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ROGER G. BUTLER, M.D.: If it helps any, I did my residency at UT Southwestern in Dallas, so I'm getting closer, I guess, to UT. I still feel like a Texan, I've been here since 1984, still a Sooner, of course, that never goes away. I appreciated the opportunity to come talk to you. Kim told me that there was need here, as far as your help in managing various psychiatric emergencies. Of course, the ones that we are concerned about the most are agitation and suicide. I'm going to spend just a short time on suicide, because I would imagine, like most facilities now, you have the assessors that you call and talk with the patients, determine the need for inpatient care or outpatient care, whatever the case may be. However, I think it's still good to know, especially if you have a lack of psychiatric coverage, to kind of know what they're looking for and how you can start that assessment. But most important of all, I think, is the management of agitation. It's about the only disorder that I can think of that y'all have to deal with on a day-to-day basis in which you have to be alert to many different things and still, at the same time, be at risk of being injured-- your staff, yourself, the patient, the other patients. And so it's really important that we have a degree of confidence and understanding of what is needed in this setting. Just a quick review, there's been 1.7 million episodes of agitation in the US. That's approximate, that's what's reported as far as aggressive acts in EDs. The ED stats-- you all probably already know this, you're in a very high risk occupation of being injured by a patient. We're, just by the fact that we're physicians, we're kind of in the same category as police officers, taxi drivers, and then we're somewhere down on the list. Of course, the ED is the most unpredictable place that you can work in a hospital, and so that places you at an even higher risk. A recent survey of the Emergency Nurses Association found that 50% had felt threatened a week before. In a separate survey, there were 25% of staff, including physicians and ED staffs, who felt they were sometimes safe. Which means only 75% felt that they were safe in the ED and in their work environment all the time. So it's a pretty serious issue not only for helping the patient, trying to figure out what's going on with them, making a diagnosis and starting treatment right away. But it also, obviously, has to do with the safety of the individuals that are working there. Some of the ideas that I'm going to talk about are treating the pro-dermal signs first, kind of recognizing what those are-- if you can do that, then you're much less likely to be injured and you're able to get the patient our of the ER faster. Considered de-escalation techniques first. I know we're all extremely busy and we want to give the Haldol Ativan as quickly as possible so that we can get the patients down. But that in itself brings up some complications that I'll be talking about later. So we really are kind of leaning towards more of a talking to the patient to talk them down, and we'll go over that in just a little bit. Of course, always, assume that when the patient comes into your ER that they have a medical issue before anything else-- it's that until it's ruled out. And even so, I know that you all are busy, I know that you have to maintain the safety of everybody in your environment, and so there should be a low threshold to treat with medications. And we'll talk about some of the better choices that I think, through personal experience, as well as consensus guidelines-- one of the ones that I'll refer to often was in 2012 by the American Association for Emergency Psychiatry. And they looked at all the data that we have so far and determined kind of what is the best practices? And you're going to see that that's a little bit tenuous, because there's really very little scientific data. If you think about it, it's very difficult to get informed consent for good randomized double-blind trials in someone who's thrashing about as they walk into your ER. So we don't have really great scientific evidence at this point-- we're still working on it. Another pitfall as far as trying to deal with agitation is you're treating somebody before you even know what the diagnosis is. The treatment approaches vary widely, not only just from region to region, but even different hospitals in the same city may have different approaches. There's all types of agitation, all kinds of causes, and we're going to talk about some of that. Of course, the safety of everybody is paramount, and that should be addressed even before an agitated patient comes into your ED. You should know where your safe area is, you should know the team who's skilled and trained to work with these types of individuals. And I think most important of all, you have to have a certain temperament. All of you know as ED physicians that you have to have a certain temperament, personality style, just to even work in an ED, and especially that's true in someone that you're assessing with agitation. Meaning you have to be a little bit like me, which is somewhat ADD, not really content with just sitting in an office and doing psychotherapy with a patient. Not that I'm saying that's bad or-- I mean there's a certain temperament that that's very good, but you have to have a certain amount of curiosity, and you have to enjoy your heart rate getting up a little bit whenever somebody come screaming into the room in handcuffs and half clothed, or whatever the case might be. And so there has to be that curiosity factor, and that's true of your ED staff. But in addition to that, which I think this is really kind of a special person that can be that, as well as just content and confident and good-natured and affable, not easily offended by what people say to you whenever they're calling you about 100 different things that I can't mention right now. So that really is a special person. And I think that requires an assessment of your staff, as well as yourself, on a daily basis. Agitation, just a rough definition, and this changes wherever you read DSM 4, different diagnoses, different syndromes-- it's a state of increased psychomotor and mental activity with heightened arousal and anxiety. Underlying all that, and I think this helps to kind of be a little bit more compassionate in our treatment of patients with agitation, is remembering that these people are humiliated, they're obviously angry, they're anxious, they're fearful, they don't know why they're in handcuffs, they're angry at their ex-spouse for misinterpreting a text that they sent them. Whatever the case may be, they're upset about being in your emergency room. And I think that just helps your assessment and your ability to kind of establish a rapport and start a more positive alliance with the patient. You all know all of these-- these are really kind of the big four, the ones I mainly want to focus on at the introduction here. And now I always put number one, delirium, when I'm talking to medical students or residents or nurses or whatever the case may be. Obviously in your situation, you know that when someone's educated and it's a new onset, you must do as much of a physical evaluation of the patient as possible and rule out physical causes. But substance abuse lasts, in our ED, which is about now 65 beds, and it changes all the time-- we sometimes have 80 patients. I don't mean beds, but we use dialysis recliners to seat them. Our main room used to be the hospital gymnasium back in the '80s when people stayed in the hospital for a couple of months, which doesn't happen anymore-- it's a private psychiatric facility. I would say probably at least half of the patients that we see come in with some issues involving substance abuse and withdrawal at any one time. So it really probably should be number one in our situation, possibly for yours, as well. In addition, medication issues are also important to consider-- iatragenic