Compromiso ontológico: Moltmann

Telephone Emergencies

Emergency departments frequently receive calls from people in the commu-nity seeking medical advice. When these calls are of a psychiatric nature, they may be directed to the consulting mental health clinician or routed to the psy-chiatric emergency department. Calls cover a wide range of questions, includ-ing issues of medications, side effects, and drug use. The clinician should try

to help to the degree that he or she can. Patients should always be assured that they can come to the emergency department for further evaluation of their complaint and encouraged to contact their personal physician or mental health clinician for further assistance. When phone calls involve threats of violence or self-harm, the clinician should attempt to remain on the line with the pa-tient, be supportive, and try to obtain as much information as possible about the patient’s location. If the patient refuses to reveal his or her identity or lo-cation, the clinician should notify other emergency department staff to con-tact the police so that they can attempt to trace the call, although in the age of cellular phones, tracing can be difficult. If a clinician is concerned about the safety of the caller, notifying police and asking them to visit the caller to check on him or her is the safest option.

Rape

Although many rape victims never seek treatment, some victims may request a psychiatric consultation, emergency department staff may request a psychi-atric consultation if they are concerned that a rape victim may be suicidal or otherwise psychiatrically compromised by the event, or a patient may reveal an assault while being evaluated for another psychiatric issue. Clinicians should ensure that all appropriate medical, legal, and counseling services are made available to the patient. The hospital’s social work department can be helpful for finding victims services available in the area. Patients who have experienced rape or sexual traumatization should be offered and encouraged to have a full physical examination by a nurse or physician trained in evidence collection, even if they do not want to press charges at that time. Women should be offered prophylactic contraception to prevent pregnancy, and all patients should be counseled about and offered prophylaxis for sexually trans-mitted diseases and HIV. Patients may not wish to report the incident, but should be offered the opportunity to do so, and whenever possible they should be assisted by a rape crisis counselor or victim’s advocate during this process. Patients who are considered “mentally ill” may experience more dif-ficulty in reporting assaults because of the significant stigma attached to psy-chiatric diagnosis. The mental health clinician may have to assume more of an advocacy role in assisting the patient in making a report if the patient wishes to do so.

Chapter 7, “The Anxious Patient,” provides further information about preventing psychiatric sequelae in victims of trauma.

Domestic Violence

As in cases of rape, the psychiatrist may be a part of the evaluation of a patient reporting domestic violence. Counseling or advocacy services, legal services, physical exams if indicated, and psychiatric follow-up should be made avail-able to patients affected by domestic violence. An adult reporting domestic violence is not required to report the events to the police. However, if children in the home are at risk as a result of the violence, the clinician may be man-dated by state law to report suspected child abuse. The clinician should avoid giving patients any pamphlets or fliers that are obviously about domestic vi-olence, because these materials can lead to escalation if discovered. Leaving the abuser is not always immediately possible or indicated for victims; how-ever, victims should be encouraged to make a “safety plan” for how to leave the home safely when they are ready. Victims sometimes require multiple tries before they successfully leave a violent situation. Once again, social work ser-vices should also be involved.

If the clinician suspects that a patient is unable to make a reasoned deci-sion about his or her own safety due to mental illness, the clinician can ar-range for psychiatric admission or make a report to adult protective services.

For example, a patient with severe psychosis may not be able to organize her-self to get out of an abusive situation and therefore may be deemed unable to care for herself.

Child Abuse

In most states, physicians are mandated to report child abuse. If a clinician has a reasonable suspicion that a child is being abused, neglected, or mis-treated by a caregiver, the clinician should inform the appropriate agency of the suspicion. Child abuse can range from obvious episodes of physical abuse and torture, to sexual abuse or exploitation, to neglect of food, shelter, cloth-ing, or even appropriate educational services. In the emergency department setting, suspicion of child abuse or neglect should be triggered when children 1) appear afraid of their parents or unwilling to speak in front of them, 2) have unexplained physical injuries, 3) have evidence of malnutrition or poor hy-giene, or 4) are found to have excessive truancy from school. If a patient with

dependent children is to be admitted to the hospital, efforts should be made to contact someone who can care for the children during the hospitalization to avoid referral to child protective services.

Elder Abuse

The aging of the population has led to a rise in the number of elderly adults in need of various levels of care. This care frequently falls to their adult chil-dren or spouses, who may lack the resources to adequately care for them.

Nonjudgmental questioning of caregivers by the clinician is the best route to-ward discovering information. For example, saying, “It seems like your mom’s care can be quite overwhelming. Do you ever feel like you can’t handle it?” is more likely than an accusation of maltreatment to elicit a relieved request for assistance. Report of elder abuse is not mandated, but suspicion should in-crease when certain situations arise, including elderly patients who are dirty, unkempt, or malnourished; who have unexplained injuries; or who repeat-edly present to the emergency department with no clear medical pathology or with medical conditions that are a result of noncompliance with treatment that is supposed to be monitored or administered by family members.

The Patient in Legal Custody

Patients in legal custody are brought for psychiatric evaluation to an emer-gency setting for a variety of reasons, including evaluation for suicidality, be-havioral problems, treatment or prevention of withdrawal, or the need for a recommendation for psychiatric observation or treatment while in custody.

Prior to interviewing the patient, the clinician should consider several key points that will determine what kind of interview takes place, whether any as-sessment is even indicated, and what question is being asked by those who are bringing the patient for evaluation. Most important, the clinician needs to re-member that patients do not surrender their right to doctor-patient confidential-ity simply because they are under arrest or serving a jail or prison term (U.S.

