Psychiatric residency training in the consideration of alternatives to hospitalization.

Residency training should prepare one to accommodate to the current rapid changes in the political, economic, and legal climate as well as to biologic developments in psychiatry. One goal of training should be to remain open-minded to creative treatment approaches and disposition options for a wide variety of psychiatric patients.

Psychiatric residency training in the management of emergencies.

As a psychiatry resident on the Emergency Service or on call at night, the resident learns to function on several levels, as consultant, liaison, colleague, and occasionally as primary physician. At the outset, the resident needs to know that he or she is not expected to know all that yet. It is especially necessary to emphasize to a beginning resident that it is acceptable and important to ask for help. The resident is never the only physician caring for an emergency department patient. There should always be other psychiatry residents, psychiatry attending physicians, other house staff, and emergency medicine attending physicians who can help and often have an interest in each patients. The resident has an obligation to involve other physicians if there is uncertainty about the proper moves to make, and an obligation to discuss the management of a patient with the physician who initially consulted, as well as any other doctors responsible for the patient. Emergency cases can be discussed at morning rounds as well as at various seminars. The resident should also know that an interested or helpful ear can always be found among more experienced residents and attending physicians. The supervisor may present the option to the resident that he or she is available to see the patient with the resident, afterwards, or not at all, and can teach by watching and commenting, by modeling, and by supervision of the observations and reactions that the resident presents. There are a number of benefits to these models of emergency psychiatry training. In the first place, all of the drawbacks seen in present systems are addressed or avoided. The psychiatry resident retains his or her identity as a physician, working in consultation and cooperation with other physicians in a medical facility, rather than in a community clinic or psychiatric hospital. When a resident sees an emergency patient in revisit one or two days later, the resident has the opportunity to observe the effect of the psychotherapeutic intervention. One outcome of this observation is a decreased reliance on medication, and an increased use of outpatient modalities. The resident also gains an appreciation of the mental health system as he or she must work with many agencies and many levels of care.

Violence associated with phencyclidine abuse.

Violence associated with chronic phencyclidine (PCP) abuse was investigated by administering a structured interview to 16 chronic PCP abusers. A more intensive study was done of another individual who committed murder and self-mutilation under the influence of PCP. The results suggest that there is no consistent association between PCP-related violence and a history of violence not related to drug or alcohol abuse. The author defines four types of violence associated with chronic PCP abuse.

The amobarbital interview.

In two apparently disoriented patients, the emergency physician's use of amobarbital quickly eliminated diagnoses of an organic etiology. Although thousands of amobarbital interviews have had no complications, the use of amobarbital should follow a thorough evaluation. The amobarbital interview is a safe and simple technique to discriminate functional from organic illness, thus avoiding unnecessary medical and surgical treatment, neglected illness, and inappropriate disposition.

Recognition and management of drug abuse emergencies.

As with any medical emergency, the initial approach to the management of the drug abuse emergency is to attend to the potential threat to life. Establish and maintain an adequate airway, with respiratory support if necessary: secure a reliable intravenous route: administer appropriate drugs and antidotes; and perform the necessary diagnostic procedures to identify the cause of the problem. Always make an assessment of the psychological threat of self-destruction before discharging a patient who has taken an overdose. Be suspicious of drug overdose ina comatose or oddly-behaving patient. Consider the possibility of multiple drug abuse. Finally, always consider the possibility that causes other than drugs may be producing these symptoms.