causes of agitation. Always consider for sudden onset-- you all probably already know this, I'm kind of speaking to the choir. If the patients is confused or disoriented and if there's a changing level of consciousness, always assess the possibly of delerium. At a minimum, these things should be evaluated. You want to make sure they're oxygenating correctly, that they're not respiratory in distress, always check a finger stick. One study found that 10% of agitated patients are hypoglycemic. So that's something that we do almost automatically when we don't know a patient. Again, it's a medical emergency. Depending on the study that you look at, 33% of hospitalized patients who've been admitted for delirium eventually pass, so there's a very high mortality rate associated with this disorder. And again, we're having to treat the agitation sometimes before we even know what's going on with the patient. So you really have to be on your toes. Again, psychosis is a symptom, it's not a diagnosis. It's a clue that there might be something else going on with the patient. This is an extremely short list, but it's the ones that I thought probably you might come into contact with the most. So you want to be sure and rule all these out. As far psychiatric causes, you have schizophrenia-- usually the number one reason that people come in agitated that have that diagnosis are because they're off their meds, which is a big problem. Bipolar disorder, both manic and mixed states, agitated depression, anxiety disorders, cluster B personality disorders, which includes antisocial, borderline. And I wanted to be sure and point out that not everybody that comes in screaming in handcuffs and yelling and cursing you has any kind of diagnosis. I mean think about your own situation. In the example I gave earlier of the unexplained text or misunderstood text, which, by the way with technology, you'd be amazed at how many-- well y'all probably see it yourselves, too-- the text that they wish they hadn't sent, the Facebook posting that they put the was misunderstood. The common one is I just want to end it all, and they're insisting they didn't mean I want to end my life, I just want to end everything with you. So often, a high functioning, active, very busy person in a profession becomes angry when they're brought in in handcuffs for that reason, and we see it on an almost daily basis. And, in fact, that's why I think, especially in my situation, where we're getting 80 to 100 patients a day sometimes, that we use these de-escalation techniques. It's not always me, by the way, and we're going to talk about that more later. It's not always one of our 18 medical staff of psychiatrists-- it's often also the nurses and the rest of the staff. I think the first three on the list here are the reasons that people often get brought to your EDs-- they're in a manic state so they get noticed out in public. They have disturbing thought content, they're paranoid, they're delusional, they're saying strange things to people at the train station in Dallas, or they're spitting on them, or whatever the case might be. They have disorganized thought, they're not making any sense-- so they're agitated already when they come in. But I think everything is kind of increased tenfold whenever they come in in handcuffs and they're being forced to see you, the physician who they didn't ask to see. The rest of the medical personnel-- they're being told to do a number of different things that they don't want to. And the final cause, I think, in someone who has a psychiatric illness that might present to you is things that we do to them, especially medications that might cause akathisia or EPS. I'm just going to kind of walk through the way we view seeing a patient that walks into our door, often in handcuffs, often brought by family and forced to come in. Always maintain a safe environment. Make sure everybody in your ED, including staff and the other patients, are safe. And I mention having a safe area or a safe room-- does everybody have that here? I mean is there a place that you can put these people that you know they're not going to harm themselves or anybody else? OK, not many. I think it's something that you should talk to your administrator about, especially if, like Ken and I were talking earlier, if it's so hard to get people admitted or transferred quickly and when they need to be transferred. Right when they walk in the door, you're obtaining the history as much as possible. I try to-- when I have a really agitated patient that comes into our triage room, I try to get to the officers and find out exactly what was going on. That can give you a whole lot of clues as far as what the diagnosis might be. Talk to family members if necessary. Have your staff talk to whoever came with the patient. Of course, vital signs are primary. Sometimes you can't do a full physical exam of somebody who's trying to hit you and kick you, but you can at least look for focal signs-- look at their pupils, look for signs of injury. Consider verbal de-escalation techniques, which starts right when I meet the patient. And decide on an appropriate medication right away, you don't want to wait too long. Speaking of de-escalation techniques, I know you're probably going to roll your eyes and go, like I really have time to do all this-- it really doesn't take that long, and I do suggest whenever possible, if one of the ED physicians are around that they at least initiate this, because you would be amazed at the power of the scrubs with your name on it or your name badge with Doctor on it has. And I think it really cannot be underestimated. We're getting away from saying calm down the patient or make him calm. The idea really is to work in conjunction with that patient and help them calm themselves and find out from them what they need or what you need to do to help them calm themselves. And again, I know that doesn't always work. I'm saying this is what we try whenever they first come into the ED. Believe me, we use a lot of medications in psychiatric emergency services at Green Oaks, which I'm going to talk about. Always be aware of your counter transference-- this isn't just for psychotherapy. I really mean that. I mean if you-- and you all probably already know this just in your day-to-day to- work life, if you had a fight with your spouse or something has happened that's gotten you upset or angry, you have to be aware of that. You can't take it out on the patient who's screaming and yelling at you. That's the last thing that you want to do, for reasons that we'll talk about in a second. You just have to have, again, a good attitude. You have to have some ability to empathize with the patient. Don't argue-- this isn't the middle school playground. There's no reason to think that you have to win a fight with this patient or that you have to make a point that you always have to be right. They'll really appreciate that, as well, and see that you are listening to them and really accepting the things that they're upset about and angry about. Always respect the personal space-- the two arms length rule really applies in somebody who's agitated. Sometimes they're going to tell you to step back even further, and you do that. You don't want to be injured and you don't want them to feel that they are about to be threatened by you, that you are going to harm them. There's often times that I don't even attempt to sit and talk to the patient. We do, in our facility, have several interview rooms where we have privacy, and some of the time we can't get patients to even go in there. There's been many times that I have chased-- not really chased, but walked around-- it looks like I'm chasing them-- walked around the ED. We do have kind of a walking area that they go to if they need to, which I think is also really beneficial. And I'll obtain as much of the history there. If they're standing, stand. If they're sitting, try to sit. You don't always want to do it by yourself, I understand. If you have a team that can meet with