Transcript Prospective Medical Clearance of Known Psychiatric Patients

Evidence Based Evaluation of
Psychiatric Patients
Stephen J. Traub, MD
Division of Toxicology
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Instructor in Medicine
Harvard Medical School
Boston, Massachusetts, USA
Leslie S Zun, MD, MBA, FAAEM
Chairman and Professor
Department of Emergency Medicine
Chicago Medical School and Mount Sinai Hospital
Chicago, Illinois
Learning Objectives
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Become familiar with drug induced
altered mental status
Understand the medical clearance process
Review the evidence that applies to the
medical clearance process
Use of adjuncts in the evaluation and
treatment of the psychiatric patients
Medical Clearance
Purpose
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To determine whether serious
underlying medical illness exists
which would render admission to a
psychiatric facility unsafe or
inappropriate.
To identify medical conditions
incidental to the psychiatric problem
that may need treatment.
To differentiate organic illnesses
from functional disorders.
To determine if the patient is on
drugs?
Drug-Induced AMS

Nature of the AMS depends on the drug
Drug-Induced AMS

With “psychotic” patients, consider:
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Sympathomimetics
• Cocaine, amphetamines
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Dissociative agents
• Ketamine, PCP, Dextromethorphan
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Hallucinogens
• LSD, Mushrooms
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Anticholinergics
• Diphenhydramine, Jimson weed
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Sedative/Hypnotic withdrawal
• Alcohol, GHB, Benzodiazepines, Barbiturates
How do we sort this out?

History
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Physical Examination
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You should be so lucky
Truly the key to assessing these patients
Laboratory Testing
MAY HURT MORE THAN IT HELPS
 Don’t rely on the “tox screen” to diagnose

History
Reliable history clinches diagnosis
 Often not available

Physical Examination
The toxicologist’s best friend
 Physical findings point us towards certain
classes of toxins
 Use a focused physical examination as a
potent diagnostic tool

“Toxidromes”
Toxic Syndromes
 What are we looking for?

Vital signs
 Thought content and speech patterns
 Pupil findings
 Mucous membranes
 Skin
 Bowel/bladder
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Vital signs
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Pulse/Blood Pressure/Respiratory Rate
Increased with most drug-related
“psychoses”
 May be normal with hallucinogen use
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Thought Content/Speech
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Sympathomimetics
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Dissociative Agents
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“Seeing things”; speech pattern usually sedate
Anticholinergics
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Internal preoccupation; less verbal
Hallucinogens
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Expansive, grandiose, hypersexual; speech pressured
Agitated delerium; speech garbled, “mouthful of marbles”
Sedative/Hypnotic Withdrawal
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Agiated; speech preserved until later stages
Pupils: Size
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Normal
Hallucinogens
Dilated
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Sympathomimetics
Anticholinergics
Sedative/Hypnotic
Withdrawal
Dissociative agents
Constricted
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Dissociative agents
Pupils: Nystagmus
Horizontal nystagmus with many drugs
 Vertical/Rotatory nystagmus with few
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PCP, Ketamine
Mucous Membranes
Secretions regulated by acetylcholine
 Dry membranes: antimuscarinics
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Skin
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Increased sweating
Sympathomimetics
 Sedative/hypnotic withdrawal
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Decreased sweating
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Anticholinergic
Bowel and bladder function
Moving bowels/urinating is cholinergic
 Decreased bowel sounds, urinary
retention  anticholinergic toxicity
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What is the evidence?
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Nice, Annals of Emergency Medicine 1988
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204 consecutive “tox screens”
Looking for one of eight different toxidromes
Successful recognition on clinical grounds
• Nurses 88%
• Medical residents 84%
• Clinical pharmacists 79%
Example

20 year old college student presents “for
medical clearance” after being brought in
by EMS. Her roommate dialed 911 after
finding her “psychotic.”
Example
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No further history available
Example
VS: P 130, BP 135/82, RR 14, T 38.8 C
 Thought/Speech: Agitated, Mumbling
 Pupils: 9 mm/nonreactive; no nystagmus
 Mucous Membranes: Dry
 Skin: Dry
 Bowel Sounds: Absent
 Foley Catheter: 800 cc urine

