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During the course of your psychiatry clerkship, you may be asked to see a patient who is in the Emergency Department (ED). Unlike on the psychiatry floor/ward or even a psychiatric emergency holding unit, the ED sees patients with all sorts of complaints, and is not particularly well-suited for psychiatric patients. Reasons contributing to the ED environment being challenging include staff frequently entering and exiting the patient's room, which may interrupt your interview; a high level of activity and noise; and a large number of distractions. Psychiatric patients in the ED are from some of the most marginalized segments of society. They may be homeless, may have untreated, undertreated or mistreated psychiatric illness, and their presentation may be confounded by acute intoxication with alcohol, drugs, or co-existing medical illness.
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Many patients are brought in by law enforcement/police, which may unfortunately exacerbate a patient's aggression or paranoia. When patients are hostile or scared, it is difficult to develop a rapport with them.
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When interviewing such patients, it is preferable to enter the room without law enforcement as long as there does not seem to be an immediate threat of physical harm to you or your team (see Figure 20-1).
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How to assess whether the room/patient is safe (see Table 20-1):
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Position yourself on the patient's nondominant side
This is usually the patient's left in 95% of cases.
Patients usually wear their watch on their nondominant hand.
Their belt buckle usually faces to the nondominant side.
Position yourself close to the exit
Do a quick visual to make sure no objects that can be used as weapons are around. ED rooms designated as psychiatric rooms are usually devoid of such objects, but if the patient is in a regular medical room, then there may be many items that could be dangerous (e.g., suction canisters, trashcans, needles, intravenous [IV] poles).
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MEDICAL CLEARANCE ORDERS
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De-escalating the situation:
Be prepared to de-escalate the situation. Recognize that the patient may not be there by choice; that they may be been treated poorly by law enforcement; that they fear losing their independence; that this new environment aggravates their paranoia; and that the ED may be a place that they mistrust.
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DE-ESCALATION TECHNIQUES
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