you. We have really, really large guys who are mental health techs, and I use them often. And they can kind of be in the background so that the patient doesn't feel threatened. And in fact, sometimes they really see them as kind of their help, I guess you could say, and so I think it kind of reassures them in some way to have extra people around. Never provoke-- that's not only verbally, but in your posture. If your arms are closed, that sends a very negative message. If you put your hands in your pockets while you're talking to the patient, they're going to think that you're about to pull a weapon on them, or maybe a shot, that you have a shot that you're about to give them. So really be mindful of the way that you're standing. Don't stand directly in front of the person and stare at them. They will be very wary of you if you're making too much eye contact. On the other hand, don't look away, because they won't trust you, what you're saying. At least, again, one person needs to establish the verbal contact. And like I said, it would be nice if it was one of you. It's not always one of us-- we have a triage nurse that's checking them in when they come in, so obviously, they're first person to talk to the patient. But if we hear them screaming and yelling, one of us tries to get into the room and find out what's going on. So if you can take a moment from your busy day and check, then I think that really helps. Introduce yourself-- use very short statements such as how are you, what's going on. Sometimes they may not get that right away. Keep in mind, a person who's delirious has disorganized thought and comprehension difficulties, and so-- I mean we've all experienced that in someone who has delirium. They're trying to tell them to sit down, and they don't even understand that. So sometimes you have to use hand motions, sometimes you have to say it in a different way, but just make sure that they are understanding what you're saying. So be concise and keep a very simple, one statement at a time. And again, it's a lot of trial and error, what really works for the patient that you're dealing with at the time? Identify wants and feelings-- what does that mean? I mean you're not going to try to do a psychotherapy session and figure out what their innermost problems are that they're here for. We're talking about just very basic stuff, things like are you hungry, are you thirsty? We always have lots of food and lots of snacks available. If you all don't, you really should consider it, because that's always very appreciated, and often that settles things just as much as talking to them or giving meds. Listen closely to what the patient is saying and make sure that they know that you understand by repeating it or paraphrasing it back. You don't want to overdo that, because they start to see that as parroting and they don't see it as being very truthful or very honest or sincere. I can always find something to agree with them on. I rarely have to get to the point where you agree to disagree. What that means is there's absolutely nothing that you can agree on, and so you just agree to disagree, but that rarely happens. There's always like the temperature's too cold, always, and I'm sure it is in your ED, and so they're going to say I'm freezing, where's the darn blanket? Yeah, it is freezing, that's why I wear this coat or whatever-- something that they can know you immediately relate to them and understand and empathize with their situation. Other things are-- I mean it may sound kind of goofy, but we take a little things and use those. If somebody's wearing a Dallas Cowboys jersey or a certain college, we'll make comments about the team or something that happened over the game the last time that the team played. Sometimes it works, sometimes it doesn't. But the point is you don't want to just spend the whole time disagreeing. They're always going to say that the cops were unfair, almost always. They're going to say that they were brutal, they were mean, they didn't treat them fairly, they should not have brought them there. I think it's insincere to say yeah, that's right, because we know that the police officers have a really difficult job. In fact, in Dallas, the ones who bring us the patients the most are trained, and they're kind of a volunteer group that wants to do this type of thing. So we know for the most part, things usually go as well as they can out in the field. But sometimes they do put the handcuffs on too tight and they'll complain about that, and it hurts and I'll say something like yes, that's red and that's sore and I'm going to talk to the nurse as soon as we get done and you'll get something. So just before them blowing up and screaming and tearing up the mental health tech's desk, that can kind of be a way to alleviate that. At the same time, it sounds like I'm doing all this permissive stuff. You know, it's kind of like how they want us now to deal with children, which it's kind of like that sometimes. At the same time, you still want to be very firm. There are definite limits in your ED. You tell them we will not tolerate you hurting anybody, hurting yourself, making threats to the other patients, and you will just stay right here in this area. So just be very clear on that and firm at the same time, and then always ask do you understand, are we on the same page here, and if we're not, how can we get there? By the way, I meant to mention there's a couple of words you never use-- you don't say no when at all possible and you don't say why. Rather than why are you here or why are you doing that, what is going on here, and what can I do to help you in this situation? I really challenge you to try this the next time that you have somebody acting up or being aggressive or being difficult, and see if it makes a difference. Always offer choices-- you know it's the old thing we always heard, and it really is true. You always give a choice in medications-- do you want it in a shot or do you want it in a pill? Now there's a way that you can put that that is trying to work with the patient and involve them in his care. It's not if you don't take this pill, I'm going to give you shot. It really is genuinely what do you want, how do you prefer this? Because we have people that come in frequently and we know how they prefer it, and often they say I want the shot because I feel terrible right now and I need immediate relief. Always mention to them that there's an endpoint that's going to be better than what it is now. We always debrief the staff, and I think that you all should probably have a plan to do that, as well. At least talk about what went right, what went wrong, were there pitfalls, where there issues that maybe could be addressed that would make things better next time? And we also try to involve the patient, at some point, in that as well. That doesn't always work. So I think really, probably, what you all want to know is what is currently the state of the art in management of agitation from the standpoint of somebody who this is all I do. My entire practice is evaluating people who have psychiatric emergencies. Probably 70% of our people that come are involuntary. They used to go to Parkland. Parkland just doesn't have the space anymore to take care of these types of situations. And we have some pretty significant spaces, and so we're now pretty much the designated place that people are brought by police. And so I can tell you that we use medication often. We also, because of our situation, because there's five MHTs in this large room at any one time, there's four nurses, at any one time we have four physicians, we're staffed with physicians 24/7 just like any other ED. We can get by with more, I think, and so I realize that your situation is unique compared to us. In other words, we have staff that are trained that are kind of on top of things, whereas you may have to act a little bit quicker than we do. But timing really is everything. You don't want to medicate too quickly or too high of a dose, because that's