1. Medical Assessment of Psychiatric Patients In the Emergency Department Medical Assessment of Psychiatric Patients In the Emergency Department

2. Aim Nothing new Chance for me to present my approach to a group of psychiatrists Feedback about “what psychiatrists want”

3. Psychiatry in A&E Psychiatric presentations 2 to 15% Often poorly managed in A&E - we don’t like psych patients - not “reg-worthy” - defered to junior doctors with minimal input form senior staff

4. Psychiatry in A&E Often poorly managed in A&E (cont) - lack of knowledge of psychiatry - time constraints - noisy & chaotic environment - lack of incentive

5. Psychiatry in A&E Because we KNOW you will sort them out for us

6. Psychiatry in A&E Can we at least recognize a patient with a psychiatric illness? - not so much

7. Medical Clearance “They’re Doctors. Why can’t they clear their own bloody patients?” A&E Consultant, My Lounge Room, 3/08

8. Medical Clearance Often used, rarely defined 3 common uses in A&E literature - psych patient with no medical illness - comorbid illness is not the cause of their current symptoms - medical condition that no longer needs treatment eg OD after a period of observation

9. Medical Clearance Depending upon the use, “medically cleared” may incorrectly imply that there is no comorbid disease Reinforces the idea that a psychiatric illness is not a medical illness (and by extension, psychiatrists are not doctors)

10. Medical Clearance A&E literature is unhelpful Written as if the patient presents to triage with a known psychiatric illness and my job is simply to determine if there are any comorbid medical conditions

11. Medical Clearance In reality, patients present with “psychiatric symptoms” and my role is to: 1) determine if the cause is a psychiatric (functional) illness or a medical (organic) illness 2) identify any medical cormorbidities

12. “Psychiatric Symptoms” Altered mood Altered behaviour Altered thought or cognition Altered perception

13. “Psychiatric Symptoms” May be caused by or aggravated by a medical illness Incidence is unclear - 6 to 75% range quoted in A&E literature Medical illness is a significant cause of “psychiatric symptoms”

14. “Psychiatric Symptoms” Unfortunately, medical illnesses often go unrecognized due to inadequate and poorly documented medical assessment in A&E Tintinelli (1994) - assessment of: mental state 40 – 80% LOC 80 – 95% orientation 70 – 90% full motor exam 50 - 60% cranial nerves 20 – 55%

15. “Psychiatric Symptoms” Reeves (2000) 64 patients with medical illness admitted inappropriately to a psychiatric unit - full history 66% - vital signs 90% - full physical exam 65% - full mental state exam 0%

16. “Psychiatric Symptoms” Much discussion in the A&E literature about the need for a standardized approach to psychiatric patients Failure to recognize the problem as highlighted by the previous studies

17. “It’s not rocket science. We aren’t doing the basics.” Michael Vaughan, England Captain 2007

18. “Psychiatric Symptoms” Problems with medical assessment are not due to a lack of imaging or esoteric blood tests. The problem is a failure to do a thorough history, examination and mental state examination ie we aren’t doing the basics

19. Medical Assessment I don’t need to know how to manage a patient with a psychiatric illness. I just need to know how to distinguish between patients with a medical and psychiatric illnesses I also need to identify any cormorbid condition in a patient with a psychiatric illness

20. Approach to Medical Assessment Stable / Unstable Danger to Self or Others Detailed History - medical & psychiatric - from multiple sources eg family, ambo’s, bystanders

21. Approach to Medical Assessment Full physical Examination - head to toe eg head / neck / CVS / lungs / abdo neuro / periphery / skin - includes vital signs eg BP, HR, RR, Temp, BSL, RAIR sats

22. Approach to Medical Assessment Mental State Examination Confusion Assessment Method (CAM) Alogrithm - delirium screen

23. Investigations No consensus on the need for Ix’s A shotgun (“House”) approach is low yield Tailor the Ix’s to the individual - Hx, PE, MSE will identify most patients with a medical illness

24. Investigations Investigations tailored to the individual - look for “Red Flag” signs & symptoms - may be none required in a “frequent flier” with their usual presentation - may be extensive in a first presentation or in a patient with a suspected delirium

25. Approach to Medical Assessment At this point you should be able to make a provisional diagnosis of a psychiatric or medical illness You should be able to identify cormorbidities that may be acute or chronic and stable or unstable

26. The Psych Reg Now I can call the psych reg After psych assessment - admit or discharge - if admission is warranted, we can work out where is the best place (based on any cormorbidities indentified) - if the patient doesn’t need psych admission, I can refer to a medical team if warranted or discharge the patient

27. “Red Flags” For Organic Illness Abnormal vital signs No previous psychiatric history Over 40 (increasing age = increasing suspicion) Focal neurology Altered memory or LOC Disorientated

28. Clues for an Organic Cause Age less than 12 or greater than 40 Sudden onset (hours to days) Fluctuating course Disorientation Decreased consciousness Visual hallucinations No psychiatric history Emotional lability Abnormal vitals / physical examination findings History of substance abuse or toxins

29. Clues for a Functional Cause Age 13 to 40 years Gradual onset (weeks to months) Continuous course Awake and alert Auditory hallucinations Psychiatric history Flat affect Normal physical examination findings

30. CAM Diagnostic Algorithm The diagnosis of delirium by CAM requires the presence of features 1, 2, and either 3 or 4: Feature 1: Acute onset and fluctuating course Was there an acute change from the patient’s baseline? Did the (abnormal) behavior fluctuate in severity? Feature 2: Inattention Did the patient have difficulty keeping track of what was being said? Feature 3: Disorganized thinking Was the patient’s thinking disorganized or incoherent (rambling conversation, unclear or illogical flow of ideas)? Feature 4: Altered level of consciousness Overall, would you rate this patient’s level of consciousness as alert (normal), vigilant (hyperalert), lethargic (drowsy, easily aroused), stupor (difficulty to arouse), or coma (unarousable)? (Any answer other than “alert” counts.)

31. Conclusion 1 Many patients with “psychiatric symptoms” have a medical illness that caused or exacerbated their presentation ED doc’s often report a patient as medically clear despite an incomplete evaluation

32. Conclusion 2 If we approach a psychiatric patient like any other patient, we may make less mistakes The term medically clear should be abdondoned We need a thorough and clearly documented medical assessment

33. Conclusion 3 This approach is probably unrealistic in a busy emergency department.