Monday, February 08, 2010

What's A Psychiatric Emergency?

People have been writing in to respond to my Emergency! post and asking what constitutes an emergency in psychiatry. Some people are worried that I'll be taken advantage of if I'm too easy to schedule emergent appointments.

So what's a psychiatric emergency?

First, let me say that by design, I keep my life a little loose. I don't like scheduling far in advance, I don't have a secretary, I try to be accommodating and mostly this works for me. Once in a great while I feel like people are playing musical appointments and I vaguely wish it weren't so, but you can't have your cake and eat it to (unless you buy two cakes, and that might well be an option). So people who miss a lot of appointments, I tell them to call when they want to come in. You want to return in 3 months? You think I know my schedule 3 months in advance? 4-6 weeks, that's it, so call when you want to come in. I may call you and shift things. I'll be nice when you call me to shift things. So when someone calls and wants to come, it's usually fine--it's how I work my life, and it's how I make my living. No one ever calls and says "It's an emergency." What they say is "can I come in today, I'm really upset" and if I have the time, I wouldn't refuse it to make some point --hmmm what would that point be?. My post was more about the person who calls with a request for an urgent appointment who then doesn't accept the time offered. People call me because life is distressing them, and that's fine. I don't typically tell patients to go to the ER, but I don't call "I'm upset" an emergency. How often does this happen? Rarely. And I suppose I believe that part of the trade off for a no-insurance, pay-up-front doc is that I'm available, and offer a degree of availability and reachability beyond what is offered in a 9-5 clinic or from a doc with a caseload of hundreds.

So what's an "emergency?" Some things in psychiatry are clearly an emergency:
  • Suicidal thoughts or homicidal thoughts that might be acted on. Chronic suicidal ideation in someone who is certain they will not take action on is not an emergency.
  • Command hallucinations telling the patient to hurt themselves or others where the patient does not clearly identify this as something chronic and ongoing that he certain he wouldn't listen to.
  • The acute onset of psychosis, especially if it leads to bizarre behavior. When someone is doing really usual things, it indicates that they are not differentiating reality from perceptual problems and they lose judgment and become completely unpredictable.
  • Anyone walking around naked in public, for similar reasons.

  • The acute onset of mania, because behavior can be unpredictable, dangerous, and expensive.

  • Any life-threatening behavior, directed at oneself or others.

  • Really uncomfortable side effects to medications, and sometimes this is best dealt with in an ER where medications to counter the side effects can be administered by injection.

  • High fevers when a patient is on certain medications-- they can be indicative of a drop in white blood count for a patient on Clozaril or Tegretol, or of neuroleptic malignant syndrome for someone on neuroleptics.

  • Severe anxiety or panic are not 'emergencies' but it would be hard to tell that to someone experiencing their first episode, it's terribly uncomfortable, and it can be confused with a heart attack-- this is one for the ER if there are cardiac symptoms and any doubt. Unless there's a negative cardiac work-up and a known history of panic attacks, calling a psychiatrist with chest pain, shortness of breath, and other cardiac symptoms makes no sense (call 911). Most patients with known panic disorder do not identify their episodes as emergencies.
  • Really disorganized behavior-- it can be indicative of a psychosis, a delirium, or a drug intoxication.
  • An overdose of any medication because it might lead to bad things shortly. Like death.
I may have missed some things, so do chime in.

Being upset about something bad that has happened is not a psychiatric "emergency", but if you can get hold of someone who can listen and say something comforting--- including a psychiatrist -- well, it's nice when that happens.

Mostly, I leave it to my patients to define when something is an emergency. I can't imagine it's every comforting to have someone say "now that's NOT an emergency."


Anonymous said...

Do you have something on your voicemail directing clients with a medical/psychiatric emergency to call 911 or go to the nearest hospital? I don't like that, and am trying to decide as I start a private practice, what I want my voicemail to say.

Rachel Cooper said...

Severe anxiety or panic are not 'emergencies' but it would be hard to tell that to someone experiencing their first episode, it's terribly uncomfortable, and it can be confused with a heart attack-- this is one for the ER if there are cardiac symptoms and any doubt. Unless there's a negative cardiac work-up and a known history of panic attacks, calling a psychiatrist with chest pain, shortness of breath, and other cardiac symptoms makes no sense (call 911).

I had this a couple months ago. One afternoon, out of the blue, I couldn't swallow, couldn't catch my breath, had radiating pains in my arms and neck and jaw (classic MI signs in women)... Happened to be a mile from a hospital and drove myself there.

While the triage nurse took me back right away, the doc was incredulous. I've never had a panic attack in my life - but the cluster of symptoms raised the anaphylaxis/MI red flag for me.

So I learned my lesson.

About musical appointments - Dinah, if my schedule is flexible (but have a scheduled appointment for late in the day), I'll give up that appointment so someone who works all day can use it. There are only so many after work slots, I figure... and while it might mean a little juggling on the part of my shrink, I'm sure karma will come around and one day I'll need a 6:00 appointment.

Dinah said...

Anon: No.
Rach: I think this is what ERs are for. Better a false alarm then dead. Would they berate a 60 year old obese smoker for coming in with the same symptoms? I doubt it.

moviedoc said...

Anon: Unless you can pick up the phone within seconds AND offer real emergency service, I believe it is dishonest NOT to have a "hang up and dial 911" message on your VM. Even hospital emergency rooms in our community have it. Do you really want that patient with chest pain to wait until you finish an evaluation or psychotherapy session before you call them (I should say TRY to. How reliable is your phone?) call them back.

Dinah said...

Moviedoc: I think most people understand that a psychiatrist is not a cardiologist, and that 911 exists for emergencies. If a answering machine doesn't say Call 911 for lifethreatening medical emergencies, and the patient dies of a stroke, it's the psychiatrist's fault because his machine didn't say "Call 911"??? If your machine says, "In case of emergency, wait for me to return your call and do not call 911" then okay. But face it "Call 911" is a cover-your-ass medico-legal statement that has nothing to do with psychiatric care. People know to call 911 or go to the ER with a life-threatening emergency-- the Psych ERs here have plenty of business. The implication the message gives is "if you've got a problem, I'm not available". Mostly, I'm more surprised at what people don't call me for! and say "why didn't you call me?"
Seconds. No one is available in seconds (you've been to the bathroom? taken a shower?) Patients have my cell and home number, and a covering doc (not the ER) if I'm away. I guess if they're standing on a bridge ready to jump and they call....but again, common sense would dictate...

moviedoc said...

