Psychiatric Emergencies in Other Medical Settings
Divy Ravindranath
Michelle Riba
Rachel Glick
Psychiatric emergencies can occur anywhere, including outpatient medical settings. These emergencies include unsafe, threatening, unusual, aggressive, or disruptive thoughts and behaviors from patients, families, or other accompanying individuals. Because practitioners don’t usually think of psychiatric emergencies occurring outside an emergency psychiatric or medical department, the keys to safe evaluation, assessment, management, and triage are to anticipate and plan ahead for these types of situations and be ready for all eventualities, to the extent possible. The goals are to keep patients and accompanying individuals, staff, and others safe; to recognize underlying medical conditions that could be causing or contributing to the psychiatric emergency; and to manage and refer the patient appropriately.
This chapter highlights major psychiatric problems and warning signs in the office setting as well as management and treatment suggestions. Although no one wants to imagine that these problems will occur, the worst mistake would be to think “This could not happen here.”
AGITATION, THREATS, AND VIOLENCE
Agitation is a complex state of elevated physical and mental activity. The agitated patient may be threatening, and agitation often precedes violence (1). Just before admission to a psychiatric unit in a general hospital, approximately 10% of patients exhibit violence toward others (2). Whether agitation occurs in a specialty clinic or a family medicine or primary care setting, it must be rapidly assessed and interventions made. If verbal interventions do not calm the patient, he or she should be immediately transferred to a contained environment such as a medical or psychiatric emergency department or a mental health crisis center (3). Often, the receptionist or nurse might be the first office staff member to notice something awry. There should be a safety plan that has been practiced and rehearsed ahead of time, like a fire drill, so that staff know what to do and when to do it (4).
Certain patient populations, with particular diagnostic categories, are more likely to be predisposed to agitation and violence (5). Diagnosis, history, and demographics should be considered in assessments of the potential for violence. Future violence is often best predicted by a history of violence (6). Family or friends often want to provide information to help in assessment and treatment. Clinicians are sometimes fearful about “bringing up” a history of violence, aggression or abuse, worried that things “could be stirred up.” It is best to try to get the history during the initial intake, if at all possible, and then use this information, if necessary, later in the course of patient care (7). Table 36.1 lists demographic and diagnostic factors associated with violence.
TABLE 36.1 Demographic and Diagnostic Factors Associated with Violence | ||||||||||||||
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In the office setting, there may be clues to impending violence. There may have been threatening phone calls or emails ahead of time to the office, warning the office that danger was lurking. Once the patient comes into the reception area, other patients, waiting in the area, may feel tension and may start to move away or look away. Accompanying family members may look worried or frightened and may want to let the office know that there is a problem but might not know how to do that without incurring the anger and wrath of the agitated patient. Table 36.2 lists some specific signs or signals of impending violence.
TABLE 36.2 Signs or Signals of Impending Attack | ||||||||||||||||
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Office staff concerned about an agitated person should alert the clinician as soon as possible, either by a code word, a message on the pager, or by telephone or intercom, so that preparations can
be made for dealing with the impending situation (8). If at all possible, no new patients should be brought into the clinic area or be put in between the agitated patient and the clinician.
be made for dealing with the impending situation (8). If at all possible, no new patients should be brought into the clinic area or be put in between the agitated patient and the clinician.
Approach to the Agitated Patient in the Office Setting
When approaching an agitated patient, the clinician should remember that the patient may feel threatened and perhaps paranoid. Certain actions can help prevent escalation of the situation (9). Because the psychotic, especially paranoid, patient requires more personal space to be comfortable, be sure to keep your distance. Staying at least a leg’s length away also makes it more difficult for the patient to kick, grab, or otherwise strike out at you. Take a neutral and nonthreatening stance and address the patient from an angle rather than in a confrontational fashion. Do not sneak up on or touch an agitated patient, because this may be a trigger for violence. Maintain eye contact, but be sure to keep this eye contact temperate. Keep your hands visible and available to fend off blows and also so that the patient knows you are not concealing a weapon. Be ready to flee, if needed. Keeping your feet slightly apart and balanced may facilitate this. Leave the office door open while you talk with the patient. Both you and the patient should feel that there is easy access to the door (see later in this section).
Certain verbal interventions are recommended (4). Agitated patients may resonate with your emotional state. As such, you can prevent escalation by remaining calm, showing concern for the patient, and responding in an emotionally neutral fashion. Addressing the patient with a formal title, such as “Mr.” or “Ms.,” communicates respect.
While using this approach, patients should be made aware that violence is unacceptable and that threatening behavior impedes your ability to help them. This allows you to work with the patient in meeting his or her needs, while de-escalating the situation. Be open to reasonable requests and offer threatening patients your attention and assistance in exchange for calming down. For example, you might say to the patient, “If you are more calm, we can talk about what you need. Otherwise, I’ll have to return when you are more calm so that we can talk further.” Specify behavior that is reflective of being more calm, such as sitting down rather than standing or pacing. Paradoxically, agitated psychiatric patients respond to supportive limit setting because they may fear losing control. Seeing that you are in control can be comforting to them.
If you are not successful in de-escalating the situation, do not be afraid to step back and let someone else try. Patients may respond to factors beyond our control, such as gender or prior relationship, for example. Thus, persons of the opposite gender, family members, or friends may have success where you did not.
Medications to help calm the patient may be offered if you have them readily available. An antipsychotic or benzodiazepine given orally can be quite helpful (10). Another alternative is to ask the patient or accompanying family members if they brought along any of the patient’s medications. The patient might be willing to take something from his or her own pill bottle. It is unsafe to administer injections if the patient is not appropriately restrained, because the patient’s movements may cause lacerations or break the needle.
Be aware of the surroundings (4). Know your exits. Just as when we are ready for takeoff in an airplane we are instructed to note where the exits are located, so, too, when we are confronted with a dangerous office situation we must know where the exits are and be positioned to allow escape. The patient needs to be able to exit the room without tripping over the clinician, and the clinician must see a way out without having to go in front of the patient.
Also be aware of the location of any objects that may be used as weapons (e.g., stethoscopes,
ophthalmoscopes, staplers, light furniture, pens, paperweights, letter openers) in relation to the patient and any objects that may be used in defense (e.g., pillows, sheets, light furniture) in relation to yourself.
ophthalmoscopes, staplers, light furniture, pens, paperweights, letter openers) in relation to the patient and any objects that may be used in defense (e.g., pillows, sheets, light furniture) in relation to yourself.
If there are others in the area, such as other patients or family members, who may be injured during a confrontation, you should consider asking them to leave or having staff members escort them to a safer place.
Have a prearranged system for signaling your staff that you need emergency assistance. This arrangement is invaluable if you are ever trapped in a room with an escalating patient. Such systems can include independent panic buttons, code words that can be communicated by phone, or an understanding that sessions should be interrupted by passing staff if there are signs of escalation, such as arguments in loud tones or calls for help.
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