Schizophrenic and Sick

Patients with schizophrenia and other psychotic mental illness are some of the most difficult to manage in the emergency department. Many hospitals lack appropriate psychiatry staff and resources and many EDs lack appropriate areas to care for psychotic patients. Often patients with psychotic mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, psychotic depression, delusional disorder, etc.) will be identified at triage and often their underlying illness will become their triage diagnosis.

Emergency medicine as a specialty has distinguished itself from most other specialties in applying worst-first thinking to most patient presentations. An 18 year old who has a new job as a ditch digger and presents with chest pain doesn’t get an automatic diagnosis of chest wall pain, we hunt dangerous beasts in emergency medicine and we wonder if this patient has Marfan’s and an aortic catastrophe, Brugada and an episode of dysrythmia, or an MI after undisclosed cocaine use. In reality the patient usually has chest wall pain, but this is how we think in emergency medicine. In fact this way of thinking is¬†emergency medicine.

For some reason worst first thinking has not made great inroads into our population of psychiatric patients. Too often we accept triage diagnoses (schizophrenia – decompensated) in a way we would never accept other diagnoses (chest pain – musculoskeletal). Often we are not asked to use our skill set but instead to do something called a ‘medical screening exam‘ and then help the patient access psychiatric care.

I have great news for emergency physicians who are frustrated with seeing psychiatric patients. These patients are sick, and we love sick patients! These patients are drug induced metabolic time-bombs who smoke 2 packs per day. They are at risk for toxidromes from both their prescribed drugs and illicit drugs. They often have typical critical illnesses (pneumonia, MI, etc.) that are recognized late. We have a lot to offer these patients, but it depends on us applying our worst-first philosophy.

In my view the best way to see a patient with a psychotic illness is in a gown, in a bed, the same as every other patient. Try to take a history, do a good examination, and pour over the patients med list. Think of the worst case scenarios and investigate them. You will find a 22 year old with hallucinations of bells who has an aspirin overdose, a 45 year old with ‘catatonia’ who needs to be intubated for profound DKA, and a 55 year old STEMI who came to the emergency department for a sandwich.