Diagnosis: Benadryl Toxicity
Received 2.0 mg physostigmine IV
 Normal vital signs and mentation after
physostigmine
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Laboratory: The “Tox screen”
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Looks for drug OR METABOLITE
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Cocaine/Benzoylecognine
Cross reactivities/false positives
Phenylpropanolamine/Amphetamine
 Dextromethorphan/PCP
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False negatives
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PCP analogs
LOOK AT PATIENT, NOT TEST
What is the data?
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Kellerman, Annals of Emergency Medicine 1987
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361 cases of suspected adult ingestions
Significant mangagement changes in ~2.5%
Belson, Pediatric Emergency Care 1999
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158 cases of suspected pediatric ingestions
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“Qualitative screens rarely change management”
Schiller, Psychiatric Services 2000
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392 patients presenting to psychiatric emergency services
Randomized to mandatory vs. discretionary drug screen
No change in disposition or length of inpatient stay
Evidence Based
Adapted from the US preventative Services Task Force Guide
to Clinical Preventive Services 2nd Ed Baltimore, Williams and
Wilkins, 1996.
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Level I randomized controlled trial
Level II lesser trials
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1-Controlled trials without randomization
2-Cohort or case controlled trials
3-Multiple time series with or without
intervention
Level III expert opinions
Not evidence based
Medical Clearance
Components
History and physical exam
 Mental status examination
 Testing
 Treatment

Protocol for the Emergency
Medicine Evaluation of
Psychiatric Patients
Level III
Zun, LS, Leiken, JB, Scotland, NL et. al: A tool for the
emergency medicine evaluation of psychiatric patients
(letter), Am J Emerg Med, 14:329-333, 1996.
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Team of Illinois psychiatrists and emergency
physicians met to develop a consensus
document in 1995
Coordinate transfers to a State Operated
Psychiatric Facility (SOF)
Psych admission must meet 3 criteria
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Evidence of severe psych illness
Clinically indicated evaluation of any suspected
medical illness
Medical problems, if present, must be sufficiently
stable to allow safe transport to and treatment at the
SOF.
Sample of Services Provided at SOFs
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Monitor vital signs
Routine neurological monitoring
Glucose finger sticks
Fluid input and output
Insertion and maintenance of urinary catheters
Oxygen administration and suction
Clinical laboratories
Radiographic procedures
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Intramuscular and subcutaneous injections
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Consensus Document
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Tool establishes the EP as the decision
maker if lab tests are clinically indicated
Observation is the means to determine if
the presentation is from drugs/alcohol
May be used for adults and children
Medical findings may or may not preclude
transfer to a SOF
Checklist developed as a transfer
document
Medical Clearance Checklist
Patient’s name _______
Date _________________
Gender ________________
Race ______________
Date of birth________
Institution _____________
Yes
No
1. Does the patient have new psychiatric condition?

2. Any history of active medical illness needing evaluation? 
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3. Any abnormal vital signs prior to transfer
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o
Temperature >101 F
Pulse outside of 50 to 120 beats/min
Blood pressure<90 systolic or>200;>120 diastolic
Respiratory rate >24 breaths/min
(For a pediatric patient, vital signs indices outside the
normal range for his/her age and sex)
4. Any abnormal physical exam (unclothed)
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a. Absence of significant part of body, eg, limb
b. Acute and chronic trauma (including signs of
victimization/abuse)
c. Breath sounds
d. Cardiac dysrhythmia, murmurs
e. Skin and vascular signs: diaphoresis, pallor,
cyanosis,
edema
f. Abdominal distention, bowel sounds
g.Neurological with particular focus on:
i. ataxia
iv. paralysis
ii. pupil symmetry, size
v. meningeal signs
iii. nystagmus
vi. Reflexes
5. Any abnormal mental status indicating medical illness such as
lethargic, stuporous, comatose, spontaneously fluctuating
mental status?
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If no to all of the above questions, no further evaluation
is necessary. Go to question #9
If yes to any of the above questions go to question #6,
tests may be indicated.
6. Were any labs done?
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What lab tests were performed? _____________
What were the results?
__________________
Possibility of pregnancy ?
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What were the results?
__________________
7. Were X-rays performed?
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What kind of x-rays performed? ______________
What were the results?
___________________
g.Neurological with particular focus on:
i. ataxia
iv. paralysis
ii. pupil symmetry, size
v. meningeal signs
iii. nystagmus
vi. Reflexes
5. Any abnormal mental status indicating medical illness such as
lethargic, stuporous, comatose, spontaneously fluctuating
mental status?
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If no to all of the above questions, no further evaluation
is necessary. Go to question #9
If yes to any of the above questions go to question #6,
tests may be indicated.
6. Were any labs done?

