The Importance of Acute Psychiatric Emergencies Training: Insights from the St Emlyn's Podcast

Introduction

Welcome to the St Emlyn's blog, where we delve into the latest topics and developments in emergency medicine. Today, we explore a crucial yet often overlooked aspect of our field: acute psychiatric emergencies. This post summarizes a recent conversation between Simon Carley and Kevin McRey Jones, highlighting the significance of addressing psychiatric emergencies within emergency departments. We will shed light on the Apex course, its methodologies, and the vital need for integrating psychiatric care into emergency medicine.

Addressing the Gap in Psychiatric Emergency Care

Kevin McRey Jones, a key figure in emergency medicine, recently joined the St Emlyn's podcast to discuss the Apex course, an initiative designed to fill a significant gap in emergency medicine training. Despite considerable advancements in managing various medical emergencies, psychiatric emergencies often remain underemphasized.

The Apex course addresses this gap by focusing specifically on acute psychiatric emergencies. Kevin explained that while many advancements have been made in managing cardiac, trauma, and obstetric emergencies, psychiatry has not received the same systematic approach. This has led to a fragmented care model where physical and psychological components are often treated separately.

The Origins and Purpose of the Apex Course

The Apex course, originating in 1992 with the Advanced Life Support Group, was created to systematize the training for managing acute psychiatric emergencies. Kevin, who has a long history of organizing and delivering courses in emergency medicine, emphasized the need for a unified approach to patient care. The course aims to bridge the gap between emergency physicians and psychiatrists, promoting a co-ownership model of patient management.

Why Psychiatric Emergencies are Often Overlooked

One major reason psychiatric emergencies have not received the same attention as other medical emergencies is the perception that these are problems best handled by psychiatrists or liaison nurses. This mindset leads to a tendency to pass psychiatric cases off to specialists rather than integrating psychiatric care into the emergency department's responsibilities.

Kevin highlighted a common issue where patients with both physical and psychological illnesses are often divided into two separate cases: the physical bit managed by emergency physicians and the psychological bit by psychiatrists. This division can lead to suboptimal care and poor outcomes, as the interconnected nature of these issues is overlooked.

The Consequences of Ignoring Psychiatric Components

Ignoring the psychiatric component of patient care can have severe consequences. Kevin pointed out that patients with psychiatric diseases often have poor outcomes regarding their physical health. This is largely because their physical ailments can be neglected due to the focus on their psychological issues.

Simon added that the outcomes for patients with psychiatric diseases, in terms of their physical health, are often terrible. This emphasizes the need for a more integrated approach to patient care, where both physical and psychological aspects are managed simultaneously.

The Need for Integrated Care

Kevin stressed the importance of co-owning the problem rather than treating psychiatric emergencies as the sole responsibility of psychiatrists. By doing so, emergency departments can provide more comprehensive care, addressing both physical and psychological needs. This integrated approach is essential for improving patient outcomes and ensuring that all aspects of a patient's health are considered.

Common Practices and Their Pitfalls

Simon discussed a common practice in emergency departments where patients presenting with apparent psychiatric problems are often assessed solely for physical issues before being referred to psychiatric specialists. This "clear them medically" approach can lead to delays in psychiatric care and inadequate management of the patient's overall condition.

Kevin acknowledged this issue and emphasized the need for emergency physicians to be involved in the psychiatric assessment and management of these patients. This approach ensures that all aspects of the patient's health are addressed, leading to better outcomes.

Rethinking Emergency Care for Psychiatric Patients

Simon reflected on the current practices and highlighted the need for change. The idea of dividing patient care into physical and psychological components, with little overlap, is increasingly seen as problematic. Kevin agreed, noting that sometimes organic problems can be overlooked when patients are quickly referred to psychiatric care without a thorough assessment.

The Apex Approach: AIOU Methodology

The Apex course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes:

• A: Assessment of aggression and agitation.
• E: Environment in which the patient is assessed.
• I: Intent of the patient, including suicidal ideation or harm to others.
• O: Objects the patient may use to carry out their intent.
• U: Unified assessment, combining both physical and psychological evaluations.

Implementing the AIOU Methodology

Kevin explained that the AIOU methodology is a co-created approach by psychiatrists and emergency physicians. This collaboration ensures that both physical and psychological aspects of patient care are addressed. The methodology aligns with the primary assessment, resuscitation, and definitive care phases familiar to emergency physicians.

