Social Media and Minors
I cannot tell you how much social media plays a part in our work with children and adolescents who do not feel comfortable asking their family members for help, either for fear of being judged or because of their own preconceived notions of not wanting to overwhelm their parents or be a burden on them. I have evaluated cases and come across minors who are posting sexually explicit pictures of themselves, cutting themselves, bullying, or making suicidal statements either on popular social media apps or websites. It is useful to have this important conversation with the patients and their families regarding what they are posting online.
Assessing and Working with the Agitated Patient
Evaluating psychosis can, at times, also coincide with evaluating the safety of your patient, other patients, and staff. Over the years, having worked within a busy psychiatric emergency room in the Bronx as a clinician, I have learned that my gut reaction to situations has proved to be an essential part of my practice.
Working in a small, closed environment and paying attention to the verbal and nonverbal cues from patients has proved to be an extremely important skill. We utilize tools in the ER as a part of the training in deescalating patients in crisis; for instance, crisis prevention intervention
By no means am I saying that physically being involved with an agitated patient, or separating the patient physically, should be an undertaking for the clinician. Most of you are already thinking, “Wait, I don’t get paid to get hurt.” You’re absolutely correct. That said, these are lifeline tools to use while working with your team. It is important to pay attention to what or how patients arrive to your ER.
For example, was the patient brought in via emergency medical services (EMS) or police, what does the EMS report say, were they escorted by security into the ER, did they require any emergent medications? In some cases, the patient presents as internally preoccupied, distracted, or disorganized, or is hearing voices, which can be due to a possible psychosis, or the patient may be under the influence of drugs.
Be curious, ask questions, and never assume. They may have had a history of arrests or violence or exposure to the criminal justice system. The patient may have had no previous psychiatric history and is completely afraid of being locked up or being labeled as crazy given that the stigma on mental health disorders still exists.
It is also very important to obtain collateral information from family, outpatient providers, or others who are directly involved with the patient. Collateral information can also be gathered from direct care ER staff. I make it a point to speak to the nurse and ask them how the patient is behaving, before I speak to the patient.
It can help to acknowledge the patient’s perspective while attempting to verbally de-escalate the situation, especially if a patient is brought into the ER and has no perceived notion of what to expect in the ER and is shocked to find out that a patient cannot leave until evaluated by the psychiatric team. The patient may consider this to be a direct violation of their rights.
As a clinician, you must be sincere and truthful with regard to acknowledging how patients feel. It can be helpful to consider the following questions as part of their initial evaluation: do they have a history of violence or noncompliance with psychiatric treatment and medication management? If so, you need to remove yourself quickly and effortlessly to inform your ER team that the patient is either psychotic, internally preoccupied, or verbally or physically agitated, and may require oral or injectable medication. A patient’s prior medical history is also taken into account prior to this step.
Therefore, asking questions of either the nurse or the patient care technician is an important part of the evaluation process to determine if the patient presents with a calm or agitated demeanor, since most often they are the first ones to come in contact with the patient during the triage process.