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What lab tests were performed? _____________
What were the results?
__________________
Possibility of pregnancy ?
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What were the results?
__________________
7. Were X-rays performed?
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What kind of x-rays performed? ______________
What were the results?
___________________
8. Was there any medical treatment needed by the patient
prior to medical clearance? 
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What treatment? ___________________________
9. Has the patient been medically cleared in the ED? 
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10. Any acute medical condition that was adequately treated in
the emergency department that allows transfer to a state
operated psychiatric facility (SOF)?
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What treatment? __________________
11. Current medications and last administered? _____
12. Diagnoses: Psychiatric_______________________
Medical________________________
Substance abuse_________________
13. Medical follow-up or treatment required on psych floor or at
SOF: _
14. I have had adequate time to evaluate the patient and the
patient’s medical condition is sufficiently stable that transfer
to ___SOF or ___ psych floor does not pose a significant
risk of deterioration.
(check one)
____________________________________MD/DO
Physician Signature
Evaluation
Mental Status Examination
Zun LS and Gold I: A Survey of the form of mental status examination
administered by emergency physicians, Ann Emerg Med,15: 916-922, 1986.
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Random sample of 120 EPs in 1983
Diagnosis
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head injury 99%
drug ingestion 96%
behavioral complaint 98%
psychiatric abnormality 95%
<5 minutes to perform the test (72%)
Tests Used
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Level of consciousness 95%
Orientation 87%
Speech 80%
Behavior 76%
Level III
Evaluation
Mental Status Examination
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Tests not used
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Handedness 35%
Calculations 36%
Proverbs 38%
New learning ability 42%
Majority perceived a need for and would
use a short test of mental status (97%)
EPs use selected, unvalidated pieces of a
standard mental status examination
Evaluation
Short Mental Status Examinations
Mini-Mental State Exam
 The Brief Mental Status Examination
 Short Portable Mental Status
Questionnaire
 Cognitive Capacity Screening
Examination

Use of the Short Tests in the ED
Kaufman, DM, and Zun, LS: A Quantifiable, brief mental
status examination for emergency patients: J Emerg Med,
13:449-456, 1995.
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Used the Brief Mental Status Examination
in an inner city ED.
Score 0-8 normal, 9-19 mildly impaired,
20-28 severely impaired
100 randomly selected subjects
100 subjects with indications for the
exam
Level I
Chi-squared analysis of the
physician analysis vs. tool
72% sensitivity and 95% specificity in
identifying impaired individuals in the ED
Brief Mental Status Examination*
Item
Score
(number of errors) x (weight)
total
What year is it now?
0 or 1
x4
=
What month is it?
0 or 1
x3
=
=
Present memory phase after me and remember it:
John Brown, 42 Market Street New York
About what time is it?
(Answer correct if within 1 hour)
0 or 1
x3
=
Count backwards from 20 to 1.
0.1. or 2
x2
=
Say the months in reverse
0, 1, or 2 x2
=
Repeat the memory phase
0,1,2,3,4 or 5
x2
=
(each underlined portion is worth 1 point)
Final score is equal to the sum of the total(s) =
* Katzman, R, Brown, T, Fuld, P, Peck, A, Schechter, R, Schimmel, H: Validation of a short orientation-memory concentration test
of cognitive impairment. Am J Psych 1983; 140:734-9.
Prospective Medical
Clearance of Psychiatric
Patients
Leslie Zun, MD
Roma Hernandez, MD
Louis Shicker, MD
Jerold Leikin, MD
Randy Thompson, MD

Purpose
• To demonstrate the accuracy of a protocol
for medical clearance of psychiatric patients
• To describe the patients who were
transferred to psych facility
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Submitted for publication
Level II
Prospective Medical Clearance
Methods
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The protocol was applied to the psych patients transferred
from an ED to a State Operated Psychiatric Faculty – (SOF).
The protocol was applied at four test EDs in the city of
Chicago that transfers a large number of patients to a SOF.
A medical clearance checklist was developed from the
protocol to provide a foundation for documentation of the
medical clearance.
The checklist was applied prospectively to all patients
presenting with psychiatric complaints from January to July
2001
Prospective Medical Clearance
Results
330 patients who met the criteria,
were enrolled into the study from
the January to June 2001.
 19.2% had new psychiatric condition
 13.4% had a hx of medical problems
 1.5% had abnormal vital signs
 7.3% had abnormal physical
examination.