Dinah: I had all the same arguments a few yrs ago when I decided to add the call 911 message. "Most" people means 51%. Many patients don't know (or care) the difference between a psychologist and psychiatrist, and what is it about our phone numbers that informs people that we are not the kind of docs that can help with a heart attack? Probably nothing. And many don't know they have "life-threatening" emergency anyway. So I don't use that language.

Covering your ass sounds self serving, but must such strategies also help patients, and if noting else reduce malpractice awards, insurance premiums, and the cost of medical care.

Informing callers has nothing to do with assigning blame, it's about helping them get the right care at the right time.

I agree with you about the patients that don't call. I almost beg them to call about dosing questions and side effects (not emergencies), and they rarely do. When they do I screen the msgs and always get back to them the next business day, if not sooner. I don't know why any patient would stick with any doc who does not return calls.

Seconds: 911 will pick up in seconds. No bathroom. No showers.

Home and cell numbers: Now you're talking boundaries. I believe we have a right to privacy. I never let patients have those numbers.

Common sense: I hear you, but judges and juries never heard of it. Remember the lady that poured hot coffee in her crotch? Common sense tells you not to jump off the bridge. A lot of good that does. We can't count on it.

Bonnie Neighbour said...

To me this really speaks to the limits of traditional psychiatry. If the only supports an individual has to deal with his troubling symptoms are through a single provider, and the only way to see or talk to that provider is at a regularly scheduled appointment or a phone call that might (depending on the perceived urgency) be returned within 24 hours, many individuals develop a learned dependency on crisis.

An example of this might play out as follows. John is feeling upset, something bad happened at home or work and his internal response is spiraling into serious distress. In the past any calls he's made to his provider, the only person he can talk to about this stuff, have been returned the next day, if at all -- unless he's in serious crisis. People learn what they need to do to get the attention they need.

For John, his initial response to his situation was expected -- something bad happened he's upset. How many Johns do we know that, that situation or a similar one becomes a psychiatric crisis so they can get the support they needed? What sometimes get labeled Borderline Personality Disorder is really a learned response to get needs met. Do you want to be part of teaching someone crisis is what's needed to get help?

There are amazing peer groups around in every locality. Often providers, particularly psychiatrists, don't know about them, or don't trust them and don't tell the people they serve about them, or may even tell people the peer groups are not a good thing. If a person is having a distressing response to a normal life event (job loss, death in the family, fight with spouse, woke up on the wrong side of the bed, etc.) who better to help them through that than someone who has been through the same or a similar situation and response? Who is better to help, a doctor or a friend? Do we want to continue medicalizing normal responses?

That's a little off topic from "What's a Psychiatric Emergency" but rather is in response to the direction the comments are going.

It is incredibly insulting (and irresponsible) when a provider or his or her staff triages calls from patients based on a voice mail.

How much time have you spent in dialogue with your clients talking -- and listening -- about what is a crisis that requires immediate help and what tools a person might have to be able to work through distress without escalating into a crisis?

What other supports do you have in place to help patients help themselves from escalating into a crisis?

Do you, unintentionally, train your clients to create a crisis situation in order to get help when needed, effectively keeping them sick instead of helping them find wellness?

moviedoc said...

Amen, Bonnie. Crisis does not = emergency. From day one we should help patients find and use for support resources other than professionals and help them know they do not need us.

Lu said...

Dinah's position makes a lot of sense to me as a patient. "If you're having an emergency, call 911" seems almost laughablly vague and obvious, besides coming off as, "I'm not here for your self-defined emergencies." However, I'm still confused by the seemingly new definition of "emergency" in today's post. If that's what an emergency is (psychotic break, homicidal ideation, etc.), is anyone really rescheduling their hair appointment because of it?

Lu said...

Sorry, obviously I meant "is anyone really NOT rescheduling their hair appointment" (either patient or psychiatrist) to deal with the emergency.

Dinah said...

Funny, reading the comments just doesn't really resonate!

Moviedoc: If you don't want to give out your cell/home numbers for the sake of privacy, then certainly Don't! But it's not an unusual practice and it's not a boundary violation: that would imply that something 'wrong' is being done. My internist has her home number on her business card (I don't, it's in a policy sheet I give people with how to reach me). Many psychiatrists I know have their home numbers on their machines for after hours emergencies.

I don't educate people on emergencies or when to call me. I take it as it comes. How many times have I been called at home in the last decade? I'd say it averages once every two to three years. How many patients routinely call me because something bad has happened in there life? I could list them-- they were mostly extreme things: child killed in accident, child killed by gunfire. Someone once called me at home at 10:30 at night over a distressing relationship event: once, ever, I was awake, I listened, I didn't chastise, the patient did not proceed to call me with other distressing life events at home or weird hours.
So I'm not looking for problems where none exist. Patients seem to get it, they know I'm available, most calls are about scheduling issues, especially today as the snow is about to fall AGAIN ?20 more inches, where will it go?

Lu: back to my last post. Patient calls with an emergency: doc offers a 3 pm appointment. Patient in crisis says he can't make it (for a good or bad reason, doesn't matter) but he can't or won't. He can come at 4, however, but doc has hair appointment. Should doc reschedule hair appointment to accommodate patient who has already been offered a same-day appointment?

I have not found that upset people seeking quick appointments then "learn" oh, you're here at my immediate disposal. Instead, they're generally quite grateful. And pretty much all of them have other support systems and friends and family. It's the ones who don't where I find myself wishing they'd call more.

No real interest in "teaching" someone in a repeated state of distress not to call or go to ER or call 911 (they'd never do that anyway)...usually they are in an agitated depressive state and funny, once they get better, they stop calling. When it gets too overwhelming for me, this is the rare time I will hospitalize someone.

moviedoc said...

I won't say providing a home phone number is always a boundary violation or "wrong," but one should ask the question.