going to hinder your assessment of the patient, it's going to hinder the disposition of the patient, all kinds of issues. It's going to delay diagnosis and appropriate treatment. On the other hand, you don't want to wait too long, either, because you don't want to get hit, and you're going to get injured, as well as the other staff. In my opinion, and most of the consensus guidelines are that you don't want to put the patient completely asleep. You want them calm-- light sleep is acceptable as long as you can wake them up and talk to them. I'll cut to the chase-- there's no best medication. Still with all the consensus guidelines, there's no one that we say, hey, this is the one to use, this is going to work every time. Probably the most important thing you want to consider is how you want to give the med, and do you have different choices for that medication? So involving the patient in decision-making is critical. We always ask the patient what's worked for you before in this situation, if they can tell us. We're computerized and so we can pull up right away what they had last time. Looks like Haldol, Ativan worked for you, is that what you want? And other things to consider we'll be talking about when we talk about each of the medications. So basically you're not going to get the answer of what medication to use from me, but at least for each individual patient, each individual situation, maybe you'll have a different idea which direction you might go. Also cut to the chase-- in our environment and most psychiatric EDs across the country, first degeneration anti-antipsychotics are still the favorite. Phenothiazines are more there just for kind of historical interest, I guess you could say. Specifically, Chlorpromazine or Thorazine probably has no place in your environment, just because of the issues of falling and orthostasis, especially someone who's volume depleted. It also lowers the seizure threshold. We occasionally use it when we know we have someone that's really healthy that's benefitted from it in the past, but we pretty much shy away from it now. By far, the most used anti-psychotic in EDs, still, is Haloperidol, and there's many reasons why. First of all, it's a highly potent and selective antagonist of the D2 receptor, that's why it works so well and so quickly and so predictably. Long track record now, 40 years or more, of safe and effective use, minimal effects on the vital signs-- and these are all things are great for you guys. No anticholingeric effects, no interactions or minimal interactions with other medications-- there is some issues about the QT interval, but in an acute environment, I don't think that's really a concern, and most everybody agrees with me. The biggest negative is the extrapyramidal side effects, and these can be a risk even after they leave your ED with a half life of 18 hours, so you do need to be sure to prepare the patients for that that are leaving. Less important, there is some people who complain of a little bit of dysphoria after they've had to Haldol over the next few hours. For me, and for pretty much our whole group and other surveys that have been done, it would still be the number one medication in one specific area, and that is acute alcohol intoxication. When you know that they are intoxicated, you get the history that they just drinking a heavy amount and you smell the alcohol. They're obviously not on withdrawal, because they still have alcohol on board, but you need to settle them down-- always use de-escalation first, of course, if you can talk to them. And if that doesn't work, then Haldol 5 milligrams IM, 10 milligrams IM works very quickly. The dose in any syndrome is 10 milligrams every two to four hours. Sometimes we give it every hour, but that's very rare. You can give it IV, by the way, we do not, and it's also not FDA approved for that, but some facilities are doing that. Maximum dose is 30, and that's been very conservative. Onset is even faster than 30 minutes, and it can be used with Lorazepam in the same vial for a more robust response. And you'll see in the-- kind of talk about some of the consensus guidelines, it's one of the faves, still, of everybody. And we always add Diphenhydramine, about 50 milligrams, sometimes 100 milligrams if we want more sedation. Just because we know that just haldol along, a big part of the time is going to result in distonia and other EPS. We don't use Droperidol, and the number one reason is because there's no psychiatric indication. And so we really are just focused on meds that we know has good backup-- medical legally, as well effectiveness. However there's a lot of EDs, mostly medical EDs like your situation, that still use Droperidol, all and it's not a bad thing. There's some definite benefits-- you can have effects within three or four minutes, IM or IV, and it's a short duration, still the only indication is anesthesia. But it's important to mention, because it is in some of the consensus guidelines. The big negative is the black box warning for potential torsades, which is very controversial. And actually, the FDA has handed that they may remove that black box warning, because the risk may not be as big as they thought it was. You probably get a fair amount of visits from drug reps on the latest what we also call atypical anti-psychotics. Is that correct, are you all inundated with them like we are, or not all? OK, so some of this may be news. Not surprisingly, the most commonly used in an ED situation are the four that-- aside from Clozaril, which that's a whole other story and it would be anything you would ever use in an ED-- but it's the ones that came out first, Olanzapine, Ziprasidone, Arapiprazole, and Risperdol, that's xyprexa, Geodon, Abilify, and Risperdol. The IM is available in a queue situation only for three of those, and that's Olanzapine, Ziprasidone, and Arapiprazole. The two that we use the most in our setting are Olanzapine and Arapiprazole. I'm going to get to why we don't use Ziprasidone, but I don't not use Ziprasidone. There's antagonists at the D2 receptor, very strong, similar to Haldol, but the benefit comes from the fact that it affects other receptors, especially serotonin, agonists. So it kind of helps offset the risk of EPS and akathisia, which is minimal. They're equally effective, except maybe not Arapipraole, and I'll get to that in a second. There's no head-to-head trials on any of these, so we can't say one is better than the other. So just kind of take all this with a grain of salt. We use a little bit of Clotiapine, but it may not be, which is Serquel, it may not be that appropriate for you guys, because you're getting so many older folks, ill people, multiple medical problems, volume depleted, and so it sets them up more for orthostasis. We are constant monitoring of the patients, and if they're fall precautions, we band them that way. And so the mental health techs, as well as the nurses are always very much on top on who might be at risk of falling. Olanzapine has been out now 10 years, available for IM. 10 milligrams is the usual dosage, you can go up to 20 milligrams a day. It's available both IM and PO [INAUDIBLE], which is a disintegrating tablet, which can be helpful if you're worried about somebody cheeking. Keep in mind that there is a long Tmax for the oral, so it doesn't really help that much in our opinion in EDs. Really, when you're talking about using Olanzapine the ED, you're talking about the IM. It's not recommended that it-- and we know the side effects-- sedation is kind of what you want. I'll just go right to the drawbacks of Olanzapine and why we don't use it so, much why we still like Haldol and Atavan, and that is because of the fact that you cannot use it with Ativan. It definitely raises the risk of orthostasis, of over sedating the patient, possibly resulting falls, and so we kind of shy away from it. We do occasionally use it, especially when people are allergic to some of the other choices. There is extensive clinical experience. We like that it's FDA