Related to inadequate initial medical
clearance
No significant difference
Transfers from SOFs to EDs - January
1, 2000 through June 30, 2000
 seizures - no dilantin level
 low back pain with h/o trauma –
 R/O cellulitis vs. DVT
Transfers from SOFs to EDs - January
1, 2001 through June 30, 2001
 intractable pain secondary to chest
trauma (Pain could not
be managed at SOF)
Prospective Medical Clearance
Results Test Performed
Most frequent test performed
Number
Percentage of
total
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Urine tox
Chemistries
CBC
Alcohol
Urinalysis
Urine preg
Accucheck
EKG
109
101
97
47
30
12
8
7
25.2%
23.3%
22.4%
10.9%
6.9%
3.0%
1.8%
1.6%
Evidence to Test

46% of psychiatric patients had
unrecognized medical illness.
• Hall, RC, Gardner, ER, Popkin, MK, et. al: Unrecognized
physical illness prompting psychiatric admission: A
prospective study. Am J Psych 1981; 138: 629-633.
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92% of one or more previously
undiagnosed physical diseases.
• Bunce, DF: Jones, R, Badger, LW, Jones, SE: Medical
Illness in psychiatric patients: Barriers to diagnoses and
treatment. South Med J 1982: 75:941-944.
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43% of psychiatric clinic patients had one
or several physical illnesses.
• Koranyi, E: Morbidly and rate of undiagnosed physical
illness in a psychiatric population. Arch Gen Psych 1979;
36: 414-419.
Psych history vs new onset
Hennenman, PL, Mendoza, R, Lewis, RJ: Prospective
evaluation of emergency department medical clearance. Ann
Emerg Med 1994;24:672-677.
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100 consecutive patients aged 16-65 with new
psychiatric symptoms.
Level II
63 of 100 had organic etiology for their
symptoms
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History (100)
PE
(100)
CBC
(98)
SMA-7 (100)
Drug
screen (97)
CT scan (82)
LP
(38)
53% ABN
64% ABN
72% ABN
73% ABN
27% sign
6% sign
5% sign
10% sign
37% ABN
28% ABN
55% ABN
29% sign
10% sign
8% sign
Patients need extensive laboratory and
radiographic evaluations including CT and LP.
Evidence Not to Test

Most laboratories, EKG and radiographic
testing should be abandoned in favor of a
more clinically driven and cost effective
process.
• Allen, MH, Currier, GW: Medical assessment in the psychiatric emergency service. New
Directions in Mental Health Services 1999;82:21-28.
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Patients with primary psychiatric
complaints with other negative findings
do not need ancillary testing in the ED.
• Korn,CS, Currier, GW, Henderson, SO: “Medical Clearance” of psychiatric patients
without medical complaints in the emergency department. J Emerg Med 2000;18:173176.
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Universal laboratory and toxicologic
screening is of low yield.
• Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO: Medical clearance and
screening of psychiatric patients in the emergency department. Acad Emerg Med
Application of a Medical
Clearance Protocol
Leslie Zun, MD
LaVonne Downey, PhD

The objective of the study was to
determine if the use of a medical
clearance protocol:
reduces costs for patients presenting
with behavioral complaints
 reduces the throughput times for these
same patients.
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
Submitted for publication
Level II
Protocol Application
Methods
Application of the medical clearance protocol in
2001 compared to none in 2000.
 The site was an inner, city teaching level I
Emergency Department with annual volume
44,000.
 The ancillary test costs were obtained from billing
data and based on 50% of hospital charges.
 The throughput time was calculated from the time
the patient was triaged to the time the patient was
discharged from the ED.
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Protocol Application
Significance
Labs
2000
2001
Significance
$241
$161
Radiology $93
$167
F=10.189,
p=.002
ns
EKG
$120
$118
ns
Total
$359
$219
F=7.983,
p=.006
Protocol Application
Results
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2000 - The throughput time ranged from 3.1 hours to
24.6 hours with a mean of 9.7 hours.
2001 - The throughput time ranged from 2.2 hours to
20.0 hours with a mean of 9.0 hours.
The throughput time was not statistically different
between the two years (p<.05).
Use of a medical clearance protocol reduces the
number and cost of testing (ANOVA F=7.894, p=.006)
What needs to be documented?
Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency
medical evaluation of psychiatric patients. Ann
Emerg Med 1994; 23:859-862.
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Poor documentation of medical
examination of psychiatric patients
298 charts reviewed in 1991 at one
hospital
Triage deficiencies
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56%
Physician deficiencies
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Mental status
Cranial nerves
Motor function
Extremities
Mental status
45%
38%
27%
20%
Level II
“medically clear” documented in 80%
The Term “Medically Clear”
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Tintinalli states it should be replaced by
discharge note
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History and physical examination
Mental status and neurologic exam
Laboratory results
Discharge instructions
Follow up plans
The term has greater capacity to mislead
than to inform correctly
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Concern about misdiagnosis, premature referral and
misunderstandings
Recommends education and process factors
• Weissberg, M: Emergency room clearance:An educational
problem. Am J Psych 1979;136:787-789.

