Biomedical subjects
Publications and source records attributed to M A Fauman.
The emergency psychiatrist must first differentiate abnormal behavior with a medical etiology from that caused by so-called functional processes. Delays in diagnosis can be catastrophic and make a compelling argument for physician involvement in emergency mental health care.
Modern medical quality assurance depends on the identification and continual monitoring of important parameters or indicators of care. Indicators are defined as measurable clinical variables, often related to high volume, high risk, or problem-prone areas of medical care. Although the identification and monitoring of indicators is often a complex task, there are several areas in psychiatry where effective indicators can be developed. The process of indicator development is discussed and several suggestions are made for effective clinical parameters to monitor.
The implementation of quality assurance monitoring is an important response to public demands for accountability in medicine as well as a requirement for institutional accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The author examines the somewhat elusive definition of quality as it is applied to medical care. He reviews the history, terminology, and reasons for quality assurance monitoring and presents the JCAHO-defined concepts of indicators and thresholds. Several common problems associated with the implementation of quality assurance monitoring are discussed along with guidelines for the development of quality assurance indicators in psychiatry.
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In response to a questionnaire regarding the frequency and type of psychiatric disorders among their patients, internists and surgeons in private practice estimated that 21.1% of their patients had psychiatric problems, that 14.6% would benefit from psychiatric treatment, and that they spent an average of 17.3% of their time treating psychiatric problems. They also stated that depression was the most frequent psychiatric disorder among their patients. More than half of the internists indicated they would treat depression, anxiety attacks, psychosomatic disorders, and organic brain disorders, which may be one explanation for the observation that more medical and surgical patients have psychiatric disorders than are referred to a psychiatrist.
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A questionnaire was sent to 206 internists and surgeons asking them to estimate the following: the frequency of psychiatric disorders and behavioral problems among their patients, the type and frequency of psychiatric medication they prescribed, the psychiatric consultation services they most valued, and the type of psychiatric problems they considered emergencies. These physicians estimated that 14% of their patients had significant psychiatric problems; the most frequently mentioned was depression. More than 25% of the physicians prescribed minor tranquilizers, sedatives, and antidepressants at least once a week. Violent behavior was considered a psychiatric emergency by the majority of physicians. There were significant differences between the responses of internists and those of surgeons.
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Violence associated with chronic phencyclidine (PCP) abuse was investigated by administering a structured interview to 16 chronic PCP abusers. A more intensive study was done of another individual who committed murder and self-mutilation under the influence of PCP. The results suggest that there is no consistent association between PCP-related violence and a history of violence not related to drug or alcohol abuse. The author defines four types of violence associated with chronic PCP abuse.
Agitated patients with organic brain disorders represent relatively common diagnostic and management problems. Therapeutic failures usually result from a failure to understand the patient's disturbed behavior, the staff's emotional response to the patient's behavior, or neglect of the biological cause and ineffective use of medication. Effective management depends on continued monitoring of the patient's mental status and physical condition.
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As with any medical emergency, the initial approach to the management of the drug abuse emergency is to attend to the potential threat to life. Establish and maintain an adequate airway, with respiratory support if necessary: secure a reliable intravenous route: administer appropriate drugs and antidotes; and perform the necessary diagnostic procedures to identify the cause of the problem. Always make an assessment of the psychological threat of self-destruction before discharging a patient who has taken an overdose. Be suspicious of drug overdose ina comatose or oddly-behaving patient. Consider the possibility of multiple drug abuse. Finally, always consider the possibility that causes other than drugs may be producing these symptoms.