-
Dr. Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to Psyched for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini series in which we cover clinical skills in psychiatry. So in the past we've tended to cover specific disorders or illnesses. But these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy.
Dr. Lucy Chen: [00:00:38] Okay. And we are rolling. Hi there. This is Lucy Chen. I'm a PGY four psychiatry resident at University of Toronto, and I'm here with my co host, Arthey.
Dr. Aarti Rana: [00:00:49] I'm a second year resident also at the University of Toronto.
Dr. Lucy Chen: [00:00:52] And we're very lucky today to be discussing a very important topic about risk and risk of and management of violence and agitation in the emergency setting. We're very lucky to have Dr. Jodi Lofchy here with us for this interview. Maybe we'll have Jodi first. Maybe you can you can talk. Tell us a little bit about who you are and sort of your experience in this topic.
Dr. Jodi Lofchy: [00:01:19] Okay. Thank you. And thank you for inviting me to your podcast to be part of the the group of very illustrious presenters that you've had so far, so happy to join in. I am an emergency psychiatrist and I am here at St Joseph's Health Centre as the service head of Adult Acute Care Psychiatry, where I've been since October of 2018. So my background is in emergency psychiatry, and when I finished my residency training at U of T a century ago, many, many years ago, there was no such thing as emergency psychiatry and basically as residents we learned on the fly. I found emergency work fascinating and being able to think on your toes and having to make diagnoses and figure out what's going on when people were so acutely ill and make sure they got to the right place in a humane and caring way, because often it was their first presentation to the psychiatric system and anything we could do to ensure that they trusted our patients, trusted us and would come back for treatment, would go a long way. And so what we could do and emerge was really, really important. But there I was aware that we weren't getting any teaching in this.
Dr. Jodi Lofchy: [00:02:36] And through my residency years, I was moonlighting. Those were the days when we could do such things because we had general licenses and I was a GP doing locums before my psych residency and I did emergency medicine work during that. And again, I like the acuity of being in the emergency. So after my residency I did a fellowship and this was the first fellowship in emergency psychiatry in Canada. There was no precedent for this. It was only a subspecialty area that had just been sort of evolving in the American than the U.S.. The American Association of Emergency Psychiatry had just started up in the late 1980s, so I completed my fellowship at the place formerly known as the Clark Institute of Psychiatry, and I finished that in 1992 and stayed on there to work in the emergency setting and become the director of that emergency services. Up to 2002, when I moved to UHN and helped create a models of best practice in the PC at Toronto Western Hospital where I worked up until 2018. I'm currently part of the emergency team here, but I also chair the CPA's section on emergency psychiatry for the country. So that's my area.
Dr. Lucy Chen: [00:03:51] And that's lots and lots of experience.
Dr. Jodi Lofchy: [00:03:53] And feel free to edit that too long.
Dr. Lucy Chen: [00:03:57] No, I think that's amazing. Well, you know, I guess firstly, maybe what I'll take us through right now is just a list of the objectives that we're hoping to cover during this episode and we're hoping to fit it all in and we'll do the best that we can to make a sort of create sort of a comprehensive sort of overview of this important topic. So firstly, in our objectives, we hope that the learner can identify risk factors for violence in the emergency department and understand the differences between static and dynamic risks. We're hoping that the learner will know how to take a history for violence and communicate that risk to others. We're hoping that the learner will describe the indications for non chemical interventions in the management of an agitated patient as well as describe some of the pharmacologic interventions in managing the agitated patient and then finally wrapping it up with how to apply legislation regarding risk of violence. So I guess we'll start off with firstly, you know, there's always effort. There's it's really important to mitigate risk of violence in the emergency setting. And for you, Dr. lofchy, with your experience, what's been the most I guess what have been the most common challenges in preventing bad outcomes? How common is it and what have you really seen in your experience?
Dr. Jodi Lofchy: [00:05:17] Common challenges in the emergency setting are there's environmental challenges, there's the clinical challenges, and then there's the challenges we bring and our team we bring as individuals, working in an intense and unpredictable environment, often doing shift work and perhaps being fatigued. So I always think about it in those three areas of the actual system or environment, the clinical, the patient challenges and then the individual in terms of the clinician and what we bring to the picture. So we do know the in terms of the system, we know the emergency department is very prone to violence, that that we have some stats about that that 10% of psychiatric emergencies involve some sort of agitation or violence and that out of looking in the states where they looked at 3.4 million emergency visits, 1.7 of those visits involved some sort of agitation. And we know it's not just when people have major mental disorders such as schizophrenia or bipolar mania, but the cognitively impaired patient. So we don't know. It's always psychiatric. It could be medical substance related presentations. All these kind of clinical factors impact on people's agitation. We know that our staff whose front line is at the highest risk, and that's typically nurses and security guards. So the environment itself, if it's not designed safely, can lead to bad outcomes. You asked. Those are the kind of challenges that we would want to create, environments that would reduce the risk. We would want to be able to get patients quickly and safely through the doors.