approved in this situation and the disintegrating tablet is available. Ziprasidone, I like and I think it's very effective. I'll get to why our ER has shied away from that. But it's actually been out since 2002. It was the first one that was available, as far as the second generation anti-psychotics, that was available in an IM form for an acute agitated patient. Average dose is 20 milligrams per injection. It's rare I would ever use 10-- maybe in an elderly patient. But usually 20 is the way you want to go with a maximum dose of 40. As far side effects, QT interval we're realizing is really not an issue, especially in just the acute management of agitation. There's no need to get an EKG in a normal healthy adult. Now if it's somebody who has significant cardiac issues or they already have problems with QT elevation, then you would maybe do an EKG, but you're not going to have to do that in a rush. Again, it's fairly inexpensive. Olanzapine's expensive, but Ziprasidone is not. And as far as the disadvantages, there is that question of QT prolongation. But more important for us was the fact that it's in a powder form and the nurses had to mix it with saline and shake it. For us, seconds count, and there was so much bounce back from them on we don't like this and we feel in danger that it's really rarely used in our environment. I still think it's very important to consider it in your environment, especially for the older patient, because it doesn't cause orthostasis. You can use it with Ativan if you need to, not a lot of interaction with other medications, so I think it's still a good choice, in my opinion. But I didn't win that battle with our nurses. I think we all know how that is sometimes. Actually, Risperdol's been around longer than any of these, and it's the most studied, even in an acute agitation. I just didn't include it as one of the top ones because if it's not available in an IM, I think most EDs aren't that interested in it. Some reviews have shown, though, that it's just as effective PO, if you compare it to Haldol and Ativan. The issue there is that if you're doing a carefully randomized double-blind controlled study, you're getting the best agitated patients, if you know what I mean. I mean you're getting the ones who are already agreeing with you, and so you can take a lot of these studies kind of with a grain of salt when you think about that. There is an M-Tab available, which means it's a disintegrating form, and that can also be beneficial. We use a fair amount of Risperdol for the mildly agitated patients, so I think it does have its place. Arapiprazole, in one of the consensus guidelines and reviewing the nine studies of the drug companies had to submit in order to have the IM forms available, Arapiprazole being one of them. Keep in mind there's no head-to-head studies, so you can, again, take this with a grain of salt. It looks like the effects are not as robust, and so people are just not, as a general rule, and also the guidelines-- the 50 psychiatrists that were part of the Beta project, which is by the way best practices for emergency assessment or treatment of agitation. I didn't explain that earlier. The consensus among those 50 very well-resected national leaders in emergency psychiatry was that it probably is not as effective. And, again, it has its place and it's on our formulary. If someone doesn't really respond so well with another medication, we will go with Arapiprazole Abilify. Asenapine is one of the newer ones, Saphris is the trade name. There's one large study, the results are going to be submitted soon. It seems like it might be good because of the Tmax being 30 minutes. There's no GI absorption-- it's all done sublingual and it's absorbed within minutes, and they can't cheek it, obviously. It's also fairly inexpensive. So it will be very interesting to see the results of that. We haven't been using it ourselves, but I think it's something that we might look into. Again, Clotiapine, not really that indicated. And Latuda or Lurasidone, there still is no information, but again it might be interesting because it has a pretty fast absorption. Benzos obviously have a long record of efficacy. They work on the GABA receptor in the brain and give some pretty general good sedation for patients. So this is the third category. We've talked about FGAs, SGAs, and now there's benzodiazepine, so these are the big three. It still is considered the number one in someone is acutely amphetamine intoxicated or cocaine intoxicated if they're not psychotic. Now if they're psychotic, then you may want to consider something different. But it's still the treatment of choice, not in our ED, because of the fact that we get a lot of people who come to us on a frequent basis with amphetamine intoxication and we feel like it's reinforcing to continue to give them Ativan when they come in, because often that's what they want. But I don't think that's necessarily the case in your situation, especially if it's somebody that you don't know, who you might suspect is a PCP intoxication. Ativan will work very quickily. It's not effective alone when psychosis is present, and the big concerns for you guys, and for us, are respiratory depression, although you have to have some pretty high doses in a healthy individual to worry about that. Lorazepam is still the gold standard in EDs, I'm sure it's in your ED, as well, when you need to get a patient down quickly. The reason for that is because the availability of it, the rapid onset, average dose about two to four milligrams a day up to eight, sometimes more if needed, especially if it's a really severe ethanol withdrawal. And as we know, it reduces agittation. If somebody comes in with akathisia, they're walking around, they're restless, they can't start moving their legs, it's one of the best things that you can give them right away. So the advantages are the rapid onset, the mode of distribution, the favorable side effect profile, essentially none. And the disadvantages-- again, if you're worried about psychosis, you're going to have to use something else. The concerns about tolerance and dependence are really concerns only if it's somebody that you know that's a significant issue. If you're just treating a naive patient, you have no worries about them hooked on Ativan, I'm sure you all know that, or Lorazepam, if you give them an injection. So just a review of kind of-- I've talked about several different medications, several different approaches, and different examples of where you might use it. The American College of Emergency Physicians in 2012 reviewed kind of the state of the treatment that we have for agitation. Class A were accepted practices with a large degree of clinical certainty, these would be large scale double-blind randomized trials. Strategies with moderate clinical certainty with a fair amount of trials and anecdotal reports and publications. And then C, strategies based on preliminary, inconclusive, or conflicting evidence or if based on consensus guidelines. There were no Level As, no class As, so no large studies that say this is the medication. As far as Level B, with there was amount of information, scientific data. Not real surprising, Benzodiazepines or first generations are good in a newly arriving to you, when we say undifferentiated-- undifferentiated, agitated, we don't know what the cause is, you can reach for either of these and be pretty confident. If you need rapid sedation, it is thought that Droperidol is still a reasonable choice. If you know the patient has a psychiatric illness, you know they're psychotic and you know that they'll respond to either FGA or SGA alone, then that's the choice. If the patient is cooperative, you might consider a combination of an oral Benzo and FGA or SGA, either one, which, by the way, we haven't talked about this the idea of giving oral first. That may seem kind of strange, but in most cases, it's not that much faster to give IM, and really when you think about it, there's more risk with IM sometimes, especially