The Interface: Ethical Decision Making, Medical Toxicology, and Emergency Medicine

Emergency Department Telepsychiatry Service Model for a Rural Regional Health System: The First Steps

BACKGROUND

Emergency departments (EDs) have recognized an increasing number of patients presenting with mental health (MH) concerns. This trend imposes greater demands upon EDs already operating at capacity. Many ED providers do not feel they are optimally prepared to provide the necessary MH care. One consideration in response to this dilemma is to use advanced telemedicine technology for psychiatric consultation.

INTRODUCTION

We examined a rural- and community-based health system operating 21 EDs, none of which has direct access to psychiatric consultation. Dedicated beds to MH range from zero (in EDs with only 3 beds) to 6 (in an ED with 38 beds).

MATERIALS AND METHODS

We conducted a needs assessment of this health system. This included a survey of emergency room providers with a 67% response rate and site visits to directly observe patient flow and communication with ED staff. A visioning workshop provided input from ED staff. Data were also obtained, which reflected ED admissions for the year 2015.

RESULTS

The data provide a summary of provider concerns, a summary of MH presentations and diagnosis, and age groupings. The data also provide a time when most MH concerns present to the ED.

DISCUSSION

Based upon these results, a proposed model for delivering comprehensive regional emergency telepsychiatry and behavioral health services is proposed.

CONCLUSIONS

Emergency telepsychiatry services may be a tenable solution for addressing the shortage of psychiatric consultation to EDs in light of increasing demand for MH treatment in the ED.

Complicated acute appendicitis? An unusual differential

Acute appendicitis is a common surgical diagnosis but several differential diagnoses exist and should be considered. Internal concealment is one such diagnosis.

We present a case of a young man taken to the operating room with a preoperative diagnosis of complicated acute appendicitis. A ruptured caecum was encountered and several free-floating drug pellets were present.

Attending doctors should consider this differential in the high prevalence areas and, whenever encountered, they should strongly consider early reporting.

Mental health and emergency medicine: a research agenda

The burden of mental illness is profound and growing. Coupled with large gaps in extant psychiatric services, this mental health burden has often forced emergency departments (EDs) to become the de facto primary and acute care provider of mental health care in the United States. An expanded emergency medical and mental health research agenda is required to meet the need for improved education, screening, surveillance, and ED-initiated interventions for mental health problems. As an increasing fraction of undiagnosed and untreated psychiatric patients passes through the revolving doors of U.S. EDs, the opportunities for improving the art and science of acute mental health care have never been greater. These opportunities span macroepidemiologic surveillance research to intervention studies with individual patients. Feasible screening, intervention, and referral programs for mental health patients presenting to general EDs are needed. Additional research is needed to improve the quality of care, including the attitudes, abilities, interests, and virtues of ED providers. Research that optimizes provider education and training can help academic settings validate psychosocial issues as core components and responsibilities of emergency medicine. Transdisciplinary research with federal partners and investigators in neuropsychiatry and related fields can improve the mechanistic understanding of acute mental health problems. To have lasting impact, however, advances in ED mental health care must be translated into real-world policies and sustainable program enhancements to assure the uptake of best practices for ED screening, treatment, and management of mental disorders and psychosocial problems.

Treating cocaine body packers: the unspoken personal risks

Cocaine trafficking is a significant problem that many Caribbean territories must face. "Body packing" is a common method of transport where the smugglers ingest several cocaine filled packages. Body packers may be taken to hospital when they are detained by law enforcement officers, but occasionally they present on their own or accompanied by persons other than the authorities. This scenario poses a difficult management dilemma in any jurisdiction. We describe our experience with one such case in Jamaica.