Dr. Jodi Lofchy: [00:07:01] And we know that if there's increased wait times or crowding and overcrowding in our emergency departments, that leads to frustration and agitation. If we have poor communication with our patients, that can lead to a bad outcome. You know, triage is a pretty opaque concept to the layperson. Many people sit in our waiting rooms and have no understanding why someone else who came in much later than themselves flying through the door quickly. And it's like, Wait, hey, I've been here a couple of hours. Why are they going ahead of me? It's not like, you know, the bakery or the deli where you take a number and you just wait your term and you're going turn and you're going in sequentially. It triage is about prioritising the most acutely ill, and we need to communicate that to our patients who are sitting waiting in the emergency department. I think that the trend towards building holding units such we have, such as we have at Toronto Western and here at Saint Joseph's where right from the point of triage, people go right into a designated area for psychiatric emergencies. That goes a long way in helping to explain the system and explain the process and settle people because they're going to be seen and they're going to be in a contained space that's designed for safety and can hopefully help to settle people and reduce the risk of violence. There's lots of challenges. Lots of challenges. Yeah.
Dr. Lucy Chen: [00:08:22] And maybe just to summarise, it sounds like what you've talked about is like sort of systemic factors in terms of structure of the hospital triaging, sort of the routines around management and kind of triage. And then you're sort of talking about environmental factors in terms of the space seclusion or holding units, sort of opportunities in terms of containing patients when necessary into a room where where that's necessary. And maybe you can tell us a little bit about what a seclusion room is or for for those who are who are not really that familiar.
Dr. Jodi Lofchy: [00:09:02] Well, I don't know that there's one definition of that, and I think they're pretty site specific. When we have rooms that people can be separated from a general waiting area that has reduced stimulation where there's not the noise of other people who might be unwell so that people are removed into a quieter space. We also know that lack of sensory stimulation can make people more agitated. And so there's that fine balance of being able to give somebody some quiet space and diminish the stimulation, but also allow them to feel that they can ask questions or that they're being cared for by a team and that the nurses and the the psychiatrist or the emergency physicians will still be seeing them. But we do want if we have to give somebody a time out in a in a way have a place where it is quieter and it's removed from the general melee of the intense, busy, noisy emergency setting.
Dr. Lucy Chen: [00:10:08] Yeah. So just to continue the summary. So systemic factors, environmental factors, sort of psycho pathological factors with regards to the patient. So in terms of the diagnosis or whether it's sort of an organic cause such as substance, dementia, delirium or head injury, psychotic factors such as mania or schizophrenia or psychosis, or if they have perhaps a forensic history or if they have a diagnosis of autism or sort of personality traits that are more predisposed to violence. So those patient factors as well, and then as well as sort of the train, the practitioner and perhaps their level of training and familiarity in that environment.
Dr. Jodi Lofchy: [00:10:45] That's right. Or if there's a certain type of patient that creates anxiety or dislike in the clinician, then you may not be coming towards the clinical interaction with patients and empathy. If it's a certain kind of patient that would push your buttons, you need to have that self awareness. And that's part of what goes on in the residency training, is learning how to manage these intense feelings and reactions to patients who at times are incredibly challenging. So knowing ourselves well, knowing when we're fatigued or when we've been too busy all day to even eat lunch and that we're going to be our patients is going to be even more thinly pulled. So we have to just be aware of the factors we bring to the interaction as well with patients who have high risk, who are high risk.
Dr. Aarti Rana: [00:11:33] And Dr. Lofchy, when it comes to the patient factors, one of the challenges, as I understand it, is these are undifferentiated patients. It's a term we use to say that these are patients where we don't know the psychopathology, right? We might be able to see some of it in that they might appear agitated, but sometimes a very quiet patient can quickly become agitated. So how do you take a risk history? How do you take a history from a patient quickly that actually helps you assess risk along the way? What are you looking for?
Dr. Jodi Lofchy: [00:12:03] Oh, that's a really important question because that's part of every type of psychiatric assessment. Before we meet the patient, we are given some information about them. So it really is important to see if there's any collateral or past history because we know past predicts future. So if we know that there's been a legal history or that right then and there, the police are bringing in the individual because there's been some sort of altercation. Anything we know about their past risk would help inform our assessment that we're going to do. The police have often put patients into their computer systems and they can tell if there's any charges in the past or outstanding charges at times. So we go online to see if we can get the information from old charts, if they're known to our hospital, that kind of thing. But if somebody just comes in calmly, we're going to do our history, as we would with any emergency patient. Right. And there might be kind of little triggers that go off that say, hmm, I'm concerned about this person, or I'm watching for signs that show that there's increasing agitation. But the actual history taking, we follow the same approach and structure that we would with any emergency assessment. But we're going as we would screen for risk in terms of suicide, we screen for violence risk. So we want to know about an aggression history.
Dr. Jodi Lofchy: [00:13:19] We want to know if there's been any charges and if so, what kind of charges are these assault charges with or without weapons, that kind of thing? Were they provoked? If we hear there's been a history of violence or unprovoked, this kind of thing, and who's been at risk? We know that those closest to the individual are always at the highest risk, intimate partners, children, that kind of thing. Or was there violence towards complete stranger, something random and much more concern? It's all concerning, but if we can't predict because that kind of thing just is something that's a one off, that kind of thing. What was the individual's response to having been violent? Did they have remorse or was there some sort of minimization or denial of the whole kind of incident and the role of substances. A lot of this doesn't occur in isolation. Many of our patients have comorbidities, and substance is a big part of the emergency presentation, whether it's a current state of intoxication or withdrawal or a current history or past. So if there's been violence, has it been in the context of any kind of substance use? So these are the kind of things that we we explore. We ask about how people manage difficult feelings in a more general way. How do they express their anger all the way from road rage to property destruction to actual physical altercations.