if they're fighting you. There's risk of the staff getting stuck, and so if we can at all possible, avoid that. Also, the person's experience usually is better, and that bodes well for compliance later on. And then finally the combination of Ban IM Benzo and Halperidol-- it's level C. The one we use the most actually has the least to back it up. But still, through experience and talking with experts, seems to be a good choice. So how do we assess-- when someone comes in, obviously verbal intervention first, introduce yourself, talk to the patient about what's going on. Try voluntary medication after you've done some de-escalation techniques. Do a show of force-- always have a number of people that can respond immediately. In our hospital, it's Code Purple-- sometimes the MHTs and the staff that we have in our ED aren't enough, and when Code Purple is called, then extra staff from the other units in the hospital can become and assist, and that can do wonders, as well. Offer something to them-- next in line, which somehow got left off and is probably the most important, and that is involuntary medication, and, when all all else fails, a quiet room with the door open with staff one-on-one, seclusion, and finally physical restraints. The whole point of this is hopefully not to get to that point. Our numbers are always going down as we use these techniques. This is something that CMS is closely watching and is making public that Joint Commission assesses, and so we really want to reduce the amount of physical restraints that we use. Of course we're still going to have to have it from time to time. So there's no national standard of care. There's recent guidelines that kind of help us. IM high potency antipsychotics are still the number one choice, especially Haldol. Impact of drugs in the ED last longer than the stay. They're going to have issues with it the next day, and further on down as they are treated in their outpatient programs, as well. Their experience in the ED affects everything, and we see that time and time again, as far as their comfort with psychiatric care, their comfort with medical care in general. Benzodiazepines are probably just as effective, and really the most important consideration is the ease of use for you guys. This is a totally different subject, and, oh I only have 10 minutes. Do y'all want to touch on suicide or do y'all have sp-- I mean we can just maybe save this for another time or something. I want to be sure and take questions on this subject because it's so important. Yeah. AUDIENCE: Eventual use of Ketamine, there have been some articles written suggesting that there's some utility in using that for the severely agitated hypothermic patients that-- do you ever use that? ROGER G. BUTLER, M.D.: We're not really set up to do that and we haven't used it, but yeah, I do know about the reports. Does anybody have experience with that here, Ketamine? Oh, I saw your hand first. Yes. AUDIENCE: We had [INAUDIBLE] psychiatrist that felt Geodon was more activating in some of the acutely psychotic patients. Can you touch on that any? And then the other thing is in the patients that have substance abuse psychosis, is there a better-- ROGER G. BUTLER, M.D.: Oh that's a really good question, because I really didn't touch on that second part. But as far as Geodon being activating, that is another reason I think some people are kind of getting away from it. It doesn't seem as sedating as-- and I think that's actually the answer. Olanzapine, Haloperidol, Droperidol, Lorazepam, whatever you might give them, they all sedate, and not necessarily is that true for people with Ziprasidone. And so, therefore, they may still be a little bit more active than people want them to be in an ED, and so, often, Lorazepam has to be given. Also, there is the risk of akathisia-- not only, by the way, with Ziprasidone, but also we see it a lot with Arapiprasole, which is another reason I think it's not that favored. And then the second part was acutely psychotic and agitated patients-- we do Lorazepam, Haloperidol, Diphenhydramine combination on almost everybody-- we call it the cocktail 10-2-50. And again, it's because of the low interaction with the low anticholinergic activity, no effects on vital signs. Yes. AUDIENCE: You mentioned delirium, and I wanted to see if you would make some comments about specifically elderly patients or patients at high risk, people with a history of dementia or stroke or brain injury. And [INAUDIBLE] you know, kind of whereas Benzos and Diphenhydramine are a much more-- ROGER G. BUTLER, M.D.: That's a really good question, and you're doing a literature search and preparing for this and other talks I've done on this subject, it's almost like that's a whole other topic. And so I purposefully did not say a lot about elderly. They don't bring a whole lot of elderly people to our facility, they usually go to the regular ED. We're right next door to Medical City Dallas, which is our sister hospital. Sometimes after they do the assessment, they do you bring those folks over. We don't get the people that are delirious, though, obviously-- they're usually admitted. But basic concept with elderly is that you use at least half or less of the dose, and we do that in our ED, we find that works well. And then you had another question about the elderly. AUDIENCE: Just about Haldol and-- ROGER G. BUTLER, M.D.: I still think Haldol is better. AUDIENCE: -- for patients in that situation. ROGER G. BUTLER, M.D.: I think because of the, and-- AUDIENCE: --genic effect-- ROGER G. BUTLER, M.D.: Yes. AUDIENCE: --of Benzos ROGER G. BUTLER, M.D.: Right. AUDIENCE: --especially having had-- ROGER G. BUTLER, M.D.: No vital sign effects. Yeah, we still do with Haldol first. I think if it was more available and more accepting by the staff, I think probably Ziprasidone would be our next choice in that group, and I think it should continue to be in EDs just because of the safety profile. There was another hand, yes. AUDIENCE: In our short time, as far as occasionally with a patient, as far as contingent suicidality, how do y'all approach [INAUDIBLE]? ROGER G. BUTLER, M.D.: I have a slide, do you want me to go back to that one? AUDIENCE: Sure. ROGER G. BUTLER, M.D.: That's a particular-- pardon? AUDIENCE: So we started a little bit late, so if you want to-- ROGER G. BUTLER, M.D.: Oh, we did? OK. I only had a few slides about suicide, because I want to be sure I understand, by the way, when you're assessing somebody who either attempted or is brought in because they made a suicide threat or saying that they're going to kill themselves, you do have a team that responds, right, that you can call from one of the HCA facilities that assess them, or you all are pretty much on your own? Oh. AUDIENCE: Social workers. ROGER G. BUTLER, M.D.: Yeah, a social worker. Which usually-- AUDIENCE: --small team. ROGER G. BUTLER, M.D.: Usually pretty-- do you feel pretty confident in your social workers? AUDIENCE: Yeah. AUDIENCE: Yeah. ROGER G. BUTLER, M.D.: OK, that's the mai-- but I think also it's good to kind of be prepared, whether you're able to do this assessment. I know you all are busy, and I'm not telling you all to be psychiatrists. But you are ED physicians, and this is one of the things that you're called on to assess, and family members may ask you, or the treatment team. Also, I think it's just good to know some of the ways that we think about admitting people. So I'll just run through the introductions-- you probably know a lot of this. Five hundred thousand ER visits for actual attempts, so there's probably a whole lot more than that. It's like one every 35 seconds in the United States. 