“Medically stable” vs. “medically clear”
Treatment
Physical restraints
 Chemical restraints
 Combination

Complications of
Patient Restraints
Leslie S Zun, MD, MBA, FAAEM
Accepted for publication
The purpose of the study was to
determine the type and rate of
complications of patients restrained in
the ED.
A prospective study for one year of all
patients who were restrained in a
community, inner city teaching hospital
emergency department.
The ED nurses or physicians completed
a restraint study checklist.
Level II
Results - Characteristics
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221 patients were restrained in the ED
and enrolled in the study from November,
1999 to September, 2000.
The mean age was 36.35 years (range
14-89).
71.7% were male.
70.9% were African Americans,15.8%
Hispanic and 12.2% Caucasian.
Results - Complications
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Complication rate 5.4%
12 complications:
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Getting out of restraints (6)
Injured others (2)
Vomiting (1)
Injured self (1)
Other (1)
Hostile or increased agitation (1)
Aspiration (0)
Spitting (0)
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Death (0)
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No major complications such as death
or disability
Chemical Restraints
What are chemical restraints?
 How is it different than treatment?
 What are the indications for
chemical restraints?
 What is the appropriate treatment
for ED patient agitation?

What do we know about ED
chemical restraints?
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Few good emergency department studies
Most studies done by psychiatric
emergency services
Few comparative trials of different
medication or combinations
Current opinion based on consensus
documents by emergency psychiatrists
without emergency physicians input

Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M,
Docherty, JP: Treatment of behavioral emergencies. Post Grad
Med 2001; S1-88.
Use of Chemical Restraints
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Diagnosis
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Dosage
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General Medical Etiology
Substance Intoxication
Psychiatric Disturbance
Single dose or multiple doses
Route and onset
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Oral
IM
IV
Consumer preference
Hoge, ST, Appelbaum, PS, Lawlor, T, et. Al: A prospective,
multicenter study of patients’ refusal of antipsychotic
medication. Arch Gen Psych 1990: 47:949-956.
Prospective study of the refusal of
treatment with antipsychotic agents
 Sample of 1434 psychiatric patients at
4 acute inpatient units
 103 of 1434 refused (9.3%) oral meds
 Older, higher social class and fewer
with antiparkinson meds
 Most patients will assent to oral
medication (>90%)
Level II
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Use of Chemical Restraints
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Offset
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Sedation
Safety
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Hypotension
Dystonic reaction
Neuroleptic malignant syndrome
Akathisia
Respiratory depression
Increased violent behavior
• Small study demonstrated marked increase in violent behavior
with high potency (Haloperidol) vs low potency neuroleptics
(Chlorpromazine).
•
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Herrera, JN, Sramek, JJ, Costa, JF et al: High potency neuroleptics and violence in schizophrenics.
J Nervous Mental Dis 1988; 176:558-561.
Tolerability
Choice of Medications
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Use of antipsychotics
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Haloperidol
Chlorpromazine
Droperidol
Loxapine
Thiothixene
Molidone
Use of atypical antipsychotic
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Clozapine
Risperidone
Olanzapine
Ziprasidone
Choice of Medications

Use of benzodiazepines
Lorazepam
 Flunitrazepam
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Use of combinations
Haloperidol and Lorazepam
 Risperidone and Lorazepam
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Problems with Current
Medications
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Sedation
Dystonic reactions
Hypotension
Problems with Droperidol