Dr. Jodi Lofchy: [00:14:44] So we're exploring it in some detail. If we feel somebody is at high risk or we we know something about their history to hear what their past is. We also want to be checking in in the interview itself. How are they feeling now? Are you able to tell me if you're having any of those feelings here today? You're always trying to assess your risk and make sure it's safe for you and your team while you're doing your interview. So it's not just asking these questions and noting down and then coming out and say, Oh, I've got a high risk patient. It's making sure this is not going to be activated because of the stress of being in the emergency setting or having been apprehended or put on a form, whatever the stressor is. Now, that might be provocative. We want to make sure you're safe and that you know how to ask the questions to check on that. Clearly, the aspect of means for violence is important. It's always in our mind, and that's why we're talking about safe environments. But have the patients been searched? We don't know that. If they haven't come in with the police, Police, we would check with them. Have they been searched? Usually they do search them, but it's not typically part of the routine, the automatic role of a security guard in the hospital or a psychiatric assessment psychiatric assistant in some of our hospitals.
Dr. Jodi Lofchy: [00:16:03] Pa, So we have to understand if there's available means, if they have that, any kind of potential weapons on them or nearby. And then as we're doing our interview, we're looking at the individual and the demographics in terms of are they falling into a high risk group, in terms of being a young male, having been through chaos and dysfunction in terms of their family upbringing? Is there a paranoia in the room in terms of they're feeling victimised or and I don't even mean delusional necessarily, but necessarily but their way of seeing the world that they've been victimised and that others are out to get them. So maybe they need to protect themselves or maybe others have it coming. So that kind of cognitive set. But obviously if there's actual psychosis and persecutory delusions or command hallucinations informing the individual that they must do something violent for whatever reason doesn't necessarily make sense. We want to explore that in great detail. So basically you're doing your regular history and mental status exam, but you're just being alert to who are the individuals in their realm who might be at risk. What does their past history tell you in terms of past experiences? Predict future and what's currently going on now in terms of how active are their psychiatric symptoms that put them at at risk and including states of intoxication or withdrawal.
Dr. Aarti Rana: [00:17:33] So in terms of a step by step approach, first you might start with the triage notes and say, is there anything in these notes in their presentation, like are they agitated? That makes me worried about risk.
Dr. Jodi Lofchy: [00:17:44] And the police would hopefully bring in the EDP, the emotionally disturbed person's form, And if they've forgotten to do that, you can remind them or triage can because there's such useful information that the police have about why this person has been apprehended or brought in under the Mental Health Act, in effect.
Dr. Aarti Rana: [00:18:02] And then in addition, it sounds like, in addition to getting the story from police, also making sure we ask about whether or not the patient has been searched, that's really important. And looking at past records to see what's their history within the emergency department or within past psychiatric assessments. And then in addition to that, looking at the environment that the patient's in before you go in and speak with them, those would all be things. And then in the context of the actual risk assessment, some of the things that you mentioned that I thought were really important are how do we characterise past risk. So is it provoked or unprovoked? What was the context for it? Was there were there any substances involved and what was the degree of impact? So is this was this I hate to say minor because I think even a small minor history of violence is still important, but sometimes there is minor violence versus something major that resulted in a charge of some kind. And the extent of that charge and when that was all of those factors. And once we have all this information, how are we writing it down that we're ensuring the next person really has all of this or that? If we're reading a note from the patient's history that how should it have been communicated to us that we're really prepared to go see this person?
Dr. Jodi Lofchy: [00:19:20] Well, that's a great question because that speaks to systems and hospitals and the way we communicate between team members and within our own group, but outside our own department as well. And various hospitals have created different systems of highlighting patients who are at risk of violence anywhere in the hospital. And that could be, again, a post op, delirious patient who's assaulted a nurse or been agitated on the ward, not somebody who's been aggressive on an inpatient ward or comes in the door that way. So there's different flags that go on electronically at different hospitals, and everybody should be at the point of orientation, informed of the way the hospital complaint completes these and communicates that this person is a high risk patient. So these days it's being done electronically. We have that on our own system here at Saint Joe's , UHN has a system of a behavioural safety alert, so there's red flags and highlights. If you look on the actual sort of patient list on the here it's sunrise and at at it was the EPR. So all different systems and I can't speak for every single hospital, but I know that's what the trend is to be able to communicate that patients you do need to like kind of be a little hyper alert when somebody has a past history so that it's being indicated throughout the hospital.
Dr. Lucy Chen: [00:20:47] And Dr. Lofchy, like you've sort of supervised residence in the Emerge before, How would you like that violence risk be communicated to you? So if there's the first year resident there on their first emerge shift, they're kind of encountering this patient, they're collating all this information. How would you prefer to receive that information? What's the kind of organised approach that a resident can take in communicating risk when they're sort of handing over?
