Saturday, December 20, 2008

I now pronounce you ... medically cleared.

Emergency room (ER) staff hold a special fondness for psychiatric patients. Overt psychosis, statements to kill self or others, inability to care for one basic needs or imminent risk do not classify as serious enough to be treated before minor physical maladies. And, even though mentally ill patients do not appear to be in distress, they require the same basic diagnostic procedures as all other patients.What does it mean to be "medically cleared?"

  • I screened a "medically cleared" 10 year old on stimulant medications in an ER and recommended transfer to a freestanding psychiatric hospital. When the receiving hospital asked for the patient's results from the lab screens, they were informed that no lab tests were done.
  • A few days ago, a crisis worker met with a "medically cleared" young adult who ingested 25 to 30 ibuprofen tablets a few hours before presenting to the ER. Fifteen minutes into the screening, the patient began vomiting uncontrollably and asked that the interview end because she was in too much discomfort.
  • An adolescent patient "medically cleared" from an ER vomited eight times in route to a freestanding psychiatric facility. He arrived dehydrated and was sent to another emergency room and medically admitted to a telemetry unit for two days.
  • I have been asked to assess "medically cleared" patients from pediatric intensive care units (PICU) prior to transfer and admission to other psychiatric hospitals. The most recent lab results were from tests taken 2 days prior to the request for assessment.

Medically clearing a patient is largely based on where the patient will be in the next few days and what supports will be immediately available during that time. Most hospitals require basic lab  screens including blood alcohol level (BAL) and drug for adolescents and adults, pregnancy screens for females and others tests to address a patient's history of diabetes, hypertension or other chronic illnesses. In cases of drug ingestion, a period of 48 hours observation on a medical unit is required prior to transfer. Intoxicated patients cannot be interviewed until their BAL is below 100 as they are medically compromised and may be hallucinating, delusional, aggressive, suicidal or homicidal because of an alcohol-induced acute episode. Patients with acute eating disorders frequently present not only as underweight but as dehydrated and fluid imbalances which may require monitoring on a telemetry or intensive care unit. Self-injury patients may present with wounds at risk for infection, inflammation or damage to major arteries, tendons or organs. 

The purpose of medical clearance is not for CYA; it is to increase the patient's chances in being able to successfully engage in the next level of prescribed care.

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