Here's Your Meds - Have a Nice Life - What I Saw in the ER

[Lucky Laser]

I was observing in the Psychiatry ER the other night and a woman came in complaining of depression, anxiety, and intrusive thoughts relating to traumatic events from her childhood and she wanted some medication to help with it. The resident on call quickly ran through the PTSD criteria ("Do you have flashbacks? Do you have nightmares? Do you startle more easily?, etc.) all of which this woman said "yes" to. The resident asked the woman if she knew much about PTSD and she didn't seem to.

The resident proceeded to prescribe the woman sertraline (Zoloft) and I think Paroxetine (Paxil) and sent her on her way. She didn't even suggest counseling or anything other than the medications that might help her. If this patient was coming into the ER for this, and had even had a past suicide attempt because of it, it just seems logical to me that the resident should have suggested some other therapy.

I am just wondering if this is common; how many PTSD patients (or even patients with things like Generalized Anxiety Disorder, Major Depressive Disorder, etc.) get sent on their way with nothing but medications and if this is something that I should be upset about or this is just how things are done in the ER?

 

[2quilt]

my opinion

I think the resident missed the mark. I was on Zoloft by itself, then Paxil by itself, but I don't think it's right to mix them, then not advise counselling, and then offer her no form of after care or med supervision. I think the rez was careless. What if the patient flips out on the meds given? Then she's right back in the ER, another huge copay, and worse off than before.

This is a good example of why I don't let residents touch me. They make alot of mistakes, careless ones, the smartass ones argue with me like they know more about my disease than I do, brush off and discount my opinions, (And honey, I have some), then shoo me away with an incomplete script and no way to get it fixed if (a) it's not on my insurance's formulary, or (b) the pharmacy can't read the writing.

I always demand to see MD's, and if the rez or the 3rd year student wants to watch or comment, that's fine. I always then ask the student how she would rate the MD's performance in my case, in front of the MD, to get a smile.

I have been in that spot, that of the woman you wrote about, and I regretted going to the ER because I did not get my money's worth.

Did an MD supervise and approve what the rez did in this case, Laser?

 

[Lucky Laser]

I think an attending always has to hear each case and approve, but I left before I found out what happened for sure. I know that the ER tends to give a lot of "band-aid" medications, but if I were her I'd have at the very least offered some more information on PTSD and some encouragement to seek therapy. I know my city has a few places that trauma survivors can go for free even!

On the inpatient unit we always try to set up follow-up for people to get therapy or whatever they need... I think the ER could have done better and that the patient could have really benefited from something more.

 

[anthony]

This is the exact laziness that physicians have become now used too... this is their method of lazy treatment; in - out, pay the bill and thanks for coming. They just don't give a shit any more... basically it is coming down to the fact that you have to search high and low to find one who does give a shit about you... not just stuff medications down your throat and send you on your way.

More and more studies are being done with quite negative results showing from those who have been on medications for decades... as they where never designed to be a lifetime treatment option, they are designed for temporary relief whilst other proven applications are used to treat a person, being the human contact psychological treatment to produce a long standing result without the use of medication.

 

[nic]

Ok, I know of two sides to this.

First, is that of the PTSD sufferer. I have had to go to the ER a good handful of times due to extreme anxiety and panic. Each time, I am hooked up to an EKG just to make sure there is nothing wrong with my heart that is causing the palpatations, (and of course my heart is always fine), then I have to wait there for over two hours while they do a pregnancy test (even though I tell them that I am 100% certain that I'm not pregnant), and then I am given 4-6 mg of Ativan and told not to drive home, (which of course I do because there is no other way for me to get my car home). Yes, this is frustrating. No, it does not help long term. However, on to the other side of this...

I was in a long term relationship with a resident (now fellow) a few years back. Their case load is insane, and they have to juggle MANY patients at once, and admitting is especially difficult. In a sense, their job is more like triage than anything else. They take care of the main emergency at hand, (as it is an ER), and don't have time for much else. Good hospitals with have social workers available to discuss long term care, but depending on what time the patient comes in, they may not be available. Brief example: My ex, H, had a patient who was poor and had no way to get home. The paperwork in order to get this guy services was just so immense and no social worker was available, so H gave him $40 to get a cab.

Most hospitals do give patients a printout of what they should do for _____, and perhaps that is something you can suggest if it is not already done. As for getting to the heart of the issue right there in the ER, I'm afraid that's a losing battle.

 

[Lucky Laser]

I know how the case load can be... we were I think... three notes behind already. I dunno... it just seems like one might expect this in a regular ER but not the Psychiatry ER... and it would only take a minute to advise the person to see someone else. Perhaps I will feel differently in a few years...

 

[nic]

While you will have an even greater understanding of how things run in a few years, I do think that your personal background will help you to remain a positive advocate for all your future patients. Don't ever get too jaded that you lose sight of why you are in the medical field.

