psychiatric emergency, what the workup consists of, what treatment is required, and finally where these patients end up after their ER visit. Why are we talking about this? Well, besides the fact that we need to destigmatize mental health treatment, it’s a very common reason for seeking care Inside the ER. These visits make up at least 5% percent of the total, but that number reaches over 10% among adolescents. In short, this topic could directly affect you or someone you love.

First off, what mental health complaints will make a patient come to the ER? Basically what you’d expect. It ranges from mild thoughts of anxiety or depression, to strong suicidal or homicidal thoughts, to actual self harm or violence, to active psychosis or hallucinations. One thing to keep in mind is that the ER may not be the best place for mild or chronic mental health complaints. If you’re in crisis or have no other option, no issue, come on in. But if you have a choice and time (as in you’re not in active danger), it may be better to visit a primary doctor or mental health professional. I’ve been lucky enough to work in ERs where a psychiatric evaluator (usually an actual psychiatrist) is available either in person or via telemedicine and going forward this episode I’ll be referencing my experiences. BUT, many ERs do not have any psych evaluator available to even talk to patients, so all they can do is transfer to a psych hospital. 

Next, what constitutes a psychiatric emergency? Essentially if a patient is a danger to themselves or others, an easy example being suicidal or homicidal ideation, abbreviated as SI or HI. So a patient who is lucid and actively suicidal say they cut themselves or overdosed on pills, sure that’s a psych emergency. That’s why it’s important to make sure patients who come in intoxicated on drugs were just trying to get high and NOT trying to overdose. A patient who is psychotic and violent due to hallucinations, delusions, paranoia, of course, that person is a danger, even if it’s not on purpose. 

Being a danger doesn’t even been to be active, it can be passive as in the person is catatonic, they’re inert, not doing anything, or just not taking care of themselves. I remember many years ago in medical school I saw a patient with schizophrenia brought in by the staff at his group home because they were afraid he was decompensating. What was the problem? Well besides not eating and not taking his medications, he was stuffing his pockets with garbage. This gentlemen met the definition of “grave disability” as while he wasn’t actively harming anyone, his mental illness prevented him from fulfilling his basic needs, like eating and hygiene, and so he got admitted. Another classic example they teach you in med school is a psychotic person minding their own business outside except it’s freezing out and they’re not wearing any clothes.

A quick aside, what do I mean by psychotic, as in having psychosis? This is a word that gets thrown around a lot. 

The National Institute of Mental Health defines it as “a loss of contact with reality. During an episode of psychosis, a person’s thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not.”

Don’t confuse this with sociopathy. A sociopath does not feel empathy for others and may engage in antisocial behaviors, but they know what’s going on around them. A person with psychosis can’t distinguish what’s going on in their own head from reality. They may be hallucinating, seeing or hearing things that aren’t there, and delusional, believing things that aren’t true.

An interesting caveat here is that if a patient is delusional or hallucinating, but not in grave harm, then we may not have the ability to force psychiatric treatment. There are many people, more than you would think, who carry on with their life and have chronic delusions or hallucinations. These thoughts are mild, been going on for years, and not a posing a danger to anyone. So, if that type of patient doesn’t want to take meds or go to a psych facility, then we can’t make ‘em.

Why do I bring this up? Because if we determine a patient Inside the ER is having a true psychiatric emergency, then they can be made to undergo psychiatric care, even if it’s involuntary. If a patient presents for suicidal thoughts and tries to bail after triaging, then that’s not allowed, they have to stay for a psychiatric evaluation. The psychiatrist will determine if treatment is necessary, and if the patient is stable for discharge (to seek care as an outpatient), or if they’re truly at risk and need be admitted to a psychiatric facility, even involuntarily.

During this process, by the way, the patient is searched and made to change into a hospital gown. Why? Cause we’d feel pretty dumb if a patient came in saying they were suicidal and then proceeded to stab themselves with a hidden knife.

In every state, if a patient appears to be suffering a true psychiatric emergency at home or wherever, there’s a procedure where they’re detained and brought to the ER by EMS or police. So ya know it’d be like the patient has schizophrenia and appears psychotic so the family calls 911. In Maryland it’s called an “emergency petition.” Basically a form that can be filled out by a mental health evaluator, a physician, police, etc, that explains why the patient needs a psychiatric evaluation. Of course, as I’ve said, the crux of this is that the patient poses a danger. 

It’s time for a break, we’ll be right back after a word from our sponsor.

Today’s sponsor of Inside the ER is…not saying you’re suicidal unless you actually mean it! Did you have a fight with your loved one and trying to antagonize them? Are you intoxicated? Are you simply bored? Well, please, for the love of fate don’t say you’re suicidal unless it’s real. If you are actually severely depressed and need help, then of course, call 988 or come to the ER. But, but, do NOT say you’re going to kill yourself to get back at your partner or for some secondary gain. If you arrive to the ER because of a suicidal comment, then we will take it seriously! That means you’re stuck with us until you can undergo a psychiatric evaluation. 

This might sound obvious to you but do you know how many times I’ve had a patient say, “I didn’t mean it, let me leave right now.” Nope, that’s not how it works. Once the process starts, there’s no stopping it. Sure, if you really didn’t mean it then maybe the psychiatrist will let you go home, but that’ll take hours, so save us all the trouble and don’t say it unless it’s legit.

And remember, if you ARE having these thoughts, then get help right away.