Dr. Jodi Lofchy: [00:21:10] Right. Well, handover is really important and I do think it involves not just the medical handover but the nurses taking care of the patients as well, the whole team. So there are different ways in St Joseph's creating a new interface for safety and incident reporting when there's any concerns about safety issues to the team or between the patients, that kind of thing. What we need to do is integrate it back into the clinical record. So I think there might there's no harm in duplication. Now if all the different boxes are being checked, you just the resident would need to know their system in terms of who should I tell that I'm concerned about this patient, that there they're no needs to highlight it. And maybe the way the orders are written in terms of level of observation or we have here communication orders, just to note that there's concerns, that kind of thing, so that the other team members can read this, that in their own consult note, it's being documented in the impression every resident will write up their note and after doing the history and their mental status exam will do an impression, It will be including a diagnostic impression with the DSM. But it will also be a narrative, a description of the risk assessment and the justification for the decisions they're making at that point for what the disposition is. So you don't just come up with a plan and say, you know, admit on a form or send out the door and and go to crisis clinic. It's like, how did you get to that decision? How have you deemed that safe or appropriate to be able to follow that course? Or what are your concerns that make the admission necessary or the involuntary admission required? So that should all be documented in your impression, so that even if somebody doesn't have time to read the whole note and often we're just saying, okay, what's going on here and what's the plan that it's all clearly laid out in terms of why this person is high risk and why you're choosing the disposition that you are?
Dr. Lucy Chen: [00:23:08] And I guess just to organise this further, I mean, there's this idea of static and dynamic risk factors and what we're really targeting are the dynamic risk factors. So maybe if we can better highlight what's considered a static risk factor, what's considered dynamic, and then maybe that'll give an approach to organising risk.
Dr. Jodi Lofchy: [00:23:25] Absolutely. And I think this is a really good way of thinking about any kind of risk assessment and people are more comfortable thinking about this or it's more common to think about this in terms of suicide risk assessment. It's this exact same approach. The concept of static risk factors are being. The historical aspect, things that are more biologically driven, and basically the concept that we can't modify or change the static risk factors, we we inherit them as the patient comes to us through the door. And this is their history and this is who they are and this is what's already happened in the past. So in terms of, you know, men maybe being at higher risk or having had a background of trauma or chaos and family dysfunction, having had past history of substance use, having a psychiatric diagnosis that they come to us with. Those are all things that are. Hardwired to an extent, but not. But we can treat and we can modify the the substance, use the psychiatric illness by engaging with the patient and offering treatment. And then we look at the more dynamic aspects is can this person is there something here that we can treat? And we know there's certain conditions and personality disorders that there isn't a lot we can do in terms of the antisocial personality, and that's why we have the legal system to assist us with that. If there's nothing else treatable that we can offer in terms of a major mental disorder such as schizophrenia, substance problem, mood disorder, etc., the things that we have more of an armamentarium to offer in terms of treatment options.
Dr. Jodi Lofchy: [00:25:20] So we are looking at the dynamic factors, where can we intervene. So I'm talking about some clinical things, but I'm also talking about social aspects and that's why it's essential we work with a team that we work with clinicians and social workers, and we liaise with community supports that our patients are well connected. If we can assist with that, that's fantastic because we want to help them outside the hospital. If this kind of cross sectional interaction in the emergency department might be the only time we see this person. The difficulties are out there not with us one day in the emerge or one night we want to try and create more of a support system and an infrastructure when they leave the hospital. So those are the modifiable risk factors and working with the team allows us to kind of put a bit of a cushion together and engage the person in treatment. And I'm back to my earliest point is this is the portal of entry, right? This is the the chance that we have to really hopefully engage this person in a positive connection and journey towards the recovery model and hope and wellness and all these things that we can offer, just hope for the future, that we have something to offer so that we can. That's our role in the emergency department, I would say.
Dr. Lucy Chen: [00:26:39] I guess just generally summarising static risk factors being more historical, generally sort of modifiable and long term risk and dynamic factors being more modifiable. It's more so the short term risk and it offers targets for risk management and risk reduction.
Dr. Jodi Lofchy: [00:26:54] Right.
Dr. Aarti Rana: [00:26:54] And it's not only it sounds like the factors that are dynamic, but risk itself is dynamic, right? So you're observing someone and their behaviour may be changing in the emergency department and we can identify those stages of risk or what are those stages and what do we look for to identify them?
Dr. Jodi Lofchy: [00:27:12] Well, that's very, very important because I mean that we don't just say, Oh, they're low risk because today they're not intoxicated or they want help. And then we we have to see what's actually going on in the department itself, because as we've mentioned already, there's lots of factors beyond our control in terms of the milieu of the emergency setting that can create an increased risk or provoke somebody who may come in the door initially calm. So we're always watching to see how things are shifting or evolving. And we have to I always talk about doing an eyeball sort of visual mental status exam before you even go out or start your shift. You sort of I think the term is an environmental scan. We look around, we see who's there, we see is it crowded, Are people sleeping, Are people pacing? Are they already in a state of potential agitation? So we need to organise our thoughts about who is no like doesn't look to be at any acute risk at this point in time. And who might be escalating because we know that there's a continuum and if we don't intervene at any stage of this kind of escalation, it will just go on and on until something very dangerous potentially can happen. So we want to organise our thinking about who is starting to escalate and what should we be looking for at each stage.
