Management of Overseas Psychiatric Emergencies
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1 Management of Overseas Psychiatric Emergencies Kenneth B. Dekleva, MD Department of State Regional Medical Officer/Psychiatrist, Moscow March 9, Bangkok CNE 1 March 9, Bangkok CNE 2 1
2 Overview Models of care: ER Psychiatry vs. Crisis Intervention Treatment and medico-legal issues Aeromedical evacuation Case examples Questions? March 9, Bangkok CNE 3 Foreign Service Life Terrorism Frequent moves Change of school Lack of spousal employment Excessive travel Environmental Loss of control Fishbowl phenomenon Work Stress Inadequate resources Family issues Lack of support system Crime War-zone deployments March 9, Bangkok CNE 4 2
3 March 9, Bangkok CNE 5 A Typical Embassy State Dept. DAO AID FBI DEA DHS FAS FCS FAA CDC NASA DoD Peace Corps DOE DOJ Treasury Other agencies March 9, Bangkok CNE 6 3
4 Mental Health Program Culture shock Stress management School consultation Management consultation Travel medicine Occupational health Medical diplomacy Disaster response General psychiatry Security/forensic issues Emergency Response Family advocacy Crime War Zone issues March 9, Bangkok CNE 7 Examples of Psychiatric Emergencies Suicide threat/attempt Psychotic agitation Violence; family advocacy Severe anxiety Victimization Alcohol/drug states Delirium March 9, Bangkok CNE 8 4
5 Emergency Psychiatric Assessment R/O serious medical conditions Risk: danger to self/others, or risk of dangerous deterioration if untreated Crisis intervention Consultation Diagnosis; treatment; aeromedical evacuation; hospitalization Documentation; medico-legal issues March 9, Bangkok CNE 9 Crisis Intervention Crisis: response to severe stress; disruption of one s psyche and its equilibrium Crisis intervention: mobilize adaptive resources; emphasis on coping and recovery; change and growth Utilization of HU, family, peer, and community supportive interventions Psychotherapeutic model: supportive; here & now ; direct, active Duration is typically brief (weeks) March 9, Bangkok CNE 10 5
6 March 9, Bangkok CNE 11 Medical Conditions as Psychiatric Emergencies Medications: toxicity; drug interactions Drug/ETOH intoxication & withdrawal states Endocrine; Metabolic Infectious (encephalitis; meningitis; HIV) Cardiac; Pulmonary Neurologic (CVA; TBI; dementia; seizures; tumors; DCS; AGE) March 9, Bangkok CNE 12 6
7 Vital Signs ABCs Triage/Assessment Pulse Oximetry Labs; 12-lead EKG; CXR Medications; IV hydration; calories Neuroimaging Medical/psychiatric consultation March 9, Bangkok CNE 13 Alcohol/Drug Intoxication & Withdrawal States ETOH; opiates; BZDs Risk assessment Calm environment; team approach; HU location Local hospitalization? Medical evacuation? Consult with RMOP, ADAP March 9, Bangkok CNE 14 7
8 Treatment of drug/etoh emergencies Labs: often not available --- reliance upon clinical assessment BZDs; vitamins; thiamine; fluids; nutrition Crisis intervention, family support Safety issues Special concerns: co-morbid medical conditions; seizures; DTs March 9, Bangkok CNE 15 Management of Suicidality/Violence Psychiatric consultation Take all threats/attempts seriously Treat underlying medical/psychiatric illnesses Consider medical evacuation or inpt. care; treat-in-place? 1:1 observation where indicated Risk assessment; elopement risk March 9, Bangkok CNE 16 8
9 Treatment of psychotic agitation RX endpoint: calm wakefulness ; sedation; diminished arousal state Rapid Tranquilization (PO or IM, q30 min prn): Lorazepam 2mg & Haloperidol 5mg; Lorazepam 2mg; Haloperidol 5-10mg Newer agents: Olanzapine; Risperidone; Ziprasidone; Aripiprazole EPS: Benztropine 2mg; Diphenhydramine 25mg NMS: % risk; mortality = 40% March 9, Bangkok CNE 17 Medico-legal Issues Documentation; consultation with MHS Aeromedical evacuation? Confidentiality; HIPAA; Tarasoff Medical clearance: return to post? March 9, Bangkok CNE 18 9
10 Aeromedical Evacuation Consultation (medical; psychiatric) Cabin conditions: crowding; relative hypoxia; airport transfers; elopement risk; dehydration Seclusion; restraint; safety; liability Medical escort? Air ambulance? Medical clearance to fly On-board medical kits Which medications available? March 9, Bangkok CNE 19 Air Rage; Passenger Misconduct Incidence: 10000/year in 2000 in US; 3-15% are psychiatric; approx. 33 medical incidents/day Causes: psych disorders; ETOH/drugs; personality disorders; stress/crowding; hypoxia Liability; Good Samaritan laws vary 1963 Tokyo Convention Restraint; seclusion; diversion 10% of diversions are caused by neurologic sx March 9, Bangkok CNE 20 10
11 Cases 1. Young female, G1P1, with new-onset post-partum psychosis 2. Adolescent male with 1 st -break psychosis 3. Young female with psychotic agitation 4. Middle-age female with history of suicidality, recurrent depression, borderline PD, and alcohol dependence 5. Adolescent male with ETOH OD/intoxication 6. Young female with phobia, recurrent MDD, postpartum, marital strain, and significant stress March 9, Bangkok CNE 21 Pearls The patient is the person in crisis Pay attention to boundaries Pay attention to your stress levels Self-care is very important; remain calm Pay attention to countertransference Most crises resolve if managed properly Offer reassurance, calm, and hope March 9, Bangkok CNE 22 11
12 Questions? March 9, Bangkok CNE 23 References Zoya Simakhodskaya et al., Innovative Use of Crisis Intervention Services with Psychiatric Emergency Room Patients, Primary Psychiatry 2009;16(9):60-65 Peter G. Teichman, Yoel Donchin, and Raphael J. Kot, International Aeromedical Evacuation, NEJM 2007; 356: Doug Puryear, An Alternative Approach to the Suicidal Patient: Crisis Intervention, Psychiatric Times, March 18, 2010 ( Michael Allen et al., The Expert Consensus Guideline Series: Treatment of Behavioral Emergencies, A Postgraduate Medicine Special Report, May 2001, pp March 9, Bangkok CNE 24 12
13 References: Air Rage JI Sirven et al., Is there a neurologist on this flight?, Neurology 2002 June 25; 58 (12): K Pierson et al., Airline passenger misconduct: management implications for physicians, Aviat Space Environ Med 2007 Apr; 78 (4): H Gordon et al., Air travel by passengers with mental disorder, Psych Bull 2004 (28): EW Fine, Air rage implications for forensic psychiatry, Am J Forensic Psych 2002; 23: March 9, Bangkok CNE 25 March 9, Bangkok CNE 26 13
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