 

[Lucky Laser]

Thank you nic, I plan to keep that in mind. :smile:

 

[Lisa]

Here's how I experienced psychiatrists.

Lisa has been fully assessed by a psychiatrist once in her lifetime, when she was 17 by the child services, and this was in relation to self-harm and not anything else. At 18, she had a spell in hospital. Whilst she was in hospital, nobody actually asked Lisa why she was suicidal - not without exclaiming "You're here for being suicidal? But you're young, you have your whole life ahead of you, what do you have to be suicidal about?!!". In her hospital 'assessment' (other than observation) she was given a checklist of questions, one of which was "have you ever been abused?" to which she replied "sort of, um, I think so". The nurse looked up, then down at the clipboard and wrote something. The rest of her stay, she didn't have any conversations with any of the staff about why she was there. There was a psychologist who worked on the ward, but there was only one patient he was treating on that ward, whom he was giving ECT.

Lisa never really wanted psychiatric drugs. Her (forced) experience of them in hospital led to her standing at the train station days after she was discharged. She couldn't feel a thing. Zilch. So Lisa stood with her toes to the edge of the platform... to get a reaction out of herself. Any reaction. That day, Lisa came off that drug (Sertraline).

2 years after her hospital stay, she is about to walk into the same conversation that she has had every 3 months since her discharge...

It's a different psychiatrist (again). He speaks with a very strong accent and doesn't have good english.

"So... you have been having nightmares, depression, anxiety, and you still self-harm, yes?"
"Yes"
"Do you have thoughts to kill yourself?"
"Not in a few weeks, no"
"Are you still depressed? Feel sad lots?"
"Yes"
"Would you like some medication?"
"no, thank you"
"Okay. You still have anxiety, yes? Worry lots?"
"yes"
"I can give you an anti-anxiety medication to treat that?"
"No"
"Nightmares... I have a medication that may help this..."
"I'd actually like to be discharged, seeing as I don't want any psychiatric treatment... "
"No, because you still self-harm and you still have nightmares so we won't discharge you yet."
"But you're not treating me with anything, because I don't want drugs!"
"Even still we must oversee your care"
"So you won't discharge me?"
"No, I will book you an appointment in another 3 months time".

In 10 minutes, the appointment was over. And still :wall:

That was my last psychiatric appointment. I got out of the psychiatric system 3 months later, when I moved to university. In my 2nd year, I got myself a counsellor from the university services.

We actually have conversations about what goes on in my mind. Miracle!

Unfortunately, you have to really search for a psychiatrist that is actually interested in more than handing out prescriptions. And when you find a decent one...in the NHS community mental health services... you may never see that psychiatrist again. You get a different one every time. The waiting lists for any other sort of treatment are usually months long, sometimes years - and they are usually time-limited to 6 sessions of CBT.

I did try psychiatric drugs again last year - citalopram. But the side effects were too extreme, and there was no other real effect other than that. I tried beta blockers too, but they gave me breathing problems. I decided in the end, I'd rather go without psychiatric drugs... I'd rather know how I actually am, rather than being confused if it's actual trauma resolution or the drug effects. I'd also rather know if I'm actually sick, rather than just having side effects. It made things more confusing for me. But... personal choice. For some it seems to work better. One thing is for sure though... it's no long-term answer on it's own.

 

[anthony]

End of the day... good one's exist, they truly do... but there are just more that don't give a shit anymore. Regardless what case loads a shrink may have, they have a choice to either see more and do less, or see less and do more. They have a choice... one produces results, one produces more money. Yes, shrinks are now seen more today as a medication check only... and the load is expected to be taken by the poor old therapist, however; the therapist doesn't have the skills or knowledge necessarily to truly cater a person with severe traumatic disfunction. They like to all think they can, but truly it is a skilled exercise.

Your better off finding that one person who truly listens and gets in your head, isn't afraid to push you when needed, and take some low dose valium to help with the anxiety at the worse times... just my opinion though.

 

[Lucky Laser]

Strangely enough, my recent experiences are making me strongly consider going for a residency in Psychiatry. I talked with one of our inpatient psychiatrists today about the whole medications vs. therapies issue and she said that more and more because of the time limitations we have, patients are encouraged to follow up with primary care physicians to talk about psychotherapy options and its too bad because those therapies are way better in the long run. But wouldn't primary care physicians have the same problem with time limitations? It seems like all we get anymore (Lisa's post being a great example) is the run around.

I am thinking that even in the ER when its busy one can take an extra minute or two to explain the importance of therapy to a patient and the fact that the medications we give shouldn't be a permanent solution. I'd rather stay an hour late finishing up notes than send all my patients into a pharmaceutical abyss.

 

[2quilt]

I hope I get you as my doc when you get your license.