Dr. Jodi Lofchy: [00:28:37] So the first stage would be just general agitation. These are the patients who might be coming up and banging on the the the glass Lexan glass where the ward clerk or receptionist is saying, When is my turn? When am I going to be seen? I've been here forever. They're starting to get a little upset because they want something or their needs aren't being met. So we're going to watch for motor changes. We're going to see them pacing more. We're going to hear their voice go up. Perhaps they're not able to contain themselves to be pleasant and calm when they're asking their questions. So the volume, the tone, and we're going to just watch for some sort of sort of adrenergic response where they're getting a little more flushed or they're starting to clench their fists and it's hard for them to sit down. So that's the anxiety, the agitation phase. And then we if that is not addressed, if we don't intervene to help de-escalate that, then things can get. More volatile. Somebody can move from anxiety and being agitated in a psychomotor agitation way to actually threatening and verbally threatening and saying if I'm not seen within a few minutes, something bad is going to happen. That's a threat. It may be non-specific, but we just don't ignore that.
Dr. Jodi Lofchy: [00:29:49] So now we're in a verbal threatening phase of an interaction and we need to actually intervene accordingly. I can talk about management after, but you had asked about what are the things we watch for? So we watch for agitation and this kind of psychomotor escalation. Then we listen to what's going on and if there's any threats, they're now in the second phase of actually threatening. And then the next phase is actually the most dangerous, where we have overt aggression, where it's no longer verbal, it can become physical and anything as a potential weapon. If somebody has come in with belongings, things can get thrown. If we're working in an environment where there's objects that can be picked up or we don't know, again, the worst case scenario, if they have a weapon, if they haven't been searched, that kind of thing. But anything is a potential weapon if used in a certain way. So that's kind of the peak of the curve when things are at the most dangerous. And after that, then people's energy spent and there's a resolution where we can actually all engage. But by the point that point, we're looking at code whites and calling back up and really kind of trying to diffuse the whole setting to keep it safe.
Dr. Aarti Rana: [00:31:01] Since you mentioned Code White, I think it might be helpful for people to know what exactly happens if we have a lot of listeners who are clinical clerks or first year residents. Some of them have never actually seen what a code white looks like. They've just heard it paged overhead. So can you describe when someone might call a code white and what would they expect would occur?
Dr. Jodi Lofchy: [00:31:19] Sure. For anybody working in a hospital environment, the code system is standardised, so there's lots of different colours, the whole rainbow and it's any hospital that you're going to work in across Canada, we'll have the exact same code system and what's nice about it, it's standardised, how to access it to you would call, you would dial five, four or five, five, five, five, five and that gets you the code white, which is asking for backup and a code white team to respond immediately when there's an agitated patient. And it doesn't have to be a registered patient, it could be a family member, it could be a concern to other it. It's an individual who's agitated and you need a show of force and a backup team and trained personnel to help de-escalate the situation and back you and your own team up. So when you're working in an environment like the emergency department, you may hear code whites being called. They may be in the General emergency Department, they may even be in the psychiatric emergency department, they may be on psychiatric inpatient wards. But there is a designated code white team 24 seven that will come to assist with with as many people as possible who can provide backup to assist. If you need to now de-escalate the patient, provide chemical restraint or mechanical restraint, get the patient into a quiet place, into a bed, and make it safe for everybody.
Dr. Lucy Chen: [00:32:47] So now we've kind of got a clerk or a resident who's prepared themselves through a review of the history. They've collated all this information. They've gotten some handover. They're now approaching sort of they're exiting sort of the nursing station and they're heading towards the sort of the the merge department interview room, I guess. Are there things to be mindful of to ensure that we're working in a safe and well equipped environment? Where are things to watch out for? What are things to be mindful of?
Dr. Jodi Lofchy: [00:33:17] Absolutely. I think this is a great opportunity for medical students and residents to check that the environments they're working in feel safe and that are designed with safety in mind. And the bottom line is, if you're not feeling safe or you have concerns, you bring somebody with you or you organise your space accordingly to be in a place that is set up that way. So ideally you want to go to an interview room that's designed for safety or interviewing psychiatric patients that would have a non barricaded door or have two exit points so that nobody could block you in that you need to know about personal alarms that what your actual alarm buzzer will do. Does it call for a backup team? Does this buzzer that this little button you're carrying around, is that going to call a code white? You need to be oriented to what are these devices that have been provided for you to to access backup? Should there be any need to hit an alarm button? You want to make sure the room that you're going in doesn't have extraneous decorative items that can be thrown that the patients are not bringing in. If they have that suitcase sign of kind of thinking they're staying in the hospital longer, that perhaps they leave their belongings outside the interviewing room. You're. Looking at what they're wearing and if they've got layers of clothes or bulky pockets that may have items in them, you may want to ask that your team together, ask them to empty their pockets, etc., before you go in.
Dr. Jodi Lofchy: [00:34:45] Sometimes patients when they've been certified and put on form ones are put into hospital gowns already. So that's kind of an equivalent of having them searched and make sure they're not bringing in any extra weapons. You want to set up the room where you're sitting and where the patient sits. And if you have extra staff members or team members with you so that you all can get out of the room quickly and nobody is feeling trapped in a corner. So that is a certain way to make sure that everybody has access out. What I typically do is I don't like a door shut 100%. I like it a little bit open. So you're not fumbling with waiting for buttons and things to open. So and also this kind of illusion of ventilation and air coming in and flow so that we can all quickly get out of the interview room. But it really depends how your department is designed and what the actual physical space is. But you do, especially if you're on call and this is the middle of the night where there might be reduced staffing. You definitely want to check out before you go in who is your backup, who is going to be arriving should you need extra help and how to call for staff or assistance quickly. You also want to look at yourself, what you're wearing before you go in. I always talk about fashion as weapons.