WARNING
Cases of QT prolongation and/or torsades de
pointes have been reported in patients receiving
INAPSINE at doses at or below recommended
doses. Some cases have occurred in patients with
no known risk factors for QT prolongation and
some cases have been fatal.
Choice of Medications
New medications
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Ziprasidone (Geodon)
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Oral or IM
Unrelated to phenothiazine or butyrophenone
IM is indicated for the treatment of acute
agitation in schizophrenic patients
Low incidence of dystonia and hypotension
Concern about QT prolongation
Risperidone (Risperdal)
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Oral
New chemical class
Indicated for treatment of schizophrenia
Infrequent dystonia and hypotension
Advantages of the New
Medications
Little hypotension
 Less sedation
 Few dystonic reactions
 Replacement for Droperidol?

Emergency Psychiatrists Survey
Binder, RL, McNeal, DE: Contemporary practices in managing
acutely violent patients in 20 psychiatric emergency rooms
Psych Services 1999; 50:1553-1556.

Survey of 20 Psychiatric Medical Directors
from Association for Emergency
Level III
Psychiatry
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17 of 20 state that it is very difficult to
determine the etiology of violent behavior
14 of 20 said the protocol was to physical
restrain patients and medicate them prior to a
medical work-up
15 of 20 stated that IM was the most common
route
11 of 20 used Haldol plus lorazepam with or
without benztropine IM.
ED Studies
Battaglia, J, Moss, S, Ruch, J, Et al: Haloperidol, lorazepam or both
for psychotic agitation? A multicenter, prospective, double-blind,
emergency department study. Am J Emerg Med 1997; 15:335-340.
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Prospective study of 98 agitated,
aggressive patients over 18 months
Used rapid tranquilization method
Given IM lorazepam (2 mg), haloperidol
Level II
(5mg) or combination
Undifferentiated patients
Haloperidol had more EPS symptoms
No difference in sedation amongst the
groups
Did not evaluate BP between groups
Most rapid RT with combination
Rapid Treatment on Psych Unit
Anderson, WH, Kuehnle, JC, Catanzano, DM: Rapid treatment of
acute psychosis. AM J Psychiatry 1976; 133:1076-1078.

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24 patients with acute functional
psychoses treatment with IM haloperidol
over 3 hours
Given 15-45 mg
Almost complete remission of thought
disorder in 11 patients
Side effects
Level II

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EPS in 8
Blurred vision in 4
“Outpatient management may be feasible
and preferred in the treatment of acute
psychotic episodes”
Treatment Guidelines
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M,
Docherty, JP: Treatment of behavioral emergencies. Post grad
Med 2001; S1-88.

General Medical Etiology

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Substance Intoxication

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High Potency Conventional antipsychotics
Benzodiazepine
Combination
Benzodiazepine
Psychiatric Disturbance

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High potency conventional antipsychotics
Benzodiazepine
Level III
Combination
Problems
Special populations

Pregnant
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High-potency conventional antipsychotics lack
known teratogenicity
Alshuler, LL, Cohen, L , Szuba, MP, et al: Pharmacologic management of
psychiatric illness during pregnancy: dilemmas and guidelines. Am J Psych
1996;153:592-606.
Children
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Low dose benzodiazepine or antihistamine
Antipsychotics risperidone or olanzapine
Allen, MH, Currier. GW, Hughes, DH, Reyes, Harde, M, Docherty, JP: Treatment of behavioral emergencies.
Post grad Med 2001; S1-88.
Level III
Problems
Special populations
Currier, GW: Atypical antipsychotics medications in the psychiatric emergency services. J Clin Psych
2000;61:21-26.
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Mental retardation

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Atypical antipsychotics
Elderly
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Atypical antipsychotics
Combination Therapy
Physical & Chemical Restraints
Experts divided on whether patients
who are calm in physical restraints
need chemical restraint
 If there is continued agitation would
add oral medication
 Relative safety of medication and
physical restraints not studied

Take Home Point
Drugs may produce “psychiatric”
symptoms
 History is frequently unreliable
 Physical examination is an accurate tool
 Toxicology screening rarely impacts
patient care

Take Home Point
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Medical Clearance process needs better
definition or use of a protocol
Short mental status exams better than
current process
Test patients with new onset on
psychiatric illness
Physical restraint is probably safe
Chemically restrain with combination of
haloperidol and lorazepam
Questions