If the Dog Bites, If the Bee Stings, If I’m Feeling Sad



The ED is a hectic place. 

Sore throats. Heart attacks. Dog bites. Broken bones. Strokes. Major trauma. If you work in an ED, you see it all. And then some. 

Is it any wonder then, with the potential for literally thousands of medical and surgical problems to stumble through the doors of an ED, that hospitals and the bodies that accredit them demand strict, regimented, standard, reproducible emergency assessments and the forms that document them? Of course not. This insures that all the basic questions are asked, that decision trees are followed, that diagnostic criteria are carefully applied, that correct diagnoses are made, and that treatment decisions are made based on evidenced based standards of care, both local and national. 

There are (at least) two wild cards in this process. Health care providers and patients.

Oh, yeah, those. Real people. Stressed people. Tired people. Hurting people. People who are throwing up and having chest pain and screaming and threatening to sue. People who are seeing their hundredth patient at the end of a double shift while trying to focus their eyes on the paperwork in front of them at the same time. Exhausted, sick, frightened, smart, superstitious, trusting, paranoid people. 

Mental health patients are people. Surprised by that, are you? Yeah. They’re people, just like you and me. They just happen to pull out guns to shoot themselves when they get really depressed, or take their clothes off and get hyper-sexual when they’re manic, or put black sheets and duct tape over the windows in their houses when they think the FBI has helicopters hovering outside their house. Other than those little details, they’re pretty normal people just like you and me. 

These normal people with not so normal chief complaints (“I think the federal government has put a metal bug inside my brain, right back here at the base of my skull, look Doc.”) come into the ED in all sorts of ways as we’ve already discussed here. Here’s the rub. These folks don’t fit the usual medical mold. Not surprised at that either, are you? Good. You shouldn’t be. Why is this a problem?

  1. A one-size-fits-all assessment in the ED does not usually address psychiatric and mental health needs fully.
  2. Substandard psychiatric histories by health care providers unfamiliar with mental health presentations often lead to the report that “the patient has been fine” and lead to inadequate assessment, diagnosis and treatment. 
  3. All that hallucinates is schizophrenia and all that is agitated is bipolar disorder. The problem with that level of reductionism? Hallucinations can come from drugs, brain tumors and iatrogenic medication interactions. Agitation can come from hypoxia, angina, and impending pulmonary embolism. 
  4. Patients who hit the ED doors with previously diagnosed psychiatric illness may not get the same attention when they have somatic complaints.  My “live patient” for my psychiatric boards was a middle aged man with schizophrenia who was complaining of atypical chest pain. My examiners expected that I knew schizophrenia backwards and forwards (I did). They wanted to see if I would adequately address these potentially life threatening symptoms in a previously diagnosed psychiatric patient. If I had ignored these issues and focused only on his (relatively stable) delusions and hallucinations, they would have sent me packing. I passed the boards. 

The ED is  often the place that mental health patients, especially if they are indigent, come for both mental health and physical assessment and treatment. Both must be addressed. 

More about this in the next post in this series.


3 thoughts on “If the Dog Bites, If the Bee Stings, If I’m Feeling Sad

  1. Greg,

    You know, the more I read of your experiences, the more I admire your calling. I can remember when Paula & I were fresh out of nursing school, brand new charge nurses on a surgical floor, caring for mundane hernia repairs-hysterectomies-cholesystectomies-and any other “ectomy” you can think of. But occasionally we had the overflow patient…the left-over patient during holidays, which was NOT our usual demographic. One particular patient stands out loud & clear…a psychiatric patient, delusional like none I had ever experienced, leaving the television on a “non channel” (you know, all snow & white noise), saying that Jimmy Carter was communicating with him through it, giving him instructions (Carter was president at that time;). Now, several things came out of that experience for me: psychiatric patients remain pretty happy as long as they receive their meds on time, I had no experience whatsoever in discussing delusions of grandeur, & most importantly, leave the freaking TV alone!! I wasn’t even going down the path of “why Carter & what instructions!” Quite frankly, psych patients scared the hell out of me! Hence my move toward the NICU!;)

    You do good work. I’m proud to call you my friend!



  2. Greg,

    Oh, it’s a calling alright … One that requires certain gifts. Gifts like compassion, patience, kindness. Also, attributes like discretion, trustworthiness. This is the man…not the doctor. The man (or woman) must have these in order to have a successful practice. As you said earlier, just about anyone can be a doctor. I agree with that. After all, it’s learning. Anyone can learn when they apply themselves. BUT so many do this for the wrong reason. Whether it’s pressure from family, the ideation of becoming a rich doc joining high class society (they have no idea how wrong they are there!), or to even prove something to themselves…if it’s not their calling, they do it for the wrong reason. And those gifts & attributes mentioned above are more than likely very much lacking in these people. You, my friend are driven to get up every morning (through aches & pains!) because being a physician was absolutely your calling. This fact I am certain of…without a doubt! You exhibit an enormous amount of compassion…absolutely your spiritual gift! You do know that you have been blessed, don’t you? So many go through life never realizing & being certain about their life purpose!

    I’m so glad you did:))



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