Department of Health and Human Services 2003a). The clinician should ask the officers escorting the patient to delineate the patient’s current legal status;

to state the charges against the patient, so that the clinician can determine if the patient understands the charges; and to explain why the patient is being brought for evaluation. If the patient is released from the emergency depart-ment, the officers should know where the patient will go next—that is, to

court, to jail, or to the community. They can also provide information about the patient’s behavior while he or she was in custody. The patient should be interviewed without the police present, but should remain handcuffed to en-sure safety.

The nature of the evaluation is determined by the question being asked, but the following general points are helpful when interviewing any patient in custody.

• Clarify to the patient at the outset what the nature of the interview is, what information will be held confidential, and what information, if any, will be disclosed to officers.

• Clarify the evaluator’s role and the parameters of the evaluation. Patients in legal custody may be under the impression that the mental health clini-cian can arrange for charges to be dropped or for provisions to be made for what sort of housing they will have while incarcerated.

• Inform the patient not to make statements during the interview about his or her guilt or innocence regarding the charges because the medical record could be subpoenaed.

• Document the interview thoroughly in the medical record, particularly an assessment of the patient’s risk for injury to self or others while in custody and any recommendations to the officers or the court for special precau-tions while in custody.

The Patient Who Does Not Speak English or Who Requires Sign Language Interpretation

All hospitals are required to make accommodations for patients who do not speak English or who are deaf or hard of hearing. Although the ideal is to pro-vide a trained medical interpreter, this is not always possible. For language in-terpretation, the best available option may be use of phone interpreter services, which can offer the widest range of languages. If emergency depart-ment staff speak the patient’s language, they can also be useful, but they should be asked to provide direct translation of what the doctor and patient are saying and to not interject their own opinions or questions. It is never ac-ceptable to rely entirely on a family member or friend who is accompanying the patient, because this practice violates patient confidentiality and may pro-hibit the patient from making a full and honest accounting of his or her

situ-ation. If absolutely no other option is available, then it is better to at least get some information from the friend or family member, but more appropriate alternatives should be sought. Hospitals have been and can be sued for not providing appropriate language interpretation services or interpreter services for people who are deaf and hard of hearing.

The Pregnant Patient

Pregnancy should be suspected in women of reproductive age until proven otherwise by laboratory testing. The range of what is considered reproductive age is vast, so liberal use of beta-HCG (human chorionic gonadotropin) test-ing is advised to avoid misstest-ing a pregnancy.

Safety data on the use of psychiatric medication in pregnant patients are limited to case reports and population surveillance, so more data are available about older medications (Menon 2008). According to the American College of Obstetricians and Gynecologists (ACOG Committee on Practice Bulletins—

Obstetrics 2008), it is better practice to treat pregnant women for their psy-chiatric problems with medication if indicated, because the risk of teratoge-nicity due to psychiatric medication is smaller than the known risk of low birth weight and other complications from having an untreated psychiatric illness during pregnancy. In the emergency department, discovery of a pregnancy can influence multiple areas of the patient’s psychiatric care but should not preclude appropriate treatment, including treatment of agitation if indicated (Ladavac et al. 2007).

For many women, discovery of a pregnancy may be an unexpected or un-pleasant surprise and thus may complicate whatever crisis brought them into the emergency department in the first place. The following are considerations for the pregnant emergency psychiatric patient:

• Disposition planning. Concerns include providing obstetric gynecological care as part of discharge planning, increased risk of suicide after discovery of an unplanned pregnancy, and referral to appropriate services.

• Pharmacotherapy. The clinician should make an informed choice of psy-chotropic medication based on risks and benefits and clearly document the thought process involved in either prescribing or refraining from pre-scribing medication.

• Restraint. Safe restraint becomes more complicated as a pregnancy pro-gresses and should be avoided if possible. Patients in advanced stages of pregnancy should not be restrained on their back due to compromised blood flow through the vena cava.

The legal and ethical issues surrounding pregnancy in psychiatric patients are complicated. Patients with psychosis or severe psychiatric illness do not automatically surrender their right to reproductive choices, including choos-ing to terminate or continue a pregnancy, chooschoos-ing to use or not use contra-ception, and so forth. The most appropriate option for dealing with preg-nancy in the psychiatric patient is to treat the patient first, because optimizing her physical and psychiatric health is the best way to optimize the health of her fetus, and to put her in the best position to make decisions regarding her pregnancy and overall health.

Conclusion

Emergency psychiatry is a developing field, providing an opportunity for ex-posure to a vast array of patients and situations. Clinicians in this practice need to have skills in consultation-liaison psychiatry, crisis management, brief psy-chotherapy, and risk assessment, as well as a broad knowledge of medicine, hospital and health care systems, and general psychiatry. To best direct the care of patients, the mental health clinician working in the emergency department must view patients as individuals, as part of their social environment, and as part of the health care system.

Key Clinical Points

• Clinicians should consider their personal safety first. Clinicians should be aware of the protocols in the emergency department in which they are working, the environment in which they will be seeing patients, and patient factors that may lead to violent escalation.

• Assessment should focus on the patient’s safety. Critical questions to consider are whether the patient’s presentation is due to a medical

condition better treated by a different clinician and whether the patient can adequately maintain his or her safety and the safety of others in the current outpatient setting.

• All emergency department encounters should be documented in the medical record, with sufficient detail that the reader of the documen-tation can understand the factors that went into the assessment and disposition of the patient.

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