Danah, you said "hospitalize someone." Do you admit and attend yourself? Maybe a separate issue but related. If I think a patient needs to be in hospital, I send them to the ER. Gone are the days when I would admit them. And if I try to send them directly to psych, I know I will be grilled for 30 minutes by a triage nurse who thinks I'm an expert on the patient's finances and insurance. I consider that I am unable to "hospitalize."

itsjustme said...

My shrink gives her cell phone number (not home though) on her voicemail but I would never call it. I am tied to my blackberry for my job. I get calls and emails at all hours for absolutely ridiculous things that really could wait until business hours, so I’ve come to really value my time off and resent all the unnecessary disruptions. I fully believe in the “do unto others” theory. Although she gives her cell phone # out, to me, it calling her on it feels like I would be crossing a boundary. A while back, I left her a voicemail 1st thing in the a.m., saying that I was very upset and was hoping to get an appointment sooner than my next scheduled one. Usually calls back with in a few hours but it turned out that she was out of the office that day but stopped in at the end of the day to pick up her mail and got my message. She called me back but I missed her call, so she left me a very detailed message about how/when to reach her. She was going to be in her office for the next ½ hour, then I could reach her on her cell from this time to that time but she was unavailable for this 2 hour period but anytime that weekend. Fortunately, I got a hold of her before she left her office. If I hadn’t, I would have just waited until Monday. Ug! I have to admit that the message she left made me see her in a new light. It showed me her dedication to helping her patients and it helped me open up a little more in our sessions.

Dinah – I agree that a 911 message isn’t necessary. You’ve gotta be a major moron to leave a message on your shrink’s voicemail about a medical emergency rather than call 911 if you’re really in trouble. Darwin at work. LOL!

Anonymous said...

I had a shrink who scheduled himself, all done by cell phone. I hated that. No matter when I called it felt like I was invading.

Anonymous said...

Thank you everyone for answering my question and the discussion about voicemail.

TheCrazyMusicLady said...

I'm on board with the 911 voicemail. Not as a here is a number to dial if this is a medical emergency, but as a reminder to anyone who may be in a real psychiatric emergency who might not be organized enough to remember that 911 is an option if they are desperately in need of help at that moment.

It's like the suicide hotline in the phonebook: not used enough. Everyone knows 911 is for medical emergencies, but I tell someone at least once a week and can be used for psychiatric emergencies as well.

moviedoc said...

Psychiatric emergencies ARE medical emergencies.

Lu said...

Dinah, thanks for the reminder about your parameters. I was a little confused by what seemed like a conflict between your two posts on this subject. I admit I still find it hard to believe (not that I'm doubting your experience) that someone having that serious a problem wouldn't reschedule their own hair appointment to come in to see you (!). As for your side of it, I don't know what it's like having a psychiatric practice, so I can't say what my expectations would be. You've already offered the person a same-day appointment that works with your preexisting schedule, and that sounds like a reasonable offer, and one that should be accepted by a desperate person.

Lu said...

Although, hmm, on second thought, I really think there are too many variables here for me to have a sensible opinion on the matter. Carry on!

Sarebear said...

Response to moviedoc, and I type this as I'm crying - because I haven't learned to believe I deserve any better in a psychiatrist. I've gotten what I've gotten, and figured that's, well, . . . . that's what's been there, so that's been who I've had. The times the first one actually listened it was like we had this almost brilliant synergy, and I long for that again . . . . but the rest of the time, in contrast, it just was two different dimensions not coming together, square peg round hole, assumptions made about what I was saying that went way off in directions that were completely NOT what I was trying to say at all . . . .

And then the second dude, who didn't return calls.

Well, after six months of trying to get a psychiatrist to take me, and most were either full practice, or retiring, or not doing that kind of work, whatever that meant . . . Well, I didn't know THEN that he was going to be that kind of doctor, or that kind of well, half-assed, not very good at the whole being a doctor, doctor, but in the end, I guess I figure . . . . . He's what I deserved?

Perhaps it's no wonder he'd take me, despite his assertion that an average of 8 new people a day would call requesting to be taken on and of course a practice can't take that many on, but if your practice is having alot of patients jumping ship, . . . .

I put off looking for a new one, given my upcoming surgery at the end of last December, but it's time to look for a new one. I don't relish the thought, since it took 6 months last time (if the Surgeon doesn't pressure me into doing the other within the next 5-6 weeks, which is the end of the window for the benficial period within which to manipulate the previously operated leg under anesthesia, if it hasn't made enough progress (heck, it's gotten to within 2 degrees that the unoperated one can bend), I'll be choosing to do the next leg round about June, which is within the next 6 months), so I may not find one before the next surgery. I'm beginning to feel the need for an antidepressant more than ever - the post-surgical depression I believe has affected my recovery negatively . . . . but as complicated as finding a proper depressant, whoops, Freudian slip, the last anti-depressant WAS a depressant (Cymbalta), lol, for me is, that's not a task for my GP . . . . so here's hoping it doesn't take 6 months, and that the quality level of the practitioner is quite a bit higher than the last one. But if the quality level is higher, wouldn't it stand to reason that their practice would be full? Seeing as how their seems to be a shortage of psychiatrists around here . . . . at least so it seemed from the last search.

Continuing to read further comments . . . .

Sarebear said...

But maybe I HAVE learned that I deserve better than a psychiatrist who doesn't return calls.

Seeing as how I (pardon my French) fired his ass, in major part (not the only reason, but a large factor) for just that reason, last fall.

When I titrated myself down off of the Cymbalta, at the end of the four weeks of doing so, when I felt the suicidal ideation imposed on me by the drug leave me I became angry that I had been unaware that that effect had still been with me, as well as other negative effects from that medication (on ME, results WILL vary), I would have fired his butt all over again.

I believe perhaps I grew to believe I deserved better than he, and took action. Well, it was more inaction than action. I just stopped going to see him.

Paperdoll said...

Hey Moviedoc,

It is perhaps best for the world (patients and movie goers alike) if you stick to writing opinions and reviewing movies. If you are not up for psychotherapy and people take advantage of you (they call for "free"), then I suggest, humbly, that the problem may not lie with your patient.

As a patient, and a medical specialist myself, I can say that there are many of us who just need some guidance, when we feel like it's an emergency. Your skills are supposed to get to the point of the matter quickly, especially when you know your patient.