Now, back to the show:

Before I get ahead of myself and delve into treatment, let’s talk about an ER provider’s bread and butter here, the workup. As in what testing is needed for a patient Inside the ER with a psych emergency? The goal of the ER provider here is to medically clear the patient, as in evaluate for any potential medical causes of the patient’s condition, or for any injuries. What is required varies wildly by patient but for starters, most patients get bloodwork and urinalysis. 

It’s important for us to know if the patient has an electrolyte problem, or if they’re pregnant, or if they’re intoxicated. Inside the ER we generally measure alcohol levels in the blood for a real time assessment, but for drugs we check the urine, which will only tell us what’s been used recently. If a patient is very intoxicated, part of their medical clearance may be waiting for them to sober up because maybe their mood will change. I recently saw a patient for suicidal thoughts and in addition to  the methadone he was prescribed, he also had heroin, fentanyl, and cocaine in his urine. While not life threatening, it was definitely interesting for the psychiatrist. 

If a patient has actually harmed themselves, that’s a whole nother consideration. If they cut themselves, they may need sutures or a tetanus booster. Or if they tried to hang themselves, they may need a CT scan to rule out injuries to their spine or carotid arteries. If they overdosed on a medication, let’s say acetaminophen aka tylenol which can cause liver failure, then the ER provider will need to consult their local poison control, and maybe even start medication and admit to the hospital. The more serious the suicide attempt, the more likely they’ll end up needing a psychiatric admission. 

Screening tests aren’t needed for ALL patients, of course. An Er provider may not feel the need to get labs on a patient who’s been to the ER many times before for longstanding mental health issues. On the flip side, if a patient has new hallucinations or change in their mental status, then I will do a larger workup to make sure nothing physical is going on.

I recently saw a patient of this type. She was in her 50s, and while she had no diagnosed chronic medical or psychiatric conditions, she apparently had an episode of psychosis about 20 years ago. Since then she’d been on no medications and was functioning normally per her family, up until a week ago when she began acting strangely and had hallucinations. For her I obtained blood work, checked her urine, got a CT scan of her brain to rule out a tumor, and even when this was normal, I was still concerned something could be wrong and admitted her for an altered mental status workup. I didn’t feel confident enough to attribute it all to a psychiatric cause.

Ok let’s say a patient is medically clear, how do we treat them? What do these people need? This first depends on how the patient presents. If a patient presents calm, voicing their complaints, and agrees to be evaluated, then they may not need any medication initially. They’ll be evaluated by the psychiatrist who may advise I start the patient on an antidepressant such as escitalopram aka lexapro or an antipsychotic maybe aripiprazole aka abilify. If a patient however presents violent either from psychosis or intoxication, or tries to run away despite being suicidal, then they will be sedated and restrained for their safety and our own. 

Years ago now when I was second year resident, I helped take care of a patient with suicidal ideation, SI. When he realized he was going to be admitted, he began screaming “let me die, let me die” and tried to elope. We moved to block him and I got thrown into a metal cabinet, busting up my knee. With security’s help, we were able to restrain and sedate him and he got admitted to the psychiatric floor. I guess he was discharged at some point because months later I encountered him again, unfortunately this time he was intubated in the ICU after he drank lye, which severely burned his throat and perforated his esophagus. Very sad but the point being, we are forced to sedate and restrain patients who are a danger. Just letting them leave is not an option. 

The sedation I’m talking about is usually an antipsychotic medication, such as olanzapine aka zyprexa, given together with a benzodiazepine, so lorazepam aka ativan. If a patient just needs to be calm, then we may try the benzo on its own first. If a patient is really agitated and difficult to sedate, we may add diphenhydramine, aka benadryl, to that. Another option is ketamine, which many EMS are allowed to give to agitated patients. Often this sedation is given as intramuscular injection since establishing an IV just isn’t practical. Restraints in this case are straps to the arms and legs, which are placed just to facilitate sedation and prevent harm. It can be dangerous to keep a patient restrained too long and so they need to be removed as soon as possible, ie when the patient falls asleep or calms down.

Lastly, let’s talk about an ER doctor’s favorite, the disposition, as in, where are these patients going? Well, that depends on the psychiatrist’s evaluation. As I said earlier, some patients are deemed not at risk and therefore discharged, often prescribed medication, with a plan for outpatient care. Some patients are simply intoxicated, and when they sober up, they recant everything and are let go, directed to substance abuse treatment. And some patients are…well…probably faking it, called malingering. I’ll discuss that more in a future episode.

The patients with true emergencies, however, such as actively suicidal or psychotic, will have medication started in the ER and need to be admitted to a psychiatric institution. It will take days of supervised treatment for these patients to recover. Some ERs have on site psych units, but most of the time, that means the patient is being transferred somewhere. This is much easier said than done. As I mentioned in episode 7 about boarding, there are just not enough psychiatric units. So patients waiting for a psych transfer can board in the ER for days and days. They will be getting medication during this time of course, but the ER is a chaotic environment and often triggering to these patients. It’s an unfortunate situation with no easy fix, just something we make sure patients understand.

Well that’s about it for this episode. I hope it wasn’t too upsetting and that now you have a better understanding of the process. As I said earlier, please please if you are in crisis and need help, call the Suicide and Crisis Lifeline at 988 or come to the ER. It may not be someone’s fault if they’re suffering from a psychiatric emergency, but they owe it to themselves to seek help and we owe it to them to provide it. We need to encourage people to seek mental health care before it’s too late. It’s a difficult thing to do and we should be proud of those who take that step.

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Thanks for listening and all the best.