DE-ESCALATING VIOLENT PSYCHOSIS: TELL A STORY

A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.

 

The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.

 

INTRODUCTION

Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”

 

PAST

“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”

 

PRESENT

“My job is to make you better. I am going to be talking to you and doing a physical examination.”

 

FUTURE

“When we are done we will determine the best treatments and the best place for you to continue to get better.”

 

REASSURANCE OF SAFETY

You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.

 

DEFINE THE RULES

“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”

 

SHARE POWER WHEN POSSIBLE

To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”

 

ANTICIPATORY GUIDANCE

“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”

 

RESTORATION AFTER USING FORCE

Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”

 

AGENDA SETTING

“What are you most concerned about?”

“What would you most like to see accomplished today?”

 

How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.

 

TAKE HOME POINTS:

-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict

 

References:

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.

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CAPACITY TO REFUSE CARE: DO THEY UNDERSTAND THE PAST, PRESENT, AND FUTURE?

A patient presents brought for medical clearance prior to transport to the county psychiatric facility. She is on a 5150 for being a threat to others. The patient states that she refuses the required screening tests. What do you do?

If she has the capacity to make decisions then she can indeed refuse care. Being placed on a 5150 does not take away her right to make decisions.

On a parallel note patients retain the freedom to make bad choices. A patient with a proximal aortic dissection can choose to refuse surgery, so long as he or she has capacity to make that decision.

To make a decision one must understand the situation, understand the choices, and weigh the potential consequences of each choice. I like to think of that as past, present, and future:

Past – do they understand their condition?

Present – do they understand their choices?

Future – can they express the consequences of each choice?

You go back to the patient and ask her understanding of why she is here. She yells obscenities and speaks of police persecution. You try to calm her down but she can not demonstrate understanding of her condition.

Therefore she does not have capacity to refuse standard screening for medical clearance. Urine toxicology tests are positive for amphetamines.

Take Home Points:

-A decision fundamentally requires understanding choices and anticipating consequences

-“Past, present, and future” helps jog your memory to ensure the patient understands their condition, their choices, and the consequences of each choice.

DELIRIUM: COUNTING MONTHS BACKWARD

An elderly patient is brought by family for confusion. You wonder whether this is delirium, or whether dementia may have developed. As covered in a previous post, dementia is defined by a deficit in memory as well as one other cognitive function. You can easily test for 3 item recall and clock drawing. But for those tests to be valid at all you have to exclude delirium. The hallmark of delirium is inattention.

Have them count the months backward, starting with December, to see if they can maintain attention. This is 83% sensitive and 90% specific for delirium.(O’Regan JNNP 2014) Interestingly, the addition of confirmatory tests (CAM) to improve specificity worsened sensitivity to 62%. Of course, delirium is not a binary event but exists across a spectrum. So some of the deviation from perfection could merely indicate a different location on the spectrum of illness severity. In light of its simplicity and ease of use, I recommend using months backward in your ED delirium screening. This is not a gold standard but does contribute value in raising or lowering the probability.

You assess months backward and the patient goes no further than November. You suspect delirium, and are relieved when you discover a UTI. You give the family assurance that the confusion will improve, though she will need to see the family physician in follow-up to confirm cognitive function.

Take Home Points

-Delirum, in the ED, is identified by inattention

-Have the patient count the months backward as a fast bedside screening test

PSYCHOGENIC SEIZURES

No signs are pathognomonic for psychogenic seizures, but the bedside differentiation is important because people with psychogenic seizures are often exposed to potentially harmful anti-epileptic treatments.

 

These signs only apply to patients with generalized convulsions.  We are looking for clues of volition, inconsistent with a generalized seizure:

 

Responsiveness – a patient with psychogenic seizures can sometimes be suggestible enough to cooperate with the exam during the event.  For example, I once held a bedside teaching session during a psychogenic event, explained the importance of tongue biting, then asked the patient to stick out the tongue so we could see whether she was biting her tongue.  She stuck the tongue out and earnestly moved her lips away to demonstrate tongue-biting.  Most cases are harder to diagnose.

 

Eyes closed – During an epileptic seizure the eyes are usually open.  During a psychogenic seizure they tend to be shut, often forcefully.

 

Nonrhythmic motor movements – During an epileptic seizure, motor movements go through a certain progression, the classic being tonic then clonic.  These are rhythmic and symmetrical.  A psychogenic seizure is variable, intermittent, sometimes nonrhythmic, with an emphasis on pelvic thrusting (Elvis sign).  Side to side movements are generally seen only with psychogenic seizures.

 

Vocalization – Before an epileptic seizure there might be stereotyped vocalization or a loud pitched cry, but this should not happen during the generalized convulsion. In psychogenic seizures, there might be vocalizations of crying and moaning during the convulsion.

 

Immediate return of consciousness – In psychogenic seizures we see immediate arousal. Postictal confusion indicates an epileptic seizure.

 

Specific signs of epileptic convulsion include cyanosis and stertorous (snoring) breathing. The patient with a seizure does not breathe during the event. The physician can feel under the nostril for signs of breathing in the patient suspected of having a psychogenic seizure. The back of the hand is sensitive for feeling a breath. Epileptic seizures often occur during sleep, whereas psychogenic seizures presumably would not.

 

None of these signs are considered 100% sensitive and specific.  But put together, the diagnosis can probably be made with a reasonable degree of certainty.

PSYCHOGENIC COMA AND MALINGERING: CHECK EYELIDS, COLD CALORICS

I have now heard several stories of prisoners faking a coma.  In one, he was intubated for a GCS of 8, and the first clue was that the television was mysteriously and seemingly autonomously rotated toward the patient.  Eventually they lay a trap involving blocking access to the television, and were able to catch him in the act.

Patients do of course lie to us, but many patients have psychogenic coma, where they are not intentionally fabricating the coma, which arises from psychological distress and is termed a conversion reaction.  How can physical diagnosis demonstrate to us that a patient is actually awake?

The oculocephalic (doll’s eye) responses can give either fixed eyes or reflex responses in these patients.  However, the cold caloric oculovestibular reflexes are thought to be highly sensitive and specific, though they appear not to have been studied in this population.  Irrigate an ear with 60-100mL of ice water.  A patient in a true coma with an intact brainstem shows a slow tonic deviation of the eye toward the ice. Patients with damage to the brainstem show no response.  A patient who is awake shows fast phase nystagmus away from the cold ear.

Plum and Posner write “it is the presence of normal nystagmus in response to caloric testing that firmly indicates that the patient is physiologically awake and that the unresponsive state cannot be caused by structural or metabolic disease of the nervous system.” Later on they do qualify this statement by suggesting that intense visual fixation might overcome this nystagmus in some situations.

Other findings that are not consistent with organic disease include resistance to eye opening and rapid/active eye closure once released.  Coma findings that cannot be fabricated include the slow smooth closure of opened eyelids and roving eye movements.

Apparently the rolling upward of the eyeballs upon lid opening is a voluntary act, though I have not been able to find a citation for that.  Dropping the arm on the face is commonly used, and usually helpful, though I have seen it give a misleading result.  With a thorough history and examination, the hope is that the diagnosis will become more clear.

Take home points:

Fast nystagmus away from the ice indicates an awake patient

Resistance to eye opening and active eye closure suggests an awake patient

References:

Plum and Posner The Diagnosis of Stupor and Coma. This is a classic text that is highly recommended.