There are some patients that can be trusted not to abuse after hours contact details. While you talk boundary issues, difficulties and general worries about being held liable for something, there are some of us who are grateful for this lifeline and it having been given, will probably never use it.

I think it all stems from the dr-pt relationship. Review of any medical defence literature will tell you, that it is the relationship that you have with your patient that is the most important.

My vote is for Meryl Streep: Julie and Julia.

moviedoc said...

Paperdoll and Sarebear: What I should have said was, "I can't believe anyone should HAVE to stick with any professional who does not return phone calls. The problem is in some areas there is a shortage, too few choices. Paperdoll seems to have been able to find someone she likes. It's good to have choices in providers. This is not just a problem for patients either. Many professionals seem to find it too much trouble to respond to their colleagues, whether by phone or email.

As for boundary issues and giving personal phone numbers to patients: We must ask ourselves whether we are motivated by a need to be popular, to have patients like us, to send the message that we will meet their needs, or even to avoid a lawsuit. I also believe it's the doc's responsibility, not the patient's, if a patient takes advantage of her.

Dinah said...

moviedoc: kind of limited list there. I used to give my office number. Oh, but on two afternoons and one morning a week I'm at a clinic, so call this number instead. On friday afternoons, I attend somewhere else, no real number to reach me at. I was constantly calling to check my messages, every few hours, weekends, too. I didn't return non-emergency calls until regular hours, but for whatever reason, I felt obligated to call in and check my messages. It does seem that part of being a doc is availability and that Call 911 isn't the level of care people should get.

So cell phones come along, and suddenly, I can have ONE phone number. It goes with me. It tells me when I have messages, I don't have to Call In to check. Who needs a landline? I am now a cell phone. Oh, but do I really want my office line on while I'm asleep? No. But the reality is that some people call at 2 AM to change appointments---they think they're calling an office, where no one will be, so why not? Fine, call, I don't want to talk to ANYONE in the middle of the night, so I turn the cell phone off and let it collect messages, when I'm in session, at the movies, sleeping, eating lunch with a friend. In the rare event that someone has an emergency and can't find me, I've given a sheet with my home number. Like I've said, I think I've been called perhaps once every 2 years.
From my point of view, I've escaped the feeling that I need to check things. I have people's cell numbers plugged in: if you're my kid calling while I'm standing in the grocery store, I take the call. if you're a patient or an unknown, you ring to voicemail,and I get back to you when I have privacy to talk.
It works for me. It's not intrusive. I don't end feeling abused. I don't do phone sessions, so once it's clear that someone wants to talk, I simply say "Why don't you come in?" and I offer the next available appointment.
I clearly tell people that my phone is a cell number,it goes where I go, it's off during sessions, and if I can't talk, it goes to voicemail. Since it's the only way to reach me, I hope no one feels like they're interrupting (they're not, I wouldn't answer). It works for me, I get my calls, I triage on how long they can wait for return (longest is usually the next day)

Works for me. If it doesn't work for someone else, that's fine too.

Maybe I'll move this to a post.

Lockup Doc said...

Dinah--What I find so surprising and refreshing about your private practice is that you've been able to keep things so flexible and have made yourself so available, but you have had very few people try to take advantage of you.

I remember when I was in my psychiatry residency, one of the volunteer clinical faculty members had his own private practice. He was constantly getting paged. He could not make it through a meal at a restaurant without receiving multiple pages (and of course, pages, unlike cell phone rings, cannot be ignored). Eventually he left private practice.

I wonder what he did differently. Did he treat a different population than you do? Did he simply set no boundaries? I don't know, but I do know that watching what his private practice life was like turned me off to the idea of ever entering into that world. I wonder what the experience is of most psychiatrists who practice as you do? Maybe I've been making wrong assumptions over the years.

moviedoc said...

Dinah, you make the subject of the cell phone sound so complicated, but you have greatly oversimplified it:

This is a considerably shortened and toned-down version of an article I wrote in response to a piece by Robert I. Simon, MD that appeared in the February, 2008 Psychiatric Times. In his article he criticized the use of "hang up and dial 911" messages and extolled the virtues of the cell phone. One wonders if he ever actually used one himself. Interestingly, too, Clinical Psychiatry News declined to print the article after I explained what prompted me to write it. Thank heaven for blogs.

Your comment is an excellent illustration of the extent to which we can customize communications today to suit our practice and life styles.

Rach said...

My sentiments mirror Lockup Doc's. There's a beauty in the balance you've created for yourself Dinah - which I'm sure you've refined over the years.

When I think about my own shrink - his system could be so refined... but instead he has multiple phone lines and fax machines, and he could be running a dog-race business for all I know!

Sarebear said...

My psychologist's system, whatever it is, seems to work for him, and it seems to be his cell phone. For the most part, he never answers it himself by voice - patients go right to voice mail, and he gets back to you, either the same day, or next day at the latest. On RARE occasions, it's been longer than that, but there's been mitigating circumstances that anyone would understand.

During a period when there was, what was it, I was tending to dump appointments at the last minute (mitigating factor: I was on the Cymbalta, was near the end of relationship with the psychiatrist and THAT was falling apart, but mostly boiling beneath the surface, medically things were heating up in other areas, w/knee shots and MRI's and other things, ie, high stress load and fear through the roof) . . . he started I guess having my number on the, put straight through to him to pick up and answer list. I was startled the first time that happened, although THAT call was with me calling to tell him what plan I'd come up with to hopefully avoid my abominable behavior of leaving him in the lurch with last minute (by a few hours, sometimes) or day before (rarely) phone calls canceling the appt. I had worked something out, cognitively, that was different than anything I'd tried before to modify this behavior that had started to develop over the summer, maybe a rare one or two in the spring.

Crud, it'd be good if I could remember WHAT that strategy was now, even though I'm off the Cymbalta now . . . . dagnabbit, why don't I write these things down . . . . guess I can ask him at the next appt, not that I'm planning on ditching him again, it just bugs me that I can't remember a strategy that WORKED.

Of course, the seriousness of my behavior was hit home by the fact that he'd put me on that "ring straight thru" list instead of "send to voicemail" list, too . . . but I wsa proud of what I had to tell him though, and that it sort of counteracted my embarrassment at him having put me on that list for not so great reasons.


