What Would You Do? What Would You Want?

Courtesy of CNN, here are a couple real-life scenarios I thought I'd share with you. Both of these videos represent the kind of cases that a psychiatrist confronts in an emergency room. I'd like you to put yourself first in the position of the patient: suppose you've been sick before, but never this sick (let's take it for granted none of this is due to drugs for now). You have an advance directive in place that says you absolutely don't want treatment even if you're a danger to yourself (again, for the sake of the exercise it's an enforceable advance directive). You never addressed danger to others in your advance directive because you never anticipated it could get this bad.

What would you want done?

If you were the doctor, what would you do?


Now for the second scenario. Is there anything about this situation that might make your wishes or opinions different from the first one? What's the difference? And if none, why not?



Thank you in advance for thinking about these problems. All of you who commented on my Emancipated Patient post have taught me something and I'm grateful. I'm putting this up to learn more about your ideas, opinions and wishes. Please keep talking.

Call the Police

What should you do if you believe someone is dangerous?  It's a sticky issue in psychiatry.  Here in Maryland, the requirements to have someone brought to an emergency room for evaluation by two physicians, include an imminent risk of dangerousness and the presence of a mental disorder.   If an emergency petition is signed by a judge, the police pick up the person in question and bring him to an emergency room for an evaluation.  In the ER, doctors can decide to certify the patient to an inpatient unit for further evaluation, or they can release the patient.  If admitted, a hearing must be held within 10 days.

Who else can file a EP?  Well, the police can.  If someone acutely agitated and violent and there is no time for a family member or interested party to obtain an EP, the police can be called and they have the option to fill out an EP and take the person to the hospital without a judge okaying the EP.  Depending on the circumstances, they also they have the option to arrest the individual and bring them to jail.   Finally,  a doctor can file an EP, but s/he must have seen the patient (--you can't get tell your rheumatologist-neighbor about your ill relative and get him to file an EP). 

So the police come -- either because they've been called in an emergency, or because a judge has authorized them to take someone to the hospital.  Most of the time, this goes smoothly.  But it doesn't always, especially since the person involved is presumably mentally ill and dangerous (the criteria for getting the evaluation).  Sometimes things get very upsetting, and sometimes they go very badly and someone gets hurt. 

In today's Baltimore Sun, there is an article by Justin Fenton that questions whether our police have the proper training to handle these crisis situations:

Baltimore Police have shot 10 people this year — eight of them fatally — leading some to question whether police are properly equipped to handle calls involving the mentally ill.

Only one of those shot was carrying a firearm, and several shooting incidents arose from calls to police about a disturbance involving someone with a mental illness. Relatives of some of those killed criticized police tactics, saying they shouldn't have lost loved ones after calling police to defuse situations that had ended peacefully in the past.

These are difficult situations, sometimes with no answer that will lead to a good outcome.   Fenton continues:

The director of the city's mental health organization praised the Police Department's training effort and said services for the mentally ill are lacking.

"If we don't do a good job getting people into treatment and something bad happens, we look to the Police Department and ask why did this person get shot," said Jane Plapinger, the president and chief executive officer of Baltimore Mental Health Systems. "Maryland is one of the best, but we unfortunately have an underfunded public mental health system everywhere in this country."

The Behavioral Emergency Services Team, or B.E.S.T. training, was implemented in 2009 and teaches officers to de-escalate mental crises, minimize arrests, decrease officer injury and direct patients to the city's mental health crisis programs for help. It has become mandatory for recruits.

"The police have been such a steadfast partner — I don't know how many [other] police departments are devoting four full days to this kind of training," Plapinger said.

The patients aren't the only ones in danger.  Police officers, or others, can be injured in these struggles. While it's not like there is an obvious answer besides calling the police, if the situation does not involve immediate danger, I often suggest that family member work to de-escalate upsetting situations and  convince a patient to go for help voluntarily, or with coercion, because even if it's coerced, these situations are often less upsetting for the patient and less dangerous for everyone if they can be done without the police.  Of course, this involves 20-20 hindsight, and the use of a crystal ball, because if there is a bad outcome and someone is injured or killed, then calling the police would have been a better solution.

