Aftermath

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Good morning, everybody.

I have another question from our studio audience today. (Please keep those cards and letters coming)

“What happens after a telepsychiatry consult? Do you get any kind of feedback about what happens to your patient?”

Excellent query.

As I have mentioned in previous posts, doing telepsychiatry is a lot like any other emergency room work. It can be tediously slow and boring. It can be horrendously busy. It can get stale when one sees the same thing over and over again. It can be tremendously exciting when a fresh new problem associated with a rare diagnosis presents itself. Another caveat of doing this work is that we often see a patient, are very invested in the story they tell, make recommendations for their care, and then never see or hear from them again.

So, what usually happens after I do a telepsychiatry consult? What is my ongoing connection to the patient? This can break out several ways.

First, if a recommendation is made to release the patient to outpatient followup, and the ED staff agree with this, then they may be sent home minutes to hours after the consult report is sent it. In that case, of course, no more contact is made. The patient is off to follow up in a local mental health clinic or with a private psychiatrist, and that is that.

If the feedback from the telepsychiatrist is to admit for safety, to restart medications, or to further observe to make a more definitive diagnosis, then it can go two ways. An inpatient bed may be found fairly quickly (something that is getting more and more rare in the state of South Carolina, where I practice) and the patient will be transferred to the other facility as soon as that is practical. There is ┬áno real “active mental health treatment” in the ED per se, so this scenario is optimal if inpatient intervention is needed.

More common is the recommendation for inpatient admission followed by days (or sometimes weeks, unfortunately) of waiting for an appropriate bed to open up. In this case, treatment may be started, at the very least the medication portion of treatment, while the patient waits. If that happens, then within seventy two hours, when the commitment papers need to be recertified in order to hold the patient in the ED, a follow up consult may be sent, and the same telepsychiatrist (or one of his or her colleagues) will re-evaluate the patient. If sufficient progress in relief of symptoms has been made at that time, suggestions for release and follow up may be made. If not, then continued hold may be suggested to the attending in the ED.

The latter is one scenario that allows for me as a telepsychiatrist to actually see, paradoxically, progress in my patient. If an antipsychotic is started for a patient who is floridly delusional and agitated to the point of needing physical restraints and intramuscular medications to prevent harm to himself and others, forty-eight to seventy-two hours of treatment and observation can sometimes work miracles. Someone who was afraid of the camera and tried to hit me through it (yes, that has actually happened) may be able to much more calmly explain how they felt on admission after three days of treatment. That is the closest we telepsychiatrists usually get to seeing a positive outcome or even a “cure”, as much as one with true mental illness can ever be “cured”.

A spinoff of this is the patient who is seen, for whom a treatment plan is crafted, who is then discharged, but then “bounces back” with the same or similar problem that got them there in the first place. This happens quite often with folks who have substance abuse problems.

Alcoholism, for example, is a “cunning and powerful” disease, and the patient who reappears in the ED with a blood alcohol level of 450 a week after being seen for intoxication is far too common. Other patients who have chronic mood disorders, psychotic disorders, or even personality disorders may revisit the ED many times with superficial lacerations to forearms or wrists, repeated overdoses with sub-lethal amounts of pills or other problems that recur. This is good in the sense that the telepsychiatrist gets a much more accurate picture of the pathology involved over time. It is bad in the sense that the patient may be traumatized over and over by the admission and evaluation experience, and emergency resources are used where outpatient mental health services should be employed instead.

Finally, if the patient has presented with a one time, first episode, self-limited process, then a consult may be done, a disposition reached and the patient discharged, never to be seen or heard from again. I like to think when that happens that we have helped them move through and past a bad patch in the road and that they go forth and live their life well and happy. I am not so naive that I think this really happens in every case, but it’s a nice thought. This may also happen with those who are itinerant or transient patients. They may or may not be back the next time the direction of the wind shifts and the leaves begin to fall with the temperatures.

I hope this gives you a sense of what happens after telepsych consultation is completed.

In the style of Steve Jobs, I have one more thing for you before I move on with my day and let you do the same.

I received an email yesterday from the powers that be that told me our merry little band has received tentative approval to work from home. Up until now, to do my telepsychiatry duties I have had to physically go into an office in the local mental health center. Now granted, this has not been an extreme hardship, in that the office is exactly six  minutes from my apartment. However, working from home would mean that I have control over the thermostat, that I get to make my own coffee, that lunch is ten steps away, and that when a sixteen hour shift is over I can walk two rooms over and fall into bed if I wish.

It’s the little things people.

I’ll be sure to let you know how that scenario plays out. Could make for some interesting writing about autonomy versus isolation and other associated issues.

As always, thanks so much for taking a little time out of your own day to read my musings. I welcome your comments, feedback, and suggestions for things you’d like to read about here.

Have an excellent day (or evening, for those of you who insist on staying fourteen hours ahead of me. You know who you are.)