Sarebear said...

Oh, I suspect one main reason he put me thru was so I couldn't just leave a cancel message on the voicemail, a sort of "easier" thing to do than to cancel to him personally. Perhaps. Or perhaps he wanted to ask me, in person, as it were, over the phone, how serious I was about therapy . . . . but I really was different on the Cymbalta.

Sounds like an excuse, I know. But even my mom has said, after I was off it for a couple months, that the "old" Sara was back. Does she mean the old depressed Sara that's "naturally" depressed or the one with some natural life in her but some natural depression too, but less since the topamax is stabilizing my mood some, and keeping the deep blackness away of the mood swings . . . The cymbalta wasn't that kind of depression, it was in bed most of the week, and change your personality some kind of thing.

Sorry, rambling, bye! . . . yup, that's me alright . . .


Battle Weary said...

Moviedoc: While I have read your comments with a somewhat amused interest, I find this, "Remember the lady that poured hot coffee in her crotch?", quite offensive. I worked with the daughter of the woman you are referring to. The woman did NOT pour coffee on herself, she was holding it between her thighs as there was no cup holder in her car (yes, unsafe), someone pulled in front of her suddenly and she slammed on the brakes. Thus spilling said coffee mostly on her lower thighs as physics would dictate. Yes, some landed on her crotch as well. Have all the facts before you use a specific incident in your argument.

moviedoc said...

Pour choice of words (so to speak). I meant the plaintiff no offense, and I did not mean to imply she burned herself intentionally. (If she did, shame on her.) There are many kinds of facts in a case like that, I would be more interested in knowing the truth, but perhaps only the plaintiff will ever know that. And I do not blame either the plaintiff or her attorney. It is the judge who is responsible for the verdict, which, like too many verdicts, seems to regard the plaintiff in this case as too dumb to know that hot coffee might burn her. It's the kind of verdict that pushes us to include "call 911" messages when we might think anyone would be smart to enough to know that.

Dinah said...

Moviedoc, I've never heard of anyone being sued because their voicemail didn't explicitly say to call 911 for an emergency. An operator may pick up in seconds (your gold standard for response) but it still takes a while for an ambulance to get there).

And if it helps for the theory of the world isn't perfect, I once called 911 for the patient, then remained on the line until EMS got there and spoke to the EMT and told them why it was urgent that the patient be brought to the ER and be seen immediately (always nice to have the pt's doc reinforce this to EMT). I hung up only after conveying this info, then EMT promptly left patient in the care of family member to bring to the hospital where pt waited hours (and nearly died). Moral: there are no perfect means of communication and we try our very best.

McDonald's coffee suit: maybe Battle Weary can address this better. Version I heard was that coffee spilling victim sued for medical expenses. Suit revealed there had over 700 complaints about the temperature of the coffee and McDonald's had refused to address it saying people liked it hot. Judge awarded the plaintiff punitive damages which amounted to the profits from ?2 days of coffee sales (which happened to be over a million dollars).

I have my own cell phone stories:

Roy said...

I also just don't get the "call 911 or go to the nearest emergency room" thing. 911 is pretty universal now. And if you didn't say "nearest" emergency room, could you get in trouble if someone goes to the farthest ER? If I was having chest pain, I don't think I'd leave a voice mail on my cardiologist's phone. Even if his message didn't say call 911, I'd like to think that I'd consider that option. But, I suppose it can't hurt to remind people of it, because when you do have an emergency, you can sometimes overlook the obvious in the chaos of the moment.

I do like the idea of putting the county hotline, "warmline", which is what we have.

The other one I don't get is "I'm on the phone or away from my desk." Thanks for letting me know of those two other possibilities, otherwise I would think you are sitting at your desk, not on the phone, intentionally ignoring me.

moviedoc said...

I have heard of no lawsuits related to 911 messages either. I just have one because I want my patients to know the score. I would give a free psychiatric evaluation to anyone who could help me discover how they got started. Hope you don't drown any more phones, but I'm hoping to try another solution (ie complication): Google voice claims to give you one number that will make all your phones ring (not necessarily the one in the washer), transcribes voice mails, and displays all in your browser. I'm waiting for my invitation. And I don't feel sorry for McDonald's.

Dinah said...

Roy has Googlevoice! He carries several cell phones and once, when we were sitting together at a meeting, I programmed his iPhone to bark when I'm the caller.

Now I dial his Googlevoice number and his body emits sounds from every pockets: barks and rings and there are fireworks and things sputter and's really cool and it all happens in stereo right in front of me!!!

moviedoc said...

Cardiologist? You must not have been keeping track of who has these messages now. They're everywhere. Pharmacies, pharmaceutical companies, insurance companies.

"I'm on the phone or away from my desk." Maybe they don't know which it is. And if they have a cell phone they could be on the phone AND away from the desk.

Sarebear said...

32 (now 33) comments and counting . . . definitely a post or two coming on this.

Actually, at therapy this week, our appt was interrupted because his phone rang and he said, do you mind if I take this? my car is sick.

His words, lol. "My car is sick"

I said, fine!. Then, after that call, from the gist, when he asked, a bit painfully, if he could make a quick call, I said, sure. He had to coordinate taking the rental he'd been told he needed to turn it in and go get a loaner. Turns out he didn't need to have gotten a rental after all. But he needed his "confabulation" friend to go with him due to the re-arrangeing of cars at different locations.

Anyway, after he'd left the message for the friend, we got back to therapy for about 3 mins then said friend called back and he had to take it and then they were all set. It was a bit awkward but he'd managed, even w/the car breaking down the prev. morning, to get everything handled and not miss a single appointment, even with the now shuffling of cars this afternoon in a free period of no appts.

The downside was the scrambling on his part when it broke down, and then the phone calls in session and crap, and more running around for him.

But you know, a car doesn't break down every day, and he let our appt go almost til the end of the hour, instead of the last 10 mins being for well it being over by then so that helped make up for it a bit.

Sarebear said...

