“Code white”, “Code black”, “Dr. Murphy to room 202″, every hospital has an overhead page that means that there is a disruptive person or patient who needs to be controlled, either for their safety or for the safety of others. Who attends these calls at your hospital? I had always assumed that these calls were similar to a code blue in mandating the immediate attendance of your critical care team leader (in my shop thats the ED doc). However at some hospitals the extra staff attending these calls is security staff, and the on call doctor is only notified by phone.
Most of these calls are for patients already admitted and on hospital wards. You might ask why we as emergency doctors should take this job onto our already overfull plate. The answer is simple, these are patients who have, with some regularity, severe underlying illness requiring recognition and treatment in a setting that allows for only incomplete information and evaluation. In other words, although these patients are (mostly) already hospitalized they require the particular set of skills and expertise that an emergency doctor brings to the table.
The classical approach to these patients has been to regard them as disruptive or demented and give them a dose of haloperidol and lorazepam and cinch the restraints nice and snug. This brute force approach fails the patients who need us most, and probably causes harm. Like everything in emergency medicine it pays to have an approach and a short differential to consider each time you evaluate an agitated patient.
Is this patient actually agitated?
When you walk into the scene assess if the patient is actually agitated or simply annoying. Occasionally sedation is being forced on the annoying and while we all know a few people who would benefit from sedation, forced sedation is an invasive action and only allowed in certain circumstances.
Does the patient understand the situation? This question assesses the patients capacity for medical decision making. Is the patient currently a risk to harm themselves or someone else? This question guides the pace of the intervention.
What are the patients vitals?
The usual answer is ‘unknown’, the patient is too agitated to take vitals. Actual vital signs are an early priority but prior to that look at the patients respiratory rate and effort, and assess their perfusion and skin colour. Your disruptive patient may actually be hypoxic, or in a shock state.
Is there evidence of trauma?
Elderly anticoagulated people at risk of falls are not suddenly not at risk by virtue of hospitalization. Trauma, including head trauma, can and does happen in the hospital.
Does the patient have alcohol withdrawal?
Elderly patients are at particular risk for unrecognized alcohol withdrawal. Delirium tremens is a life threatening but treatable medical problem. Many agitated patients are treated with antipsychotics such as haloperidol or loxapine, which have a limited role in alcohol withdrawal. Is the patient tremulous, tachycardic or hyperadrenergic? Consider alcohol withdrawal.
Does the patient have infectious or metabolic encephalopathy?
Consider (meningo) encephalitis, sepsis, uremia and elevated ammonia, if the picture fits.
Does the patient have a medication reaction?
Since hospitalization has the patient been started on a medication that could cause disinhibition and delerium? In particular look for anticholenergic drugs, tricyclic antidepressants and benzodiazipines.
In summary, the agitated hospitalized patient represents an emergency situation. Some of these patients do simply have behavioural problems, dementia or psychiatric disorders, but many others have emergency medical problems that need to be urgently addressed. The mortality rates for hospitalized patients who develop delirium of any cause is high (reported variously between 20 and 50% 6 month mortality). Some of that mortality is simply because delirium itself is a associated with frailty in the elderly, but some likely represents the various underlying diseases that can present as agitation and delirium.
When you are called to a ‘code white’ keep your wits about you, and evaluate the patient just like you would in the ED. Check vitals, consider hypoxia, trauma, shock, withdrawal, encephalitis and drug effects. and treat accordingly.
If you like saving truly sick patients from dangerous interventions then start attending these calls. You’ll find patients with hypoxia, PE’s, brain abscesses, intercranial bleeds and anticholinergic drug toxicity (all things I have actually found in these patients). And the best part is that the patient is already admitted!