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Foreword Behavioral and Psychiatric Emergencies
Amal Mattu, MD, FAAEM, FACEP Consulting Editor
I’ll admit that we emergency physicians (and likely many other acute care providers as well) are a strange lot. We tend to relish caring for the sickest of patients, often even those on the verge of death. We often talk about that “great case” we saw during a shift: the cardiac arrest, the crashing asthmatic with a difficult airway, the patient with sepsis or diabetic ketoacidosis with a pH of 6.9, or the patient with cardiogenic shock requiring dobutamine and norepinephrine. It’s unlikely you’ll ever hear one of us refer to the patient with an uncomplicated ankle sprain or gastroenteritis or migraine headache or simple pneumonia as a “great case.” None of these patients tend to suffer much morbidity, and they are at low risk of mortality. It’s also unlikely that you’ll ever hear an emergency physician refer to a patient with depression and failed suicide attempt, or a patient with agitated delirium from drug use, or a patient with acute psychosis as a “great case.” Why not? Perhaps a major reason for this mindset is that we tend to assume that these patients have a low risk of morbidity or mortality. And perhaps another reason is that we often assume that we cannot change their course of illness. Both of these beliefs, as it turns out, are wrong, and they are likely the result of a lack of education regarding behavioral and psychiatric emergencies. Despite the fact that psychiatric illness is a rapidly increasing problem in our society and a tremendous burden on health care resources, traditional emergency medicine training still requires a relatively small amount of time be spent on this area. Continuing medical education emergency medicine conferences at the national and international level also have a paucity of sessions devoted to psychiatric and behavioral emergencies. A general lack of education leads to a lack of understanding and appreciation of the importance of this area in our practice. We are therefore fortunate to be able to present this issue of Emergency Medicine Clinics of North America, in which Guest Editors Drs Kuo and Tucci have assembled an outstanding team to educate us about the latest advances and approaches to behavioral and psychiatric emergencies. Perhaps the most important of the articles Emerg Med Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.emc.2015.09.002 0733-8627/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
emed.theclinics.com
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Foreword
comes early in the issue and addresses the initial medical clearance of these patients. This article addresses some of the common pitfalls associated with clearance, including the frequent initial overtesting of patients that leads to increased hospital costs and emergency department (ED) lengths of stay and also addresses the pitfalls of performing cursory examinations. Readers are reminded that many patients with behavioral emergencies are suffering from underlying medical conditions that can be disastrous if not diagnosed rapidly in the ED, and that “shotgun” lab testing is inferior to the performance of a good history and physical examination when it comes to diagnosing medical illnesses. The authors then go on to discuss the initial management and stabilization of agitated, psychotic, and delirious patients in the subsequent two articles. They address issues that go far beyond the traditional A-B-C’s of emergency medicine but are equally important. Chemical and physical restraints are discussed and the laboratory workup as well. The authors also educate the readers about the challenge of distinguishing delirium from dementia and provide some nice diagnostic pearls. Traditional psychiatric conditions are then discussed, including depression and suicidality, personality disorders, and disorders that are associated with somatic symptoms. Drug abuse and withdrawal, which are contributors to many behavioral disorders, are then addressed in a separate article. The authors provide four excellent articles that address psychiatric conditions in special populations: pediatric patients, elderly patients, pregnant patients, and trauma patients. I’d venture to guess that many acute care providers rarely give much thought to the special considerations that these latter three groups, in particular, deserve. The final articles address ethical issues in managing patients with psychiatric conditions and also health policy issues on a national level. That last article deserves special attention by anyone that is involved in public health and patient- or specialty-advocacy. The article discusses issues that we will be facing in the coming years and also the need for increased resources if we are to succeed in managing these patients properly. The Guest Editors and authors are to be commended for their hard work. This issue of Emergency Medicine Clinics of North America represents an invaluable addition to the emergency medicine literature and core curriculum. Although behavioral and psychiatric emergency conditions are not generally regarded as “great cases” to deal with in the ED, readers of this issue of Emergency Medicine Clinics of North America will certainly develop a newfound respect for these conditions and might even develop a new level of enjoyment in managing patients that are suffering from these conditions. Amal Mattu, MD, FAAEM, FACEP Department of Emergency Medicine University of Maryland School of Medicine Baltimore, MD, 21201, USA E-mail address: [email protected]