Oh, woops, one more comment. I actually said, after the calls were done, i said this is funny, i was just reading on the Shrink Rap blog I read about situations like this, so this is funny (aside from the inconvenience to you, of course, I said to him, I THINK.) If I didn't, I'll mention next time I didn't mean to sound insensitive, cause that does sound insensitive now that I look at it . . . .eeeeek. I may have said that it was an odd or funny coincidence, which is more about the coincidence than his car breaking being funny.

moviedoc said...

OMG: Can anyone tell me how to put a "call 911" message on Skype?!

moviedoc said...

Confession, Sara: When my office mgr isn't there I keep my phone on the armrest of my chair so I can click "ignore" when it rings. But I don't take calls.

I do let pts. take or make calls during visits, but I have seen office with signing asking waiting room occupants to turn off their phones. We have not tried it. What I really want to do is buy a 50's phone booth on ebay and put it in the waiting room.

Sarebear said...

Oh my gosh Dinah that sounds hilarious. If you guys were out Segway-ing that'd really make people turn their heads!


Sarebear said...

Moviedoc: get a british old "Tardis" style phone both, oops unless it's got windows, you'd wonder what they'd be doing in there . . . put a window in it then. But still, that'd be cool!!

I feel like we have a mini=Shrink Rap chat room going on lol

Dinah said...

I want to know, if you get a phone booth in the waiting room, will it ring with your Google voice?

two of my neighbors have red British phone booths in their yards.

Sarebear said...

That's a good question! And why do your neighbors have red British phone booths?

In their YARDS, of all places? And do they work? I'm assuming NOT . . .

Anonymous said...

Dinah: Do your neighbors with red phone booths call each other...on these red phone booth phones? LOL

Battle Weary said...

Dinah...yes, the coffee spilling victim sued for medical expenses, and was awarded $200,000 plus punitive damages equal to 2 days of coffee sales at McDonalds. The 700 complaints was actually 700 claims of burns in the 10 years preceding this incident. At the time this occurred, McDonalds had a written policy of keeping the coffee at 180-190 degrees Fahrenheit! The victim in this case was 79 years old, and suffered full thickness burns over 6% of her body. She was hospitalized for 8 days and had to undergo skin grafting. McDonalds coffee temperature is substantially lower now!

Anonymous said...

Regarding interruptions during a session, my shrink once ripped the cord out of the wall to stifle what I think was his landline. It was weird. I was speaking and the phone would ring, and I would pause because it was distracting and I didn't want to be drowned out, and then I'd continue with the rest of my sentence, and another ring, and another ring, and then the doc calmly walked over to the phone jack and gave the connection a good yank. That made me feel special, I guess. I don't know what happened to the caller. I wonder if s/he got voicemail or a busy signal.

Surely, he's perfected his phone system by now.

Anonymous said...

When it comes to psychiatrists and cell phones, I'm with itsjustme. My psychiatrist gives his cell phone number to patients, but I only call it if he specifically tells me to (for example, one of us is away and he wants an update on how a particular medicine is working) or if something goes wrong with the medicine (bad side effects like mania or anxiety, for example). Otherwise, no way am I calling him, no matter how awful things get.

Anonymous said...

I agree with Dinah, i think that saying "if this is an emergency call 911" is not a good idea,, it is like insulting the intelligence of the patient.. if the patient has an emergency, they would know that they need to call 911 b/c 911 would respond faster!!
And i don't think that there is anything wrong with giving the patient home phone number or cellphone.. patient-doctor relationship is not buisness relation,, there is health and trust involved, The doctor works as a doctor b/c they won't to help patients.. And patients even if they have the phone number of the home of the doctor, they are not stupid,, they won't call for no urgent need.. And i also feel that when a doctor calls the patient from a unknown or blocked number, i really feel that this is not respctful to the patient.. I know a doctors who they would not answer a phone call at all or return it and who they would not like and complain if the patient called them for an urgent matter one minute before 5:00 pm.. because they finish their responsibility at 5:00 pm!!

Anonymous said...

i meant "doctors work as doctor because they "WANT" to help patients..

Unknown said...

Thank you for being the caring doc that understands that psychotic episodes are dangerous just for the fact that they are unpredictable. My mother is bipolar with persistent delusions. She is currently lapsing into a manic, delusional episode (her last one was 2 years and 3 months ago-coincided with my son's impending birth). Unfortunately, despite the fact that I know my mother better than anyone on this planet, her doctors still ignore my recommendations and repeat the same non-answer, "Well, unless she's an imminent danger to herself or others then we can't do anything. Call us when she's worse." By that time she's pissed through her savings, left her rent unpaid (thus depleting my son's college fund) and is running around the town naked. THEN she gets hospitalized but the damage is already done. I have power of attorney and heath proxy but still got nothing. ARGH

Roy said...

Nicole, I'm sorry to hear about your mom's (and, thus, your) situation. Unfortunately, I see this frequently. It's not the doctors who can help (bound by legal limitations of your state or province), it's the law-makers. Go to them to explain how the current laws don't protect your mom, ask them to make changes. These changes would include outpatient commitment laws and advance directives with actual teeth (most current Advance Directive laws permit a patient who is actively psychotic or manic to cancel what they previously wrote in their AD when they were thinking normally).

The trouble with these is balancing freedom and autonomy with safety and self-direction.

Unknown said...

Thanks, Roy, for responding so quickly. I appreciate your advice and understanding. I would love to lobby my government for this type of change but I'm not much of a mover or a shaker and I'm quite busy getting my master's, working part-time, and raising my 2 year old and 60 year old mother. lol I realize the doctors' hands are tied, but it's just so frustrating for me. I want to help, but I can't really do anything. So I find that I tend to just withdraw from her until that day comes when I get the ER call. It's just too emotionally draining to watch and deal with so then she gets all angry and bitter because I'm not paying attention to her. Sorry for rambling. No one around me understands and all my aunts and uncles can't be bothered to deal with her anymore so it's just me and my husband.

Sarebear said...

Part of me wonders, if I survive another 23 years, if Nicole is gonna be my daughter, 23 years down the line . . . . and if my siblings will be how her Aunts and Uncles are. They already aren't a support system anyway, so . . .

Not that I run around naked, and I'm not judging anyone for doing so.

I just . . . well, I just doing see me being around, 23 years from now; it's hard, with my physical medical prognoses, let alone with the mental medical health stuff.