Dr. Jodi Lofchy: [00:36:01] There's certain things that if you're wearing necklaces or long and dangling earrings, that kind of thing that anybody could grab on to and pull and you're putting yourself at risk. Women who have long hair have to think about that, not having ponytails that could be grabbed or hair that's going to be potentially a weapon if they're on call, males who maybe are dressed more formally. Really, psychiatry is not a place to be wearing ties, especially on call. And I always joke unless they're those quick release ones that you have and that speaks to the lanyards as well. Everybody wears their hospital ID, but I think these days most House staff have quick release with three breakaway points with the lanyard so that even if somebody's pulled from the back, that there's no way that you could be harmed by your own hospital ID. So these are the things to think about before you go in if you're not in an emergency setting, but you're seeing somebody who's a new patient to you on an outpatient ward, you have to go through the same kind of thought process and you really don't want to be seeing new patients. At the end of the day, when there's less staff around, the receptionist may go home at a certain hour and you're still booking patients a little bit later. You save the new patients for early in the day when there's sort of a robust response going to be available should you have any concerns.
Dr. Aarti Rana: [00:37:24] Thank you. You've really highlighted the importance of preparation and all the things that have to happen before you even go in to assess a patient. And I've still been in situations where despite all of that, I'm in a room with someone and they sometimes very calmly express some kind of violent ideation or for whatever reason that I can't even anticipate during the course of the interview, start to become agitated. So let's talk about de-escalation. The word kind of implies we're trying to bring someone from one stage of risk down to a lower stage. So what is de-escalation? How do we do it?
Dr. Jodi Lofchy: [00:37:59] There's verbal de-escalation. And I guess that technique and approach to de-escalate somebody would apply to those first two stages of pending violence, the agitation, anxiety stage and then the verbal threats. And we use all these verbal techniques to help bring somebody back to a place where they can communicate calmly and clearly, if possible. So the earlier we recognise, the better, because our techniques will vary based on what we're hearing. When you're seeing somebody just calmly talking about some violent thoughts or fantasies or ideation, but there's no signs of motor agitation that's separate from somebody when you're in the interview who suddenly can't sit still and has to get up and pace around and you have to keep saying, are you able to sit down? You can't ignore what's going on. So whatever they're bringing to the interview you have to address. So if somebody is calmly starting to talk about some violent thoughts, feelings, fantasies, ideations, you need to say, are we at risk right now? Do we need to take a break? Are you telling me you're having these thoughts about acting on this now? It's just like suicide. It's one thing to have ideation. It's another thing to have intent. You want to understand the degree of impulsivity, though, that this person brings to the interaction and what their history is. How have they acted on it before? So that's back to the history. So if they're telling you about it, it's more an exploration.
Dr. Jodi Lofchy: [00:39:27] But if something's going on, that's where we de-escalate, where it's getting more. It's in the room. So verbal de-escalation is always for setting the stage with, you know, an empathic and respectful connection with the patient and already appreciating that they may come into this interview very frustrated that our emergency systems are set up, that they've probably told their story three or four times before they get to you as the psychiatric team. And you may actually have to say, we need to you may actually have to tell the story again once I review with my staff or bring in a senior resident or another team member. So you're trying to appreciate that. I know you've been waiting here a long time. I know you've already talked to a lot of different people. Did they explain who I am and why I'm talking to you now? No, I have no idea who you are. I just want to go. Okay. So the idea is trying to empathise with the frustration and the time they've spent and what they're telling you. I hear that you want to go. You're not ignoring it. But we need to understand why you're here. And if there's any way we can help before we figure out what's going to happen. So it's really important not to make promises that you can't keep. That's a really important rule because that will come back to haunt you If you people are listening to you.
Dr. Jodi Lofchy: [00:40:48] You would be surprised, even in a state of escalation and yelling and threatening and calling you terrible names, they are listening to what you're saying. So it will come back. Doctor, you said that once I talk to you, I can go now. Why can't I go? Whoa. Now you're worried that they're certifiable. They're not going, so you're retracting. So be careful how you're engaging, what you're promising. Only promise. Things you can carry out. Such as I. We will get through this as quickly as possible so we can make a decision that's good for you and that we can help you as best as we can. So you're trying to engage. You're when people are agitated, they can't hear. It's a little sound bites. You know what it's like when you go to the doctor and everybody comes in with their questions because they know the minute they go out, they're going to forget everything you've said or even with a family doctor. If they're hearing something that is distressing, potentially, you forget because you're so aroused with emotions and affectively charged. So you have to speak in soundbites. You can't give a paragraph, you can't give double barrelled, you know, instructions or saying, do you feel this or do you feel that you have to actually say, I hear what you're saying, end of sentence.