Foreword Behavioral and Psychiatric Emergencies
Amal Mattu, MD, FAAEM, FACEP Consulting Editor
I’ll admit that we emergency physicians (and likely many other acute care providers as well) are a strange lot. We tend to relish caring for the sickest of patients, often even those on the verge of death. We often talk about that “great case” we saw during a shift: the cardiac arrest, the crashing asthmatic with a difficult airway, the patient with sepsis or diabetic ketoacidosis with a pH of 6.9, or the patient with cardiogenic shock requiring dobutamine and norepinephrine. It’s unlikely you’ll ever hear one of us refer to the patient with an uncomplicated ankle sprain or gastroenteritis or migraine headache or simple pneumonia as a “great case.” None of these patients tend to suffer much morbidity, and they are at low risk of mortality. It’s also unlikely that you’ll ever hear an emergency physician refer to a patient with depression and failed suicide attempt, or a patient with agitated delirium from drug use, or a patient with acute psychosis as a “great case.” Why not? Perhaps a major reason for this mindset is that we tend to assume that these patients have a low risk of morbidity or mortality. And perhaps another reason is that we often assume that we cannot change their course of illness. Both of these beliefs, as it turns out, are wrong, and they are likely the result of a lack of education regarding behavioral and psychiatric emergencies. Despite the fact that psychiatric illness is a rapidly increasing problem in our society and a tremendous burden on health care resources, traditional emergency medicine training still requires a relatively small amount of time be spent on this area. Continuing medical education emergency medicine conferences at the national and international level also have a paucity of sessions devoted to psychiatric and behavioral emergencies. A general lack of education leads to a lack of understanding and appreciation of the importance of this area in our practice. We are therefore fortunate to be able to present this issue of Emergency Medicine Clinics of North America, in which Guest Editors Drs Kuo and Tucci have assembled an outstanding team to educate us about the latest advances and approaches to behavioral and psychiatric emergencies. Perhaps the most important of the articles Emerg Med Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.emc.2015.09.002 0733-8627/15/$ – see front matter Ó 2015 Published by Elsevier Inc.
emed.theclinics.com
ii
Foreword
comes early in the issue and addresses the initial medical clearance of these patients. This article addresses some of the common pitfalls associated with clearance, including the frequent initial overtesting of patients that leads to increased hospital costs and emergency department (ED) lengths of stay and also addresses the pitfalls of performing cursory examinations. Readers are reminded that many patients with behavioral emergencies are suffering from underlying medical conditions that can be disastrous if not diagnosed rapidly in the ED, and that “shotgun” lab testing is inferior to the performance of a good history and physical examination when it comes to diagnosing medical illnesses. The authors then go on to discuss the initial management and stabilization of agitated, psychotic, and delirious patients in the subsequent two articles. They address issues that go far beyond the traditional A-B-C’s of emergency medicine but are equally important. Chemical and physical restraints are discussed and the laboratory workup as well. The authors also educate the readers about the challenge of distinguishing delirium from dementia and provide some nice diagnostic pearls. Traditional psychiatric conditions are then discussed, including depression and suicidality, personality disorders, and disorders that are associated with somatic symptoms. Drug abuse and withdrawal, which are contributors to many behavioral disorders, are then addressed in a separate article. The authors provide four excellent articles that address psychiatric conditions in special populations: pediatric patients, elderly patients, pregnant patients, and trauma patients. I’d venture to guess that many acute care providers rarely give much thought to the special considerations that these latter three groups, in particular, deserve. The final articles address ethical issues in managing patients with psychiatric conditions and also health policy issues on a national level. That last article deserves special attention by anyone that is involved in public health and patient- or specialty-advocacy. The article discusses issues that we will be facing in the coming years and also the need for increased resources if we are to succeed in managing these patients properly. The Guest Editors and authors are to be commended for their hard work. This issue of Emergency Medicine Clinics of North America represents an invaluable addition to the emergency medicine literature and core curriculum. Although behavioral and psychiatric emergency conditions are not generally regarded as “great cases” to deal with in the ED, readers of this issue of Emergency Medicine Clinics of North America will certainly develop a newfound respect for these conditions and might even develop a new level of enjoyment in managing patients that are suffering from these conditions. Amal Mattu, MD, FAAEM, FACEP Department of Emergency Medicine University of Maryland School of Medicine Baltimore, MD, 21201, USA E-mail address: [email protected]
