A 50-year-old male with a history of schizophrenia presented to an ED with a chief complaint of “needing medical clearance for psychiatric placement.” The patient reported gradual onset of agitation and depression and “aching pain in the body,” including the chest. The physical exam showed a blood pressure of 205/105; the EKG revealed Q-waves in leads V1 and V2 with nonspecific lateral T-wave changes.
“He was diagnosed with psychosis, medically cleared, and sent to the psychiatric facility. Within 24 hours, he was found unresponsive in cardiopulmonary arrest and failed resuscitation attempts,” says Mark F. Olivier, MD, FACEP, FAAFP, an EP at Lafayette, LA-based Schumacher Group & Hospital Physician Partners.
The subsequent malpractice litigation alleged the EP failed to address the hypertension and EKG findings.
“There was no medical decision-making documentation by the ED provider addressing why they did not feel these EKG findings could potentially be due to acute coronary syndrome,” Olivier says. The case was settled on behalf of the hospital and the ED provider.
In this case, Olivier says, “a period of medical observation for blood pressure and glucose control, along with a cardiac evaluation, may have proved beneficial prior to transfer to the psychiatric facility.”
The term “medically cleared” may be outdated, says Michael Wilson, MD, PhD, director of UC San Diego Health’s Department of Emergency Medicine Behavioral Emergencies Research Lab, pointing to the medical screening examination required by EMTALA for all patients who present to the ED.
“If during the medical screening no physical signs or symptoms are noted to explain the chief complaint, then EPs are expected to focus on the chief complaint,” Wilson says.
If, on the other hand, the EP notes other symptoms or signs that may be causing the patient’s symptoms, then the current standard of care is to order further testing as needed for workup of this condition, Wilson says.
If the patient has an unrelated medical condition that is not detected on a reasonable screening exam, he adds, EPs are not necessarily expected to treat these.
“However, many of these, like diabetes, may still need treatment after the emergency department,” Wilson says, adding that risk-reducing practices include a careful history and physical exam, including the review of systems.
“Potential pitfalls include focusing too early on the psychiatric complaint or assuming that the patient is ‘just psych,’” Wilson notes. “This may happen if the EP is uncomfortable working with psychiatric patients.”
Dangerous Assumptions
EPs sometimes assume that delusions, hallucinations, agitation, and other psychiatric complaints are due to a psychiatric illness without performing a complete history and physical examination.
“Sometimes psychiatric patients are unwilling or unable to give a complete history,” Olivier says. In this case, he suggests these approaches:
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Try to obtain and document additional history from family, friends, emergency medical services personnel, and possibly the patient’s local healthcare provider or psychiatrist.
“This additional history may provide further insight on whether the symptoms may be due to a medical cause,” Olivier says.
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Obtain an accurate medication list to rule out medication-induced side effects, which can mimic psychiatric symptoms.
“Are any of the medications new, which could be a potential precipitant of the problem?” Olivier asks.
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Perform and document a complete physical examination, including a neurological and mental status exam, looking for medical causes for the patient’s psychiatric complaints.
“Based on your history and examination, decide whether further ancillary studies are needed to rule out organic causes of the patient’s presentation,” Olivier says.
All abnormal vital signs should be explained and not assumed to be due to a psychiatric problem, Olivier advises. Persistent tachycardia, for instance, can be caused by multiple medical conditions, including pulmonary embolism (PE). A recent malpractice case involved a patient with a history of anxiety who presented with mild shortness of breath and was diagnosed with anxiety attack and discharged — only to return days later in cardiac arrest due to a PE. The ED provider failed to obtain pertinent history of a recent hip surgery.
“Repeat vital signs to make sure they normalize prior to medically clearing the patient,” Olivier says. “If they do not normalize, document your medical decision making as to why you don’t feel the abnormality is due to a medical problem.”
Olivier cautions EPs to “be careful with fever in psychiatric patients. Fever can be a sign of infection and may present as delirium, especially in an elderly patient.”
EPs also should be particularly careful with their evaluation when diagnosing a new psychiatric illness.
“In these patients, it is especially important to make sure you attempt to rule out medical etiologies,” Olivier says.
The ED chart should reflect repeat assessments of the patient, especially prior to discharge or transfer.
“Repeat evaluations should support that the patient is ‘medically cleared,’” Olivier explains. He says this is especially important for patients who remain in the ED for extended periods of time prior to transferring to a psychiatric facility, who may get put aside while care continues for other high-acuity patients.
“Before final disposition, make it your practice to reevaluate the psychiatric patient, making sure medical issues have not developed and that he or she remains stable,” Olivier says.
The EP is responsible for determining if the patient has a medical problem as well as the psychiatric problem he or she presented with, underscores Bruce Janiak, MD, a professor in the Department of Emergency Medicine at Medical College of Georgia. If a patient reports hallucinations with a history of schizophrenia and says he or she hasn’t been taking their medication, this calls for a different approach than a patient with new onset of psychosis.
“The history is problematic, and the answers may not be as accurate as you would like, but the patient may be the only source,” Janiak says. Severe hypertension or altered mental status could end up being hypertensive encephalopathy, tachycardia could be a drug reaction, and a high temperature could be a drug reaction or infection. “Those must be ruled out, or the patient cannot be sent to psychiatry,” Janiak warns.
Once the EP has ruled out a medical condition, another legally risky scenario presents itself: the lengthy delay for the psychiatric consult, during which time the patient could worsen. “When psychiatry says, ‘We’ll be there in 24 hours to see the patient,” there isn’t a lot we can do at that point,” Janiak says. “The patient is in limbo.”
SOURCES
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Bruce Janiak, MD, Professor, Department of Emergency Medicine at Medical College of Georgia, Augusta. Phone: (706) 721-1005. E-mail: [email protected].
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Mark F. Olivier, MD, FACEP, FAAFP, Emergency Physician, Schumacher Group & Hospital Physician Partners, Lafayette, LA. Phone: (337) 354-1125. Fax: (337) 262-7275. E-mail: [email protected].
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Michael Wilson, MD, PhD, FAAEM, Director, Department of Emergency Medicine Behavioral Emergencies Research Lab, UC San Diego Health System. E-mail: [email protected].