Dr. Jodi Lofchy: [00:42:00] You're upset. And yes, I'm upset. Obviously, I'm upset. Okay. You've been waiting a long time. I see that. And and many of our patients, again, English is not the first language they have there. Substances may be impairing cognitive challenges. There's lots of reasons why we have to speak very simply, very succinctly, very clearly, and so that we are identifying accurately what's going on. And if we're wrong, someone's going to tell us, no, I'm not upset because I've been waiting. I'm upset because my kids were just taken away. I'm upset because, you know, I just lost my job. I haven't even told you why I'm upset. You're right. We haven't had a chance to sit down and talk. So can we do that? And you know, it's not about can we? Because then they might say no, so I'll take that back. Like, I'd like to be able to do that now. We'd like to be able to talk. It's not asking permission to do your job. You have to say, we need to hear what's going on so we can help you. Right. So the idea is limit setting, empathy, respect. There's a very, very good article from the Beta project Janet Richmond wrote on verbal de-escalation, and she's a very experienced emergency social worker who has written an excellent article on an approach to verbal de-escalation with sort of the ten domains. And that's something.
Dr. Lucy Chen: [00:43:19] Maybe we'll include that in the show notes.
Dr. Jodi Lofchy: [00:43:20] Yeah.
Dr. Lucy Chen: [00:43:23] So thank you. Dr.. So I think we the resident has now sort of attempted to validate, empathise, respect the patient as best they can, understand the circumstances and sort of work with the patient. But this patient's really still continuing to escalate and they're sort of emerging out of stage 1 to 2, progressing really into stage three. They punched a Wall.
Dr. Jodi Lofchy: [00:43:45] Okay, So now you're no longer verbal, now it's physical. When they get physical, we get physical. So now we're at overt aggression. Right. So I think what happens typically, though, people medicate to early because they haven't really gone through the verbal de-escalation. But I'm not saying you stay in there until it's not safe. You should be able to see it coming. Obviously, if you can't and I can speak from personal experience, having had an assault, significant assault where I didn't see it coming, somebody went from 0 to 100 who is very psychotic. There's times you may not. So you have to be comfortable protecting yourself and your team and getting out of the room quickly. Right. If it's property damage, you get out of the room, it's not you at that point. But that's when you start thinking about, okay, we're not we're beyond negotiation here. We need to intervene physically. So then you ask the questions about medication in terms of your choices at this point. And I think you don't need to know what's going on. We often our patients are new to us. We don't know their histories. It may be a first presentation, a first break. We haven't worked them up properly with what substances are on board, etc., etc. So we have to just kind of can use our skills of observation and the mental status findings we've found already to ask some pretty broad brush strokes about diagnosis.
Dr. Jodi Lofchy: [00:45:09] Is this person psychotic or not? What is our provisional diagnosis at this point in time? And are we looking at somebody who sort of, you know. Throws their pen or paper work down on the floor versus punches a hole in the wall. How severe is this agitation or has there been an assault? So is this mild agitation somebody starting to pace? They can't sit down, they can't listen to your instructions or has something very potentially dangerous happened. So that's going to help us both with medication choice in terms of what we're choosing as well as the dosing. If there are psychotic features, if they're known to have a psychotic illness, we may start with an antipsychotic and a benzodiazepine. If this person is has no psychotic illness, it may be only substance related or personality related, then we may be choosing to start with a benzo alone. Our choice of route will also be determined by the severity of the agitation. Somebody may actually say, Look, I'm feeling out of control. I need something. Okay, We agree. Would you like to take that by mouth or in a needle form? So there may be a point of negotiation where somebody can agree to take it sublingual. Often when you come up with them with a needle to them, they'll say, Whoa, I want that. I'll take it. I promise I'll take it by mouth.
Dr. Aarti Rana: [00:46:34] So you may be able to negotiate what route?
Dr. Jodi Lofchy: [00:46:36] There's a certain point when you can't where it's severe agitation, somebody is at risk, there's an assault, and you're giving an IM because we know it's the quickest onset of action and we can't wait for anything else to kick in. You asked in a question in terms of the earlier questions you distributed, but when we think about mechanical restraint and it fits in, my discussion here is that you would never sort of come in with an IM when somebody is still agitated, hitting walls. You do need to this is where your code white and you have enough people to actually get someone onto a stretcher and put them into mechanical restraints briefly to stabilise or immobilise before you give an IM, because we know that there's a high risk of the wrong limb being an injected if the patient isn't stabilised mechanically before, it doesn't mean they have to stay in physical or mechanical restraints in any kind of excessive way. And that's an important point. We're just doing it briefly to get the medication given in the safest way possible. So yeah, those are some of the concepts of medication. And in terms of I don't know, I don't think for the purposes of time, I don't know how specific you want me to be in terms of choices of of agents, but.
Dr. Lucy Chen: [00:47:56] Yeah, yeah, yeah, yeah, yeah. For sure, I guess. Finally, just to touch on the last topic, which is how we apply legislation when we have to pull out that form one when this person, this person certifiable.
