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Mental health in the ed
- 1. Mental Health in the ED DR IAN TURNER
- 2. Common Presentation Types Self-harm Mood disorders Psychotic episodes Acute behavioural disturbance Personality disorders Combinations
- 3. Challenges Resource intensive Delay in assessment can result in escalation Safety Legislation Duty of care
- 4. ED Doctor’s Role? STABILISE SITUATION RISK ASSESS SEEK MEDICAL ISSUES DETERMINE LOCATION
- 5. What are your tools? Clinical skills Medications Mental health teams Legislation
- 6. Clinical Skills History Examination Collateral Relevant investigations Mental state examination
- 7. history examination collateral BACKGROUND CURRENT TREATMENT SOCIAL CIRCUMSTANCE MEDICAL FINDINGS RISK ASSESSMENT
- 8. mse APPEARANCE / BEHAVIOUR ATTITUDE SPEECH AFFECT / MOOD THOUGHT PERCEPTION COGNITION INSIGHT/JUDGEMENT
- 11. risk assessment 90% OF SUICIDES HAVE A DIAGNOSABLE MENTAL DISORDER RISK FACTORS PROTECTIVE FACTORS
- 12. risk assessment TRAAPPED SILO SAFE TRAAPPED SILO = INCREASE RISK SAFE = DECREASED RISK
- 13. risk assessment T – TRIGGER R – RATIONAL THINKING LOSS A – AGE A – ACCESS TO MEANS P – PREVIOUS ATTEMPTS P – PREVIOUS PSYCHIATRIC CARE E – EXCESSIVE ETOH/DRUGS D – DEPRESSION/HOPELESSNESS S – SICKNESS I – IDEATION L – LACK OF SUPPORTS O – ORGANISED OR SERIOUS PLAN S – SOCIAL SUPPORT A – AWARENESS F – FUTURE ORIENTATED E – ENGAGED
- 14. risk assessment WORD YOUR ASSESSMENT USING RISK AND PROTECTIVE FACTORS RATHER THAN JUST QUANTIFYING LEVEL OF RISK DOESN’T NECESSARILY REQUIRE A DIAGNOSIS
- 15. “ ” Mr. X presents with multiple suicide risk factors including daily drug use, depression with a sense of hopelessness and a concrete plan to hang himself, which he tried to hide. He had cleared space in his garage to carry out the hanging and was disappointed when the setup was discovered by his girlfriend. He also has limited social support and a chronic medical illness which limits his ability to work. There are some protective elements such as a willingness to engage in the therapeutic process. He also does not seem to be withholding information and shows no signs of agitation or psychosis. He does, however, demonstrate debilitating anxiety which has been unresponsive to treatment in the ED. I spoke with his mother who reports that Mr. X has been making suicidal statements over the past few days with increasingly erratic behavior. Considering the above, my conservative estimate of this patient’s suicide risk is high and I feel he warrants hospitalization.
- 16. “ ” Mrs. J presents with her third suicide attempt in the last year. Again, this was an overdose of 10 homeopathic sleeping tablets with the intent of not waking up, triggered by an argument with her husband relating to her alcohol intake. This has been a constant source of conflict between them over the last year with the patient binge-drinking at the end of stressful work weeks. She has a history of depression which is being managed with anti-depressants and weekly review with a psychiatrist. She has also been attending an alcohol support group. After sobering up in the ED, she regrets her actions and is glad no harm has come to her. She has work commitments this coming week which she doesn’t want to miss and is due to see her usual psychiatrist in 3 days. I have spoken with her psychiatrist and confirmed her upcoming appointment and that he will make phone contact with the patient tomorrow. Considering the above, I find Mrs J safe to go home with her husband today. She is able to contact her psychiatrist over the weekend if needed, and I have provided her with a 24-hour crisis phone line if she is feeling unsafe.
- 18. restraint BRIEF 5 POINT PERMANENT PHYSICAL CHEMICAL
- 19. medications YOU BENZODIAZEPINES TYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS NMDA RECEPTOR ANTAGONIST SECURITY
- 20. mental health teams MANY REGIONAL VARIATIONAL COLLATERAL INFO
- 21. legislation STATE TO STATE “AT RISK” DUE TO FRAME OF MIND ASSIST IN DETAINING PATIENT
- 22. legislation ASSESSMENT ORDER MENTAL ILLNESS + SERIOUS HARM NO OTHER LESS RESTRICTIVE MEANS
- 25. “clearance” ENSURING AS REASONABLY POSSIBLE THAT NO UNDERLYING MEDICAL PROBLEMS ARE CONTRIBUTING TO THE PRESENTATION THAT WOULD PRECLUDE ADMISSION TO A PSYCHIATRIC FACILITY
- 26. “clearance” Established psychiatric diagnosis with: Lack of specific medical complaint Negative physical findings Stable vital signs You may not need to do anything if…
- 27. “clearance” Electrolyte disturbance Endocrinopathies Encephalopathies Seizure disorder Infection Medication/drug effect/withdrawal Otherwise consider:
- 29. 72 male Found by passer-by in an empty field In his car Hose pipe attached to exhaust Transferred for assessment Looks well but agitated about being found Happy to be assessed but does not want to be admitted Sedate? Section? Admit?
- 30. 17 female Found crying in bathroom by mother Brought in by mum 8 Panadol tablets because boyfriend cheated on her Worried how she will cope with upcoming exams No psychiatric history Superficial variably healed transverse incisions Sedate? Section? Admit?
- 31. 36 male Brought in by concerned wife Immigrated from Iran 1 year ago Undertaking PhD in theoretical physics 1/12 odd behaviour Reclusive, missing days at uni Writing reams of equations at home Solved the universal equation of life “complex transcendental relationship between the 39 gods of the 13 universes” “my job to inform the world” Well dressed, vigilant, tactile Sedate? Section? Admit?
- 32. 23 male Police in ambulance bay with patient in divisional van The van is rocking with louds bangs coming from inside 4 officers were required to restrain patient Patient was running naked in street initially Sedate? Section? Admit?
- 33. 27 male Arm laceration after falling through pub window Wants to go home after suturing Orientated to T/P/P Knows his phone number and address Smells of ETOH Annoyed that you want to observe him for 4 hours Wants to leave Sedate? Section? Admit?
- 34. 38 female BIBA abusive and aggressive Well known to your department “bipolar and schiz but they can’t do a fuckin’ thing about it” BAC 0.32, normal vitals Initially co-operative, over familiar Becomes rapidly violent when questioned about ETOH intake but you de-escalate her verbally She now wants “to go for a smoke” Sedate? Section? Admit?