Addressing Challenges in Psychiatric Emergency Care

Rapid tranquilization is a common concern in managing psychiatric emergencies. Kevin emphasized that the goal is to use the minimum level of intervention required, whether that involves oral medication or, if necessary, safe rapid tranquilization. The course teaches a balanced approach to ensure patient safety and effective management.

The Role of Risk Assessment

Psychiatry is a risk-driven specialty, focusing on assessing risks of violence, flight, and harm to self and others. Kevin highlighted the importance of minimizing these risks through a structured, systematic approach. This methodology allows for a comprehensive evaluation and management plan that addresses both immediate and long-term risks.

Structured Approach to Both Psychiatric and Physical Assessment

The Apex course emphasizes a structured approach to both psychiatric and physical assessments. This dual-focus ensures that all aspects of a patient's health are considered, leading to more comprehensive and effective care.

Collaboration Between Psychiatrists and Emergency Physicians

The course promotes collaboration between psychiatrists and emergency physicians, encouraging them to learn from each other and develop joint solutions to patient care challenges. This partnership is essential for providing holistic care and improving patient outcomes.

Co-Assessment and Risk Management

The course highlights the importance of co-assessment and risk management. By working together, psychiatrists and emergency physicians can provide a more unified approach to patient care, addressing both physical and psychological needs simultaneously.

Substance Abuse and Psychiatric Symptoms

Substance abuse often complicates psychiatric emergencies. The Apex course takes a symptom-based approach, focusing on the specific challenges presented by patients with delirium, confusion, aggression, and self-harm. This approach allows for a more tailored and effective management plan.

Prevalence and Importance of Addressing Psychiatric Emergencies

Psychiatric emergencies are more common than many realize. Kevin noted that about 5% of patients in emergency departments present with direct psychological or psychiatric symptoms. Including substance abuse and alcohol-related cases, this number can rise significantly. Addressing these emergencies systematically is crucial for improving patient care and outcomes.

Conclusion

The Apex course represents a significant advancement in the training and management of acute psychiatric emergencies. By promoting a unified approach to patient care, it addresses a critical gap in emergency medicine. Collaboration between psychiatrists and emergency physicians is essential for providing comprehensive care and improving patient outcomes. For more information on the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website.

Final Thoughts

Reflecting on the discussion, Simon emphasized the importance of integrating psychiatric care into emergency medicine. The dichotomy approach, where physical and psychological issues are treated separately, is increasingly seen as inadequate. The Apex course offers a pathway to more comprehensive, patient-focused care, ensuring that all aspects of a patient's health are addressed.

How to Learn More

For those interested in learning more about the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website at www.alsg.org. The course is offered in various locations, providing opportunities for emergency physicians and psychiatrists to enhance their skills and knowledge in managing acute psychiatric emergencies.

By embracing this integrated approach, we can ensure that patients receive the comprehensive care they need, improving outcomes and advancing the field of emergency medicine.

March 2018 Roundup: Evidence-Based Medicine and Exciting Announcements at St Emlyn's

Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in!

Catching Up After Winter

As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you.

Exciting Upcoming Events

Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss.

St Emlyn's Live

St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money.

The Teaching Course in Manchester

Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career.

Evidence-Based Medicine: The Great IV Fluid Debate

One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital.

The Normal Saline vs. Balanced Fluids Debate

The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions.

Recent Trials in the New England Journal of Medicine

Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards.

Cluster Randomized Trials

The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust.

Key Findings

The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices.

Practical Implications in Emergency Medicine

As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling.

Local Practices and Preferences

In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution.

Teaching the Next Generation

We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference.

The Teaching Course in Cape Town

Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth.

Success in South Africa

The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided.

Chris Weymouth’s Experience

Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience.

Cardiac Arrest: Predicting Outcomes with Pupil Responses

Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations.

The Study from France

A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive.

Sensitivity and Specificity

The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on.

The Gray Areas in Resuscitation

Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action.

ECPR and Prolonged Arrests

With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues.

Upcoming Events and Final Thoughts

As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up.

Join Us at St Emlyn's Live

Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today.

Stay Tuned for More

We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community.

Conclusion

March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.