I do wish I had that crystal ball. 

A Cry for Help

When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the psychiatrist who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

----
Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/psychiatrist and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?

Doctors to Go to Jail for Asking Patients About Guns in the Home

Imagine the scenario where you are an ER physician, nurse, or social worker and a person is brought to the hospital by the police for making a suicidal threat.

"I want to die. My wife left me and our house is in foreclosure."--"Do you have any plans to harm yourself?""My dad shot himself when I was little. That's how I would do it."--"Do you have any firearms at home?""OFFICER! Can you arrest this social worker? He just asked me if I have guns at home."[officer]: "Come with me sir. You have the right to remain silent..."

This is the scenario that could actually happen if Senate Bill 432 passes in Florida. The bill makes it a felony to inquire about firearms access or to include any information about firearms access in the medical record, punishable by up to 5 years in jail and/or a $5 million fine. Excuse my French, but WTF?!

An article in the Psychiatric News by Bob Guldin explains that the bill was introduced in both the House and Senate at the suggestion of the National Rifle Association (NRA) to prevent intrusion into the constitutionally protected right to bear arms.

It has been shown that removal of firearms from the home reduces the risk of a completed suicide. So you'd think such a bill would get laughed out of the legislature? Florida child psychiatrist and APA Assembly recorder said, "This bill is not a stunt... the financial power of the NRA in Florida will make it very difficult for sensible legislators to vote against this bill."

I note that a second version of the bill has been proposed, one that reduces the fine to a minimum of $10,000 for the first offense and a minimum of $100,000 for the third offense. It also reduces the offense from a felony to a "noncriminal violation" and compels the states attorney to pursue a possible violation or face professional misconduct charges. This version does permit certain health care providers to ask the question only in certain specific situations (e.g., an emergency "mental health or psychotic episode") but cannot tell anyone else other than the police. Apparently, a similar bill passed one house in Virginia five years ago before dying.

Next will be a bill that outlaws common sense.

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Clink comments: We've talked about issues related to guns before here, in Dinah's post "Guns and the Mentally Ill" and again when I mentioned a poster session that talked about gun ownership laws nationally. At my last American Academy of Psychiatry and Law conference I mentioned that 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.

So now we have a dilemma: in states where you need a physician's certificate to buy a gun, how can that same physician then be banned from asking about ownership?? I can imagine the session in which a patient comes in to be "cleared" to buy a weapon.

MD: "Well, you're taking your medicine and your symptoms are all under control. You tell me you're feeling well and you'd like to buy that awesome weapon you've been dreaming about."

Gun buyer: "Yeah! I've done the research and I know exactly what I want."

MD: "I need to know whether you have cognitive skills and emotional stability to handle a responsibility like that. Tell me, have you ever owned a gun before?"

Gun buyer: "Awesome!! Now I can sue you for infliction of emotional distress for violating my Second Amendment rights. Those triple damages will really help me stock up my arsenal."

Bottom line: The NRA can't have it both ways. If they involve psychiatrists in restoration of gun rights, they can't ban them for asking questions about ownership.

My Three Shrinks Podcast 50: More About Geeks

In this show we continue with our guest Dr. Pat Barta of the Adventures in Telepsychiatry blog.

We talk about electronic health information systems and Clink continues her rant which she started in her post Rage Against The Machine. Roy mentions the Certification Commission for Health Information Technology and the American Recovery and Reinvestment Act which provides funding incentives for doctors who use health information technology. We cover developing standards for behavioral health information technology, including personal health records which allow patients to store their own information voluntarily "in the cloud", on a server. Dr. Pat Barta talks Open source health record systems and information security.

Health Data Rights is an organization that developed a proposed declaration of rights for patient data. Another organization addressing this is SpeakerFlower, of which Roy is the spokesperson.