Dr. Jodi Lofchy: [00:48:10] And that's a really important thing to think about at the end is about are they in the right place? I mean there's lots of violent patients who maybe shouldn't be. Well, I'm using the word patient, so that infers that there's something medical going on and that we have a role to play. But a violent individual is not always best served in a hospital setting. So the use of the form one is when we have concerns that there's an underlying possible mental disorder that's contributing to the risk and the agitation and the violence, that there's something psychiatric that we need to investigate further. We don't need to know for sure. We just have to have concerns and some observations in our interaction that there might be some psychiatric symptoms or mental status findings that would allow us to complete the form in a valid way, saying that there might be an illness that's contributing. So we would use the form one to complete a fuller assessment to actually make that conclusion about what's going on here and why is this person so agitated when they're threatening harm to themselves or others. But when we're witnessing that there's been agitation or aggression? And one of the aspects of the form, one I think is actually a really good box that you can check off is causing another individual to fear bodily harm. Nothing has to have happened but just your and again, I understand that subjective and we all have different thresholds for concern and anxiety based on many factors.
Dr. Jodi Lofchy: [00:49:45] But that doesn't matter if you are a physician completing that form. One Any M.D. who's fearing potential violence from this individual can complete the form one, and that would be the risk. And you would explain how you came to those concerns, but you would also have under the future test to explain why you think there might be an illness here that's contributing. So that would allow us up to 72 hours to figure out if there's something psychiatric or if this person remains at risk and requires a longer admission, either as a voluntary or involuntary patient. The other important aspect of the legalities of working with violent patients in the emergency department is our duty to inform, and that if we know that other people are at risk, if there's been threats made towards others outside the hospital or inside the hospital, what is our responsibility to alert the police or that individual? And we typically would inform the police if somebody is being released in the emergency setting, we're usually holding people and we would want to go back to your communication in writing, in our documentation, make sure we're clearly communicating with our inpatient colleagues that before the point of discharge, this risk needs to be reassessed and any other individual, if they remain at risk, there would be that duty to let the police know or the individual know about the risk that exists. So those are the two emergency aspects of the the forms and the legalities that we think about in the moment.
Dr. Aarti Rana: [00:51:21] And for context for our international listeners. In Ontario, which is a province in Canada, we have a mental health act. I feel like I'm an untested doctor. Lofchy Let's let's see how much I know we have a mental health act that allows us to hold to essentially hold people for a period of up to 72 hours for psychiatric assessment when they are exhibiting behaviour that's putting themselves or others at risk, a potentially or actually witnessed. And also they have to have some evidence of a psychiatric illness.
Dr. Jodi Lofchy: [00:51:53] And that's the third criteria. Just if you're educating our listeners from afar that that or that there's the evidence that they're at imminent risk for lack of self care, that they can't, they're putting themselves at risk because they're not able to care for themselves.
Dr. Aarti Rana: [00:52:07] And I want to highlight the aspect of there being some evidence of a psychiatric illness. That part I didn't actually really understand until I got to residency that there was a distinction between just putting oneself at risk for, say, because due to a medical condition. Right, Right. Versus a evidence of a psychiatric illness. And that's really an important criteria in the form. If we're not seeing evidence of a psychiatric illness, we can't actually employ the system.
Dr. Jodi Lofchy: [00:52:34] That's right. And that's what the point I made earlier about our legal system, that we have jails when people are homicidal, that they should be charged with uttering threats or with assault or whatever the actual violent indication is, if there's no evidence of anything psychiatric going on.
Dr. Lucy Chen: [00:52:52] So I think those are all our questions for today. Dr. Lofchy, We're very lucky to have. Had you on our show. I guess any lasting sort of impressions or sort of wisdom you'd like to impart on young learners, clerks, young residents in our program and and afar who are listening to this podcast episode right now?
Dr. Jodi Lofchy: [00:53:12] Well, I think the emergency setting is an exciting place to work, and I think young learners, trainees now are working in environments at the best time possible because you're getting education both as medical students, as residents about the importance to learn about how to assess and manage yourselves with agitated patients that the residents and even medical students are learning self-defence techniques to have physical ways of responding if threatened with assault or put in a dangerous situation. You're getting training that was never available before. So when we look at the stats and we look at the literature about resident assaults and that kind of thing, we need to revisit it because we are now we now have the educational programs in place and providing training that's lowering the risk. And those earlier statistics about residents, you know, maybe frontline people being more at risk, I think we have to think that those numbers are going down and that you're feeling more comfortable and confident to be able to have the tools that you require to work with all patients that you're going to encounter in the emergency department, that our hospitals are more sensitive to what we need in our settings, in the environments that we're designing for psychiatric patients are safer than ever. So I think it's an exciting time to be a trainee and it is exciting time to work in the emergency department. I've been doing this for decades and it never gets boring. It's always exciting. And and in fact, as I sign off, I'm heading down to the emergency department here to see what awaits. So I thank you for the opportunity just to share some of the experience I've had over the years.
Dr. Lucy Chen: [00:54:51] All right. Thanks a lot. All right, Stay Safe, folks, that's it for today.
Dr. Alex Raben: [00:54:56] Psych is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organisation. This episode is a part of our mini series on psychiatric skills, which are intended to provide you of residents with content directly related to the intractable professional activities or EPAs outlined by our program. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside. You will still find them entertaining and educational. This episode is produced in hosted by Aarti Rana and Lucy Chen. Audio Editing by Jordan Bawks. Our theme song is Working Solutions by All of Music. A special thanks to Dr. Jodi Lofchy for serving as our expert this episode. You can contact us at