Psychosis

He was brought in, from a nursing home, by ambulance. We heard him being wheeled through the automatic doors, shouting abuse at the ambulance officers and anyone else in sight. I drew the short straw and put my name alongside his on the computer screen. A quick chat with the ambulance officers revealed they had been called to the nursing home because this patient had undergone a rapid change in his mental state. He had only been there a week and had suddenly changed from being a quiet, cooperative old chap into what we saw now – an aggressive, abusive, loud and disruptive person.

I was able to calm him briefly and ask him a few questions but his answers were always shouted and his behaviour was quite inappropriate to his circumstances. Our attempts to examine him were frustrated by his aggression and the ECG was quite useless as he kept pulling off the leads and would not lie still for any length of time. Trying to take blood proved too dangerous for him and the medical staff. Eventually I decided to sedate him to facilitate a proper and full examination and an interpretable ECG to be taken.

Rather than inject him with a sedative I elected to use an oral sedative in wafer form. Simply placed on the tongue it rapidly dissolves and is absorbed. We had no trouble convincing him to open his mouth and allow the nurse to place the wafer on his tongue. In a very short time he was under control and we were able to achieve all our objectives.

The physical examination proved unrewarding. We took blood for a battery of tests and when he was taken away for a chest x-ray I called his son. He was not able to add anything to the history but did confirm his Dad had been quiet, cooperative and inoffensive up until a few days previously. He was somewhat distressed at his father’s condition.

Some hours later the patient had again become aggressive and difficult and we were forced to use injected sedation before transferring him to a ward in the hospital under the care of his GP. Then a phone call from the laboratory threw a whole new light onto the scene. Our patient’s serum troponin level was very high indicating severe damage to his heart. We concluded that at sometime in the previous week he had suffered a major myocardial infarction – a heart attack. This probably resulted in inability of his heart to maintain an adequate blood supply to his brain with the consequence being brain damage due to lack of oxygen and the demented behaviour we had observed.

I rang the GP to let him know of this development then rang the patient’s son. I explained the situation and had to inform him that it was highly unlikely that any improvement could be expected. Both GP and patient’s son decided to come to the hospital and I arranged they should meet. I do not know the outcome.

So, we had a patient present as a psychiatric problem but the process of diagnosis revealed the cause to be medical.

That is rarely the case with psychotic patients presenting to ED. Many are “Frequent Flyers” and well know to the staff. They are brought in by the police, friends, relatives or of their own volition. And most become a major problem to us because, all too often, we have nowhere to send them. Rarely can we let them go home because they are out of touch with reality and at very significant risk of harming themselves or others. Trying to get them into a psychiatric treatment facility becomes a frustrating process of ringing around and being fobbed off by one facility after another. Unfortunately, the basic issue is political – there are nowhere near enough facilities available to manage such patients and those that do function are usually full. So we are stuck with them.

It is not uncommon to have such patients in the main ED area all day or even for days on end. Often two police officers will remain in attendance or one of the hospital security personnel will have to sit with the patient. Unattended psychotic patients will do irrational things. Some become violent and throw chairs and furniture about or assault staff or others. It can be terrifying for all including other patients and children not to mention the staff who have to deal with it. Sedation is often necessary; I have never used or seen used physical restraint such as tying people to beds.

Psychotic patients are a minority of those patients requiring psychiatric diagnosis and treatment. Psychotic patients are, basically and simplistically, out of touch with reality. They are human beings suffering a terrible, life destroying affliction that can be humanely and professionally managed. But that humanity and professionalism is hamstrung by the blissful ignorance of senior health bureaucrats, politicians and do-gooders. A few years ago it became politically trendy to treat psychiatric patients in the community. Major psychiatric facilities were closed with the loss of many psychiatric beds to the point where there are not enough to manage even the acutely ill. The whole concept became a disaster with poorly managed psychotic patients often left to their own devices in the community.

One major problem with these patients is that, left to their own devices and on medication, they will often decide that there is nothing wrong with themselves and cease taking the medication. They then inevitably drift back into ever deepening psychosis and loose touch with reality. I was once asked to see one such patient, brought in by his work foreman because he was behaving very strangely. Going through the normal assessment process I asked the patient if he had ever had any serious illnesses. He replied that he had been a schizophrenic once but a course of tablets had cured him and he had stopped taking them. The condition masked his insight and he was incapable of realising his behaviour was bizarre and he was drifting back into psychosis.

Then there was another young man who was on the screen as wanting a repeat prescription. Unfortunately, due to higher priority patients, he had to wait a long while. When I got to him I was taken aback when he asked for a particular antipsychotic, he was visiting from another state and had run out of medication for schizophrenia. He even presented a letter from his GP confirming his diagnosis and treatment. I rang the GP who confirmed the patient’s story adding that he was one of his easier-to-deal-with schizophrenic patients. I happily wrote the prescription.

But not all ED patients with psychiatric conditions are psychotic. We see severely depressed patients, severely anxious patients, obsessive-compulsive patients, patients attempting suicide, ( unfortunately many others succeed), and so on. Many we can manage in the short term and with the help of their GPs or psychologists. Many we can’t manage and go through the agonising process of trying to get them professional help. Rarely, we can get them an urgent appointment at a mental health clinic.