13.5% of Americans will think about suicide at some point in their lives, which I was really surprised about. Just right off the bat, we admit every psychotically depressed patient who is suicidal. So that's the number one risk and the number one hospitalized-- especially postpartum. I would never let a patient go who is postpartum, psychotic, and suicidal. It wouldn't be possible. We know about 8 out of 10 patients who attempt or complete suicide have left some kind of clues to somebody. Women attempt twice as often, men complete four times as often, which probably isn't surprising because men use more lethal means-- gunshot, hanging, that type of thing. So here's one of the risk factors right off the bat. If they've been previously hospitalized for depression, they're at much higher risk than the general population. About 13.5%, depending on the study that you look at, will commit suicide at some point down the line. We talk about risk assessment-- never ask a psychiatrist can you come predict if this guy's going to kill himself. You all know that-- there's too many variables and too many things to consider, and that changes from moment to moment. But there's, again, several factors to consider, not just what happened that brought this patient in. What was the text that they sent, what was it that they yelled to their spouses through the phone, or whatever the case might be. You always want to the lethality of someone who took 10 Tylenol during an argument with their boyfriend or girlfriend versus someone who looked into who has guns that they know, what things do they need to settle in their will or give away in preparation for their suicide. Those are two very different things, obviously. We spend too much time just focusing on risk factors. We also need to look at protective factors that I'll touch on in just a minute. Talk to family members if at all possible. Number one risk factor is previous tent attempt, which that's kind of a shame, because a patient who's attempted suicide can no longer get that off their record. But it is something to consider-- it's probably about 30 to 100 times greater than you and I being at risk of suicide. The second risk factor is the amount of lethality with that episode that you're seeing them with. So if they had the gun, pulled the trigger, shot themselves in the head, but there was no bullets, not to their knowledge, then that is a high risk person. General risk factors, as we know, male, over the age of 45. The older you get, the more risk, especially for men. Family history of suicide, especially first degree relatives, substance abuse significantly increases the risk, chronic illness and pain, no light at the end of the tunnel. I always ask someone how does the future look. If they say I can't see the future, that's a big concern. Recent loss, humiliation, death, divorce, legal issues are to be of concern. Anxiety seems to increase the risk significantly if treated. There's a level of risk from the patient that says I wish to be dead all the way up to as soon as I get the gun I'm going to shoot myself-- I know where to get it now, and everything in between. I mention protective factors-- there's things like positive relationships, do they have a spouse or significant other? What do friends mean to them? Do they have a pastor they can call and talk to that they have a high regard for? If they don't have any of that, it's a concern. An experience of belongingness-- I always ask about children, if they have children, and what their feelings would be if they were not here, if they killed themselves. Well, would they be better off without me, which is always a concern versus well, I know I can't do that to them. I know this may be rough for me now, but I've got to get through it because I have to be there for them. Their beliefs-- I always ask what happens after you die as part of my assessment, and if they say well I immediately go to Hell, then I know that maybe there's some possibility of working with them. And future orientation-- if I'm talking to somebody who just attempted suicide and they're worried about getting to a job interview the next day, then I'm not as concerned. This is just kind of my own personal experience, as well as talking to other physicians who deal with this on a regular basis, and these are kind of the automatic times we hospitalize, in case you're wondering how we're thinking about things. There's a strong feeling of regretting that they survived the attempt is a concern. Any time the gun is involved, especially if they've grabbed it, they've held it, they've purchased it-- and I also wanted to be sure and point out the gun, because they never leave our ED until we know where guns are if they've attempted suicide, even if there was not a gun involved. Number one way that people kill themselves is with a firearm. It's also the number one way that impulsive suicide completions occur. And so you should be asking, as well, or at least have your team find out about the guns. Also consider the limited social support, how much they're going to participate with what we call a suicide prevention plan, and refusal of help. In other words, if they require any kind of medical work-up we usually admit those people. If they don't have any protective factors-- and this is my final slide. And I have a specific interest about this, because these people are high utilizers of our services and our time, of the funding that we're so fortunate to get in Dallas County through the North Star Program, through value options in which they fund every single person who comes into our ER gets immediate care. Whether that be just our assessment and treatment in a 23-hour observation situation, which is what we are versus admission versus referrals to RTCs, residential programs verses outpatient referrals-- medications, everything is provided to them. And so that's a large amount of money. I know it's not all about the money, but when you're involving hundreds and thousand-- like Ken said, we average 1500 to 1800 a month. We're going to get a large number of this, and basically the definition of contingent suicidallity is people who use suicide threats because they want to be admitted-- three hots and a cot. We have a large homes population that we serve, and usually that is the situation-- they're homeless but they're not always homeless. Sometimes they're just wanting to be our of the situation that they're in-- they've just recently been kicked out or they don't like where they live or there's numerous reasons that they might be contingently suicidal. They're often single, male, but not always-- we have a fair amount of females. There's often substance abuse and legal problems. This makes it a little bit hairy, because I just mentioned one of the risk factors is legal issues and substance abuse, but as a general rule, substance abusers do tend to be contingently suicidal, but not always. They often have a diagnosis of antisocial or borderline, they have a long history of legal problems. And you'll see they may complain about psychiatric symptoms, but if you really, when the patient doesn't know that you're looking, or if you get in information from your techs about how they're doing, they'll say that they're joking with the nurses, they're joking with the other patients, they're laughing at what's on TV, or whatever the case might be. Often they feign psychotic symptoms-- the voices tell me to kill myself. That isn't auditory hallucinations until you have proof that it's auditory hallucinations. If they tell you Doc, these voices are telling me to kill myself, I immediately question whether those are actual legitimate auditory hallucinations. Now, this isn't it a definite way to look at auditory hallucinations, because people who have severe psychotic depression will tell you, after some hesitation, that they do have people talking to them that they think are telling them they want them to die. But they usually don't volunteer that information. They will try to keep it from you, as a matter of fact, because they don't want to come across as crazy. So someone who's too enthusiastic to tell you that they have auditory hallucinations telling them to kill themselves, it's something else going on, until proven otherwise. They also may say that they're paranoid, that they think somebody is about to kill them and they show no signs of