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Conference 5/7/2020

We are heading into our 7th week of virtual conference. Big thanks to last weeks excellent lecturers! This week we feature lectures from Drs Scarborough, Crist, and Pham, as well as our usual Q&A session with Dr R Kirby.

But first..

Happy May the fourth this week! For those of you not in the know, May the 4th is unoficially national Star Wars day. So get your nerd on!

Next up..

This month is a new block topic, Psychiatry. Somewhat fitting that this topic aligns with the ongoing pandemic of coronavirus that has swept the world. This has caused a significant amount of mental, emotional and physical stress on just about everyone the world over. Before we get into things, I want to take a moment to commend you all for persevering, adjusting on a moments notice, dealing with new norms on a near-daily basis, and acclimatizing to the mindset of playing the long game.

This brings us to a new topic that will hopefully be rolling out on the website in due time – Physician Wellness. Wellness is a hot topic on everyones minds. But what exactly is Physician Wellness?

When did the movement for ‘wellness’ start, and what was it in response to? More importantly what does wellness mean for our culture in medicine?

I think my own definition of what is healthy for myself – is and should be different from the next physician, and them in turn different from the next. After all we are all different and unique individuals, so what works for me might not work for you. I think it is probably pretty hard to apply blanket rules on what we should be doing in terms of “wellness” that can apply to everyone.

So with that said – Keep a lookout for the wellness section coming soon where we attempt to delve into what physician wellness is, and what we can take away from it in our careers and lives.

Now onto business

Here is an article from EMDOCS regarding medical clearance of psychiatric patients that is worth reviewing.

Blood testing for psychiatric patients or “required labs” prior to “medical clearance” is certainly a debated topic in EM right now.

The ACEP clinical policy on diagnosis and management of adult psychiatric patients recommends that routine laboratory testing is not necessary and should be tailored to history and physical findings in alert, cooperative patients with normal vital signs and a noncontributory history and physical exam (Level B).1 A study done on ED psychiatric complaints showed that history alone was about 51% sensitive for determining whether to escalate labs and workup, and labs alone was about 20% sensitive.(2) The study showed that asking the patient if they had a medical complaint or problem was 92% sensitive compared to history alone. (2)

So what does that mean? should we not be testing any psychiatric patients with labs or other evaluations?

Well, not exactly. Some general rules about workups for psychiatric patients should pertain:

  • Patients with new psychiatric diagnoses without prior history should at minimum recieve labs. (3)
  • Don’t confuse pediatric or adolescent psych symptoms for true psychiatric disorders without workups and exclusions of conditions such as NMDA encephalitis or toxicologic induced mental status changes. (4)
  • A new psychiatric disorder in those over age >50 is worrisome and should prompt considerations for brain imaging. (3,4)
  • Routine head CT in patients with psychiatric complaints is not recommended in the absence of the following: age >60, concern for head trauma, focal neuro deficit. (5)
  • Urine drug screenings might be important to identify addiction but are nearly useless in identifying toxidromes, which should be guided by exam, vitals and symptoms. (6)


How about TSH and thyroid studies in psych patients?

Well, a study in Annals of Psychiatry in 1995 showed that TSH was abnormal in many psych patients with depression and that we should be screening patients with any symptoms of myxedema or thyrotoxicosis. (7). Another study in Treatment in Psychiatry 2012 noted that ” Nonthyroidal illness is a common finding in psychiatric patients, and abnormal thyroid function test results may represent an adaptive response to acute illness rather than true thyroid disease in this population. Thus, abnormal
thyroid test results should be interpreted with caution.” (8) Overall, this does correlate with ACEP clinical policy that we should base testing on clinical signs, symptoms and presentation and perhaps not just the isolated psychiatric symptom alone.

Thats it for now, stay tuned for virtual conference this thursday 5/7 See you then.

Image Credits
Unsplash.com – NEon Brand Digital marketing.


References

  1. Lukens et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2006;47(1):79-99.
  2. Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 1997;4:124-8
  3. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994; 24:672-677.
  4. Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. Can J Psychiatry. 2009;54(7):493-501.
  5. Wolfson A, et al. Harwood Nuss’ Clinical Practice of Emergency Medicine, 6th Edition, Philadelphia, Lippincott Williams & Wilkins, 2015
  6. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol. 2009;47(4):286-91
  7. Ordas DM, Labbate LA. Routine screening of thyroid function in patients hospitalized for major depression or dysthymia? Ann Clin Psychiatry. 1995;7(4):161-5.
  8. https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2011.11040631

Stefan Meyering DO, FAAEM, FACEP

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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