Challenging patient Flashcards
Define homelessness
1) primary - such as sleeping rough or living in an improvised dwelling
2) Secondary - staying with friends or relatives and with no other usual address including people in specialist homelessness services
3) Tertiary homelessness - boarding hourses or caravan parks over both the short and long term wtih no sevure lease and no private facilities
Discuss clinical features of homeless patients
High rates of complex physical and mental illness and substance dependence.
Due to poverty and social isolation access to health care is impeded
Presentation with infections disease (TB and HIV) penetrating trauma, depression, schizophrenia and ethanol and drug abuse are common.
Management requires mutidisiplinary approach and an understanding of the social and financial constraints the patient faces.
Discuss challenges associated with the prisoner in the ED
Security
- perceived threat to safety of staff and other patients
- potential for violent incidents
- presence of non hospital security staff
- Weapons in the emergency department
Patient care issues
- clinical management of complex illness
- medical psychiatric and addiction co-morbidities
- maintenances of confidentially
- discharge planning
Discuss clinical features of prisoners in the ED
Commonly younger men and frequently indigenous. Presentations are most commonly injury related and are overall more severe as compared with those in the general male population.
Mental health issues and high suicide rates are common
Substance withdrawal is implicated in 9% of presentations and 6% of admissions.
Episodes of violence are uncommon and rate of security incidents may be lower than for the non-prisoner population.
Presence of weapons is a concern
Discuss management of a prisoner in the ED
The urgency with which a prisoner is assessed depends on a combinations of medical issues and security considerations; prioritization in order to expedite management and decreased LOS in the ED
Confidentiality concerns with guards presence needs to be weighed against safety concerns.
Opportunities for follow-up of medical conditions may be limited. OPD is time and resource intensive and logistically may be difficult for prison staff. As such may need more intensive workup in the ED prior to discharge
If discharged needs specific instructions regarding care and ongoing ix/management.
Discuss the violent patient
Behavioural emergency can be defined as an unarmed threat by a patient or other characteried by agitation, aggression violence and irrational or altered behaviourl.
Respectful and clear communications with lowered voice level eye contact and non threatening body language may establish a rapport that enhances a therapeutic bond between clinician and patient.
Explanation of treatment decisions and the reasons for them may alliviate confusion while bargaining and rewarding compliance can diffuse tension. It is reccommended taht while also setting clear behavioural limits the patient should be allowed a semblance of autonomy and control.
Discuss clinical features in treating an agitated or violent patient
Aims of clinical assessment in the face of an acute behavioural issue
1) diagnosis: what is the aetiology of the behaviour
- psych
- substance
- organic
- personality
2) Risk assessment: can the patient’s autonomy be over-ridden
- can he or she be kept in the ED against his or her own will
3) Arousal assessment
- doesthe patient require containment or sedation and how rapidly
Risk assessments are often made rapidly and intuitively in the highly agitated and aggressive patient. THe decision to contain and restrain an aroused patient is primarly based around the perceived threat of harm to self or others.
Clinical features that are suggestive of hihf risk include
- trheats or actual self harm
- suicidal behaviour or ideation
- threats or actual violence to others
- ALOC
- injury
- Substance intoxication and incompetence.
Discuss legal and ethical considerations surrounding sedation and restraint
Australian law strongly upholds the fundamental principle of individual autonomy and mental health legislation mandates a ‘“least restrictive”approach to involuntary care
The ability to detain and treat people wihtout their consent is lawfully recognized in emergency situations, committal under legislation (e.g mental health acts) suicida prevention, to protect other frum harm, self defence, or in the best interest of incompetent patients.
ED staff are comprehensively protected under the law if they act in good fiath and with integrity when managing acute behavioural distrubance.
Discuss management of the aggressive patient
Containing a highly aroused and aggressive patient requires a team of trained staff - a minimum of six people comprising hospital security staff and orderlies with medical and nursing for team leadership, documentaiton, drug admin and subsequent monitoring.
Least restrictive and traumatic measures are advocated
DIscuss Pharmacological management fo the aroused patient
Should the situation allow oral dosing is the least distressing approach for patient s and staff.
Endpoint should be a calm co-operative patient. Sedation to the poitn of loss of airway protection is deangerous.
- Should be nused in a quite calm and gently lit environment.
- sedated patients should be montiored with basic obs, a 12 ECG
- Supportive care is essentials, a chemically sedated paitent is the doctors responsibility.
Specific agents
- Diazepam 5-10mg orally
- olanzapine 5-10mg sl
- Droperidol 10mg IM up to 20mg
- Midaz 5-10mg IM
Discuss physical restraint
Can initially proceed on the floor and move to a trolley as soon as practical
A five point hold is recommended involving securing the head as well as the upper and lower limbs in a firm grasp.
PPE
Saftey of staff is paramount
Try not to inflict harm to the patient.
If using shcakles patient should be supine with soft edged strong fabric shackles. -Cocurrent chemical restraint is recommended. Prolonged shackling is inhumane and carries risk of MSK injury, resp compromise and psychy trauma.
Discuss risk of restraint
PATIENT
Physical injury to patient - MSK, fracture dislocation
a-asphyxiation
Psych damage
Medical
-rhabdo
Medications adverse affects
- Respiratory depression
- aspiration
- Prolonged QT + sudden cardaic death
- antichoinergic effects such as delirium and urinary retention are risk with virutally all antipsychotics and are generally seen at high doses.
STAFF
Physical injury to staff
Needle stick
Discuss managing violence in an ED setting
Concept of zero tolerance is not workable in a health care setting in which clinical aggression is conjoined with a duty of care between the clinician and the patient
Three cor components comprise a strategic approach to managing violence
1) environement (appropriateness, saftey)
2) staff (education, training, teamwokr)
3) systems (reporting, follow-up, peer support, policies)
Environment
- comfortbale environement with clear visibility
- visible cameras
- Visable secruity
Staff
- traing in verbal de-escalation,
- role play
- Peer education sessions
- awareness of personal factors
- awareness of cultural factors
System
- Docutumentation and follow-up
- debriefing and support
Define drug abuse and addiction
A maladaptive pattern of drug use indicated by contrinued use despite knowledge of its being a socail occupational psychological or physical problem that is caused or exacerbated by the use
Addiction is defined as a primary chronic neuobiological disease that develops as a result of genetic psychosocial and environmental factors and manifest as abuse of a substance to the extent that the user is periodically or chronically intoxicated, exhibits compulsive use has great difficulty in voluntarily ceasing or modifying his or her substance use. Typically tolerance is prominent and withdrawal syndrome frequently occur if interrupted
List feature raising suspicion for durg seeking
- Previously documented drug seeking behaviour
- inconsistent history or examination finding
- request for specific narcotic or other drug
- unwillingness to try simple analgesia
- higher than expected analgesia requirements
- demanding or aggressive behaviour
- Complaints of lost or stolen prescriptions
- letters from remote medical pracices supporting the provision of medications
- presentations that are possible to feign -migraine, renal colic
