“I am King Tut! I rule this world! I have many girlfriends including Taylor Swift. My girlfriends will give me money. They have lots of it! I can stay with one of them,” yelled out a young African American patient who was being walked to the emergency department triage desk in handcuffs by police officers. “What is your name, sir?” asks the emergency department (ED) clerk at the desk. The patient suddenly lurches toward the clerk, writhing and struggling, pulling the chain on his handcuffs taut against his wrists, yelling, “King Tut! Call me King! King Tut! Ruler of the world and all others combined. Do you follow me? Are you with me?”
James, a young resident physician, is prepping himself to examine this new patient. James has many questions and uncertainties running through his mind as the patient is walked by his workstation and placed in room 16. “This is my first night in this ED, it is now 2 a.m., I’ve seen nine patients already and the attending physician wants me to talk to this guy. What the hell am I supposed to ask him?! How am I supposed to treat this guy? What medications should I recommend? I barely remember my psychiatric rotation from medical school. Damn! This is going to suck! I feel so unprepared for this. Okay, I’ve got to pull myself together. What was it that that psychiatrist I completed my psych rotation with in med school always reminded me of using? That’s right, diphenhydramine, haloperidol, and lorazepam, the good ole B-52.”
“Nurse,” James yelled. “Please prepare an IM [intramuscular] dose of diphenhydramine 25 mg, haloperidol 5 mg, and lorazepam 2 mg for our new patient. Oh, yes! And contact psychiatry please. Thanks.”
The previous scenario has been an increasingly common occurrence in emergency department settings over the past decade. Patients with mental illness are flocking to emergency departments with an increasing severity of psychiatric symptoms. According to the 2007 Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample (Owens et al. 2010), individuals with psychotic disorders were seen in emergency departments throughout the United States at a rate of 9.9%, and per the Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics National Hospital Ambulatory Medical Care Survey (Albert and McCaig 2015), 17.3% of all patients seen for treatment in EDs between 2009 and 2010 were treated for psychotic symptoms. Comparatively, there is a rate of 4.5 per 1000 individuals afflicted with nonorganic psychotic disorders in the community (Zimbroff 2003). As touched on in earlier chapters, the influx of mental health patients with psychotic symptoms into local EDs has been ignited by the decimation of outpatient resources available to these patients in many communities around the country. Access to outpatient psychiatric care for many of these patients, including medication consultations via a psychiatrist and mental health counseling or therapy via a licensed clinician, have been dwindling leaving the only option for relief of their psychiatric symptoms as a trip to the local ED. Many of the EDs are understaffed and ill-equipped to properly treat and diagnose psychotic disorders in these patients that present for help and relief of their symptoms.
It can be common for many emergency department staff to feel anxious and unprepared with being able to adequately treat psychotic disorders in the patients that present with these. Common questions that may arise when presented with a case of psychosis include: How do I properly diagnose the disorder? What treatment options are available? What symptoms do I need to be aware of? What medications will help relieve the psychotic symptoms?