Dinah talks about her blog postWhat's An Emergency? and wonders how flexible psychiatrists should be when a patient says they need to be seen right away. Which situations are truly emergencies? What should you do if a patient turns down multiple appointments offered for that same day? Should your office voicemail tell people to call 911?

Finally, Dinah wonders what has happened in states with medical marijuana laws. She mentions KevinMD's blog post Medical Marijuana Has Doctors Asking Questions. Should marijuana be prescribed for attention deficit disorder? How do you do clinical research on a controlled substance?

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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."

Emergency!

I often get calls from patients who want to come in "as soon as possible." Especially new patients, but sometimes established patients. I try to be as flexible and accommodating as possible, but sometimes it gets a bit inconvenient. Now I'm in confabulation mode, but I'm curious about readers' opinions of how one should respond to emergencies. Often, I offer an appointment asap and the person requesting it can't make it and asks for another time. So it becomes a bit of juggling of priorities. And I'm left wondering how much the doc should be thinking about juggling (if at all). So let me fly some scenarios by you, and I'm curious as to what you think. The details are all confabulated, but the essence of the stories have gone down in some form over the past few years.

For both the doc and the patient, I'm going to use the example of a hair appointment as a non-urgent but meaningful conflicting issue. It can be hard to schedule hair appointments, they take a while so they aren't that easy to reschedule, and someone else is inconvenienced (the stylist) by a change, and the consequence of delaying the appointment is meaningful (ya gotta live with ugly locks until you can get rescheduled). For the sake of my confabulation, you don't have to pay for a missed appointment, and it's hair, life goes on even with a bit of frizz (tell me about it).

For the sake of the uncontrollable, I'm going to use the car breaking down-- no one asks for this, it throws a miserable wrench in life, it's unanticipated, and if you can't get there, you can't get there. It could be "I was in the ER with chest pain," or "my husband locked the deadbolt and took the keys to work (and oh, we live on the 10th floor so I couldn't crawl out a window") but the broken car is the example of beyond someone's control to a reasonable degree.

Story #1) So patient calls and wants to come in emergently (asap). I look at my schedule and I have lunch time free, I finish at 3, and I have a hair appointment at 4. I offer 12 noon. Not good, patient has a hair appointment at 11:30, can I see her at 4? I can't (though I don't say that it's because I have a hair appointment). What's a shrink to do?

Story #2) Patient is having an emergency. Ah, a few days ago I came to see pt outside of regular office hours because pt was so clear it was an emergency and it couldn't wait until next available appointment. It was an emergency and I remained worried about pt. Pt canceled follow up appointment because his car broke down, but it was still an emergency, so could I meet him later in the day when relative would be home from her hair appointment and could bring patient? I quietly think: it's an emergency, relative knows it's an emergency. Can't relative cancel hair appointment? But it's been presented as this is something that would either be unacceptable to relative, or pt would be uncomfortable asking this of relative (and this I understand). Patient asks if I can move appointment to later in the day, a time I'm usually in the office. Oh, but I didn't have any appointments scheduled that particular day that late in the day, and I scheduled....you guessed it...a hair appointment! We looked at our schedules and couldn't come up with another time for many days and this is what we scheduled for.
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Do you want to know what I did? In the first scenario, I offered the patient a half appointment at the end of the day, and I was a late to my own "hair appointment," but every thing got done. I felt a little uneasy about it because-- The patient's other obligation actually felt a bit less conflicting then an actual hair appointment, and let's just say my own obligation got short-changed, and the issue at hand wasn't a psychiatric emergency.
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In the second scenario, I felt more conflicted. I know the patient wanted to come and he was out of control of the some of the scenario (? did he ask relative to skip hair appointment? Did he offer to drive another family member to work and borrow their car?). If this same patient had called and did not already have an appointment for that same day, and if my schedule was completely booked, I would have come back in the evening after my new doo to see him.

So what do you think?

Shrink Rap: Grand Rounds is up at Health Business Blog!