I would quite possibly be too crippled from arthritis pain, to do much of anything. Increasing pain and decreasing function, and MORE PARTS WILL GO. And that's just over the next 10-15 years, although that time period was a guess, two years ago, it has turned out to be a sorry damn accurate one, as the other knee has gone too . . . . and an ankle is feeling about oh I'd say, if it's anything like the knees were, about roughly 4 years out from going, if I'm lucky . . . I don't know what they can replace in an ankle?

Anyway. ALL respect to you Nicole. From my point of view, as much as I can sympathize, I do. And I am horrified, to feel that I might become that kind of burden, in addition to the other kinds of burdens that I am. But I already suspected this kind of thing, for awhile now. It's just a little bit harsh, to get a peek at what my future might be like.

Then again, maybe therapy and medication will help me more, I don't know.

I sure hope some laws will get changed to help YOU and your mother, Nicole, I do.

Sara (hoping I haven't been insensitive)

Unknown said...

Sara, please don't feel down by my post. I've met a lot of bipolar people during my travels and most of them are not like my mother. Her delusions last a long time (months) but then disappear and she is "sane" or whatever the technical term is. The problem with our relationship lies in the history of our struggle and my mother's own personality. It's not only the illness that causes us to struggle. She has some definite personality quirks that I don't think are related to her illness because they're always manifested no matter what state of mind she is in. These quirks do more damage than the periods of illness which are easily forgiven. Mostly, my mother wants more than I can possibly give. She asked to move in with me when I was engaged and only 24 years old. It's one thing to take care of an elderly parent during their last few years and it's another to do it for 30-40 years. My marriage would not survive that stress. I need my mother to maintain her independence during her long periods of sanity, and I need a strong support system (family and governmental power)to help her during the few months every 2-3 years when she is not. Not having either of these things is what makes me feel so alone and bitter.

Ugh, again rambling...My point is this: Our situation is unique to us and is complicated. Your experience may be different. Despite all that has happened, I am in school for my Master's, own my own home and am happily married with a wonderful son. I was raised by a very flawed individual (not a reference to her illness) but was well loved, and I turned out well (IMO). Don't look at my periods of frustration and generalize it to be the big picture because it's not.

Anonymous said...

Seemed to have joined the party a little late... To me it is clear that certain things constitute an emergency, but when it comes to those of us who suffer from just plain old run of the mill debilitating depression, when is that? I have often wondered at what point I should call my shrink -- when is it enough of an emergency to justify bothering him? Is it justifiable to call when I can no longer function at work? When I can no longer function at work and people are starting to notice? When I can't get out of bed? Does the level of emergency depend on the time of day (early vs late) or the day of the week (work day vs weekend)? Ultimately, I always err on the side of not calling - and I am sure I am not the only one who does so.

Dinah said...

Last anon: One doesn't need an "emergency" per se to phone-a-shrink. It seems to me that "I'm not doing well" is a fine reason to call. I think the thing that differentiates an "emergency" is the request for an immediate call back, a same day appointment even if the doc's schedule is already full, or the request for a phone intervention at night or on the weekend. Having trouble at work might be a business hours hours problem and warrent a between-appointments call. I say 'might' because a brain surgeon who is having a bad reaction to his meds and has to perform emergency surgery on Sunday might be justified in calling his shrink with an "emergency" on the weekend. It's really hard to generalize this stuff.
But it seems to me that people do call with non-emergencies and this is fine.

moviedoc said...

I have to comment on Dinah's brain surgeon with side effects. Side effects are rarely emergencies, but I like patients to call me about them even after hours because they are so much easier for me and the patient to handle with a quick phone call and rarely justify an ambulance or ER visit. Many can wait until the next business day, but even if you're not a brain surgeon, I don't want you to suffer.

Anonymous said...

If I call my doc I get a phone machine message that says she will call me back in 2-3 day. So calling her is pointless.

The best way to get a docs attention is to show up in their drive way at home and honk you horn. At least that is what I have been taught by my experiences with HMO and medicare docs.

Roy said...

Re when to call (not for an "emergency" but just between sessions), I agree that calling for bothersome side effects is wise, to nip them in the bud and prevent an ED visit. Can't tell you how many consults I've done on people admitted to the hospital, there for 3-4 days, big work-up, and then they call me in and I find that it is all from serotonin syndrome, or the hyponatremia is from Celexa, or the severe headaches and jitters is from Lexapro withdrawal after running out of it 3 days before admission.

If one is having active depression symptoms, in general and ideally, these folks should be seen every week or every other week.

Anonymous said...

Wow you doctors seem awesome! i would love to have similar doctors like you!! My shrink never answers a phone call.. And never call back if you leave her massege,, and You can't have her direct phone number.. And is just so hard to deal with her.. I thought all doctors are the same.. but reading what you are writing makes me feel that my doctor is not good in communication with her patients at all..

Sarebear said...

Thank you, Nicole, and again, my heart goes out to you.

It also helps me to know what it is that you need from the government, because even if we aren't in the same country (BAD me if I can't remember that we're in the same one, lol! altho if you see me blog you'll see I'm a bit stressed myself right now) when I DO feel strong enough to advocate a little, those are things that are going on the list. It is my eventual goal to be able to talk to government people about stuff like this.

I actually did, once, on a radio call-in, to the Governor of my state - Governor Jon Huntsman, who is now of course the Unite States Ambassador to China. Quite a thing for a former Governor of Utah, and one so young, but he speaks the language and even has children adopted from that land.

His father had strong ties to the country too, I think he had performed some official capacity a long time ago to there as well but I digress . . . . and I even took my ADD meds, ugh!

Sarebear said...

I've been hesitant to report a potentially dangerous one, as I'm not entirely sure it's related to my psych med - I've been on topirimate for some time, Topamax before it was available in generic form as of April '09. Used as my mood stabilizer. Prescribed dosage is 200mg a day, but for along time I'd been lazy and only taking one, sometimes 1 & a half but it had effectively gone down to 1, & I'd never really ramped it up to the full 2 a day for long periods of time.

Anyway, I recognized that hey, I'd better get back to my "usual" dose of 150, because I'm gonna be under a lot of stress. So, up to 150.

Then, about halfway or maybe I think perhaps 3 weeks into January at least, I'm pretty sure, I decided to go up to the full dose. So, 200mg/day, there we go.