that. There's no signs of being paranoid, no signs of talking to themselves or there's no law disorganized thought with these people. I realize that's not going to necessarily be a decision that you all make comfortably, since you don't see these people dozens of times every day, but I'm just kind of letting you know how we think about contingent suicidality. There's one large study that the VA did, so obviously it's an issue with the VA, as well. They serve a large number of males who are homeless that have legal difficulties. And a category that they identified right off as contingently suicidal, based on several factors-- looking at them seven years later, none of them completed suicide. And by the way, when you talk to people who are contingently suicidal, if you really do a good investigation, you'll find rarely have they even attempted it. We find one of the common ways that they say that they're going to do it is they're going to run in front of the train or in front of the car. I don't know why, but that seems to be-- I don't know if that's because when they tell the police that out on the corner, that immediately gets their attention and they know they've got to do something, or I don't know if they just feel like that's a more dramatic way to kill yourself, which by the way is rare, to be hit by car, as a way to kill yourself. But anyway, that's often the way they present. And then looking at truly suicidal patients that had an Axis I diagnosis and comparing them with the contingent, there were 10 suicides in the seven-year period of the control group. So if you can identify contingently suicidal patients, which I think we're getting a little bit better at but we still probably could tweak it a little bit more. So far there's been no bad outcomes. Usually in most cases we will-- we do have the luxury of having the patient stay overnight, if necessary, and we can really do a good assessment of them over a period of time. And again, you get good feedback from the techs and the nurses about how they're acting, and often they're satisfied by the next day and they're not suicidal. They may have made arrangements of family members to stay with, or we give them information about shelters or places that they can go, and that kind of helps alleviate it. For the ones that we have that are repeatedly in our program, we feel a little bit more confident, even when they're saying Doc, I'm suicidal. So it does occur that we discharge people. But you know, when you think about it-- and Ken and I were talking about the issue with psychiatric beds in y'alls area. It's similar to our area-- if we hospitalized 1800 patients a month, there'd be no where to send them. I mean we'd have to send them to Oklahoma or other parts. So we discharge about 70% of the patients that we receive. About 30% are admitted-- for whatever reasons they might be brought to us, whether it's agitation, psychosis, or suicide. So we are discharging a whole lot of people with pretty decent outcomes. Does that answer your question, specifically? Who had the contingent-- oh, there you are. OK, I forgot who had-- AUDIENCE: --the social worker before, classically it's usually a male patient [INAUDIBLE] or opiate dependence, and often times, it's exactly what you described. They usuallly say they're going step out in front of a car if you let them go. ROGER G. BUTLER, M.D.: Yeah, don't you get that a lot? AUDIENCE: You know, it's just a lot easier for the social workers and ourselves if they have a history of frequent flyer or the ones that don't, I'm just curious how, what would you recommend as far as documentation, as far as disposition-- ROGER G. BUTLER, M.D.: That-- and that's the key. I didn't even mention documentation. I think as long as you're documenting-- yeah, we are able to have multiple people see the patient sometimes. Almost always everybody sees two different psychiatrists-- they see them the day that they come in within an hour or two, and then the next day for disposition, so it's two different psychiatrists. If there still is a question, sometimes we'll even have a second opinion. But I think as long as you're documenting and you're documenting your way of thinking. If at all possible, get collateral information from a family member. Look at their past records. How serious have the suicide attempts been, if any. I've been amazed at people that we've had like six, seven times a year over the last three or four years, and people think that they might be acutely suicidal, and I've reviewed and never seen a suicide attempt. And so previous suicide attempts are one of the biggest risks factors for attempting suicide. If they're absent, you've eliminated one of the biggest risk factors. So you kind of get to know the people and kind of know what to look for. Yes. AUDIENCE: Do you think that no harm contracts are-- ROGER G. BUTLER, M.D.: I'm glad you mentioned that, because I didn't have a slide for that. They have their utility, we don't use them at all. And the reason AUDIENCE: I feel like the social support's more important than the no harm contract. ROGER G. BUTLER, M.D.: That's why we call it suicide prevention plan, which I didn't go all through that, but suicide contracts have one place, and I think that's with a therapist or a psychiatrist that is long-term that you follow. But even then, I think if you have someone that's suicidal, you still need a suicide prevention plan, and you always have to stay on your toes. Because the problem with contracts, and the reason we don't use them is because it can make you feel complacent, that's number one, and number two, they have absolutely no medical legal binding. There's no way that you could ever use that if there was a bad outcome. And so we don't even want to get started down that road. We use things like that who's your major support, what are the phone numbers that you're going to call if you start to think about suicide in the future, what things do you enjoy doing, what will you do if you're in a bad place? There's a number of things that we do. Those we think are a lot more helpful than contracts. Yeah. AUDIENCE: This is not agitation, we have a couple of patients with acute catatonia that have sat in our ER-- ROGER G. BUTLER, M.D.: Oh, I-- AUDIENCE: --couple of days. ROGER G. BUTLER, M.D.: --didn't mention that, did I? AUDIENCE: And we have been told Ativan-- ROGER G. BUTLER, M.D.: Yes. We still use Lorazepam in those people. Yeah, definitely. AUDIENCE: And doses? Can you give us a little information? Because these people can sit for days before we can get them somewhere. ROGER G. BUTLER, M.D.: We usually order it about two milligrams, depending on how big they are, how old-- one to two milligrams routine three times a day. If they can't take it by mouth, we order it IM, but we prefer PO. But yeah, the half life is 10 to 15 hours or so, and so that CID covers it. We've had some pretty good results in a short time, but sometimes you need more than a day or two for effects. And then you might want to add a second degeneration anti-psychotic, as well. But really the Ativan for the acute catatonia. Yes. AUDIENCE: It seems that Seroquel, when people have had Seroquel overdoses, that they frequently have to be admitted and can't be medically cleared for [INAUDIBLE]. I usually, if I'm watching somebody more than 12 hours, will go ahead and admit them and they're real tachycardic and-- ROGER G. BUTLER, M.D.: Right, yeah, blood pressure issues. AUDIENCE: --anything that really-- ROGER G. BUTLER, M.D.: I'm sorry? AUDIENCE: Their blood pressure may go down some-- I mean heart rate may go down some when they're sleeping, but they're in the 150s when they're awake, and I just wondered if you would speak to that a little bit. ROGER G. BUTLER, M.D.: Not being kind of the medical expert in what to look for, because we don't treat overdoses-- I mean we refer those to Medical City, but yes, I've heard the same thing, that it takes a little bit longer-- telemetry issues with arrhythmias and that type of thing. AUDIENCE: OK.