Check out this week's Grand Rounds by David Williams at Health Business Blog.

Interesting topics include PTSD of being ill, Twitter discussion about remembering doc's instructions, and EMTALA and ER visits.

L.A. E.R. Tragedy . . . Emergency Mental Health Care

Connect the dots between these two stories...

Dr. Cory Franklin has a Commentary in the Chicago Tribune about this tragic story of a lady who died in an L.A. E.R. waiting room with bystanders calling 911 to help her because she couldn't get help in the ER.

Shortly after another bystander made a second futile 911 call imploring paramedics to take Rodriguez to another hospital, she died of a perforated bowel. A security videotape, still unreleased to the public, is said to show her writhing on the hospital floor unattended for 45 minutes. At one point, the tape reportedly shows a janitor going about his business mopping the floor around her.

. . .
This should be the audio of the 911 call... [removed due to misbehavior... try this link to listen: Youtube]


Mary Beth Pfeiffer in yesterday's Huffington Post discusses our broken mental health system.

In the 1990s, Virginia built 18 new prisons and closed 1,400 mental hospital beds. Across America, state spending on prisons spending tripled in the last 25 years while spending on mental health care rose by about a fifth.

And if you thought the era of shuttered hospital beds was over, consider that America lost another 57,000 psychiatric beds from 1990 to 2000. As a result, from 1992 to 2003, American hospital emergency rooms saw a 56 percent increase in people experiencing psychiatric crisis. It's time to stop the bloodletting.

Where is our compassion, our humanity, our duty?

Tarasoff Overview & Inservice

Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.

First some background:

In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.

Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.

This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.

Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?

If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.

Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:

§ 5-609. Mental health care providers or administrators.

(a) Definitions.-

(1) In this section the following words have the meanings indicated.

(2) "Mental health care provider" means:

(i) A mental health care provider licensed under the Health Occupations Article; and

(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.

(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.

(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.

(c) Duties.-

(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.

(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:

(i) Seek civil commitment of the patient;

(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or

(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:

1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.

(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.

[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]

The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.

E.R. Call

Panda Bear MD poses the following ED scenario for an on-call orthopedic specialist:

“Good morning, Dr. Smith. Sorry to wake you up but this is Dr. Bear at the County Hospital Emergency Department. I’ve got a 25-year-old gentleman, snowmobile versus barn, with an open mid-shaft fracture of the left femur but otherwise without significant injuries. We have him in a traction splint and his distal pulses and sensation are intact. On the way through the barn he dragged the end of his broken femur through approximately fifteen feet of cow manure and I’m afraid it was about thirty minutes before his drunken friends decided that he probably wasn’t going to walk it off.”

“How’s he doing now? Fine. He’s fully alert and oriented and threatening to sue everybody in the place. Can you come in and see him?”

Would you come in? It is easy to come up with a similar scenario for psychiatry. Yet, it has been a long time since psychiatrists gave up on ERs. I don't have figures, but I'd wager that it is not easy to find an ED where a psychiatrist evaluates the guy with the overdose or the woman with new-onset paranoid auditory hallucinations. More often, they have social workers evaluating these patients. The problem is, many of these patients are better served with a physician with psychiatric expertise, as a good percentage of these folks have medical problems which are dressed up as "psychiatric problems"... things like steroid psychosis, metabolic encephalopathy, and drug-induced syndromes.

Hospitals are increasingly paying specialists to be on call, recognizing the increased risks of treating ED patients, many of whom lack insurance and regular medical care. That includes psychiatrists. The hospitals are now able to see the savings in terms of improved patient flow, higher quality care, reduced liability, and lower length of stay, when using ED psychiatrists. The trouble is finding docs who are willing to take on this lifestyle. Psychiatric hospitalists are starting to crop up more, as they tend to work shifts (eg, 8a-8p), have staggered work days (eg, 5 days on, 4 days off), and get benefits. These are primarily consultation-liaison psychiatrists (like me). Any of you CL docs out there, let us know about any ER call you do.