Well, as of about two weeks ago I noticed a dry area, that was maybe a rash pretty quickly a day or two later, on my left wrist/forearm, above where a general hand-washing roughly ends . . this being the winter, I thought, well, that's probably why that's there, then, because maybe some soap is left there and not rinsed off, or whatever, maybe you need to wash farther up . . or dry winter months, which sometimes DO make my hands get dry and red. Occasionally hand soaps do that too, but only when it's a different formula than usual, & this isn't.

Still, it wasn't an IMMEDIATE response to upping the topirimate dose, and I can't remember if I went up to 200mg 2 weeks into Jan. or 3 to 3.5 weeks in - I'm fairly certain it was a later Jan. decision, though.

Anyway, so the last time I had a rash reaction to any med, let alone a psych med, was WAY back when I was first seeing a psychiatrist, & he tried me on Lamictal. They pulled me off of it fast.

But see, this time, I'm currently NOT under a psychiatrist's supervision, the dry/red skin COULD be just because of winter & the location is different than last time, although it has started to appear on the other wrist/forearm in the same location, about 5 days ago, & so I decided to down dose to 150mg. As of this morning, it's starting to look light brown, so I think it is going away.

Which means that it may very well be because of the med. As well, I wonder if it's because it's the generic form, since I'd never been on 200mg of the generic, & I'd been on 200mg of the brand name - OR it could just be that the dry skin is responding to my attempts to wet & wash the area better too, but . . my gut is saying, it's quite possibly the med. After 3 days of a lower dose (I'd have to check my records, because of all the pain pills I'm taking, I write down ALL the meds I take, or try to, and what time I take them. See upcoming blog post - what I started to type here became too long, so since I just posted a post on another subject, my next post on Pain Management, will come within a day or so.)

I've still been trying to wash farther up the arm, though.


I have been afraid that my doc woulda just yanked my mood stabilizer, when I've been doing fine on it forever. At 150 and 100. I told myself, that if I sense ANY change in my breathing, I am calling 911 right away (ie, potential furthering of allergic or life-threatening syndrome reaction to med), if this rash does not start to get better within a few days, I'm calling the doc, etc.

HUGE irony - original word verify is itchout, not that it's been itchy.

Anonymous said...

Enlightening post and comments. As a resident in a University psych program, I imagine your accessibility and definition of emergency varies a lot depending on where you work.

I have some patients who think that getting C instead of A on a test is an emergency, and then there are those who don't call when they have serious side effects/are suicidal even though I've asked them to.

My voice mail clearly states that I check it twice a day and will return calls the same day or the next. I advise them to call 911 if they need help, or to call the central helpline, where a doctor is available every 24 hours. I added the 911 message after hearing from colleagues that a patient called 911 after hearing the message, and that it saved their lives. We are told in our program never to give out cellphone/home numbers.

Meridith said...

Too many people have access to far too many drugs, especially those of the psychiatric variety including prescription antidepressants, anti-psychotics, seizure medications (for people who don't get seizures), sleeping pills, ADHD drugs and more. This sets the stage for prescription drug abuse, chemically-induced suicide and violence and unintentional overdose. We must put a stop to all this over-advertising and over-prescribing. We seem to be rapidly sending our culture down the tubes.

Please fill out my survey for a book I am writing about FDA reported side effects of prescription drugs. It's at

andrewjmars said...

This article made me realize that psychiatric emergency does exist and a lax schedule of a psychiatrist does help rather than a rigid one. Though a rigid counseling with a psychiatrist provides a constant support to the patient, most of us could not place an hour or two in our schedule. Other psychiatric problems may mimic physical problems such as heart attack, to know whether or not it is one, Read the article Relax! It's Not Schizophrenia Or A Heart Attack

boya badana said...

My sentiments mirror Lockup Doc's. There's a beauty in the balance you've created for yourself Dinah - which I'm sure you've refined over the years.

When I think about my own shrink - his system could be so refined... but instead he has multiple phone lines and fax machines, and he could be running a dog-race business for all I know!

Anon in Bean Town said...

My doctor does a lot of research, so I don't know how many patients he sees. I don't remember what his message said when he was a resident, but now his voicemail says.

"You've reached X in the department of psychiatry at Y. If you are a private patient and are experiencing a psyhiatric emergency between 8AM and 6PM, please call Tel number and ask for me to be paged. If it is after hours or a weekend, please go to your nearest emergency room. For all other non-urgent matters...."

But we've talked quite a bit about what this means in practice and what ER I should go to if I needed to. (The one at the hospital where he trained, still has a part-time appointment and where my PCP is. He's known there and they would probably know how to get in touch with him under certain circumstances.)

In 6 years, I think I've paged him twice -- other when the reception people page him to let him know that I'm there or I do it, if I'm 5 minutes away-- (once was when he was really late--30 minutes or something.)

I was reading this thread, because I was trying to figure out what I thought was an emergency (which he's decided to leave up to me, for the most part), because my sister seems to be exhibiting some psychotic symptoms, and it's really affecting my own functioning. I'm not quite sure how I'm going to make it through the day.

I do already have an appointment scheduled for this evening, so I can wait.

Anonymous said...

Thanks for the forum. It seems that, in general, people know no limitations these days and have no tolerance for discomfort. An example might be a patient who calls an emergent phone line to say she cried at work and couldn't stop. (Actually, I think I've cried at work as well...) Is being unable to self-soothe an emergency?

Anonymous said...

I am interested in this forum although I haven't read it all.I was in enormous insomnia hell last night--following a migraine and possibly a bad med interaction. As the hours went by through the long night, I became distraught and agonized. Not E.R. material, but had no one with whom to communicate at 3 AM, "the dark night of the soul." I am a high functioning clinician myself, but that doesn't mean I have a psychiatrist at my beck and call. Wee hours Interventions available ranged from E.R.s to BEST teams, and although I FELT like hell, those are not levels of care I require.
As a seasoned therapist myself, I don't take middle of the night calls from my own patients, but wonder how the generic "go to your nearest emergency room" is helpful to those who are not suicidal, homicidal or psychotic. A playwright friend of mine once called a play "Self-torture and strenuous exercise."