Psychiatric Emergency Services elective

Hello EDC!

I recently completed 4 weeks at the county hospital in a dedicated psych ER and I feel like I saw another side to this city that I live in and I ended up loving this rotation. This psych ER unit, of 10 beds, was instrumental in getting patients access to either inpatient psychiatric hospitalization, connection with outpatient mental health or chemical dependency resources, or setting them up with housing options. On staff are social workers, ARNPs, mental health specialists, RNs, ER and Psych Residents, and of course the Attending Psychiatrist. We worked as a team making decisions and determining, with limited resources, the best outcome for our patients. This was hard. On one occasion, I spent the majority of my day trying to set a patient up with housing only to have him tell us that this was inadequate and threaten suicide if he wasn’t admitted to the hospital. I won’t lie, these patients were difficult. Coming up with a plan for safe dispo was sometimes impossible and we were left escorting them out of the hospital with security’s help.

The weather made things even more challenging as many of the local shelters often kick people out at 7am, patients would show up to the hospital claiming that they were suicidal and be provided with a warm bed, breakfast, and a clean bathroom.

What I loved about this rotation was how immensely challenging and gratifying it could be. When a patient arrived with first-break psychosis and their family was concerned, or the pt was brought in by police because of drug abuse 2/2 underlying mental health disorder, or pt was suicidal because life dealt them a bad hand, these were the patient cases I really enjoyed and feel like I could provide the most help. I truly believe that each time they came into our unit, it was a step closer to getting better and realizing the weight of their problems.

Some of my favorite patient cases included:

  • Capgras Syndrome (Impostor syndrome)
  • Narcissistic & Borderline Personality d/o rolled into one person
  • New-onset schizophrenia vs. bipolar w/ mania
  • Paranoid schizophrenia resulting in fear of food/sleep
  • Major depressive d/o with psychotic features & substance use
  • Chronic, untreated schizophrenia in decompensated state

In Washington State, doctors are not permitted by law to declare whether a patient requires hospitalization. Instead, county-appointed designated mental health professionals (DMHPs) fill this role. When patients come into the psych ER and are clearly suicidal, homicidal, or gravely disabled (unable to care for self), the DMHP is contacted to assess the patient. If the DMHP agrees the patient meets one of these safety concerns, they are detained and involuntarily admitted to the hospital or to another facility. We spent a lot of time working with patients that qualified.

The best advice I received on this rotation was to do the best you can with the resources available to you and no more. I loved working with these patients, but they could be difficult and in the emergency setting it is easy to feel like you are not doing enough for your patients and that they are not grateful. But the reality is that if someone wants help, then this was the place where people had the opportunity to start getting their lives back on track.

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Count down to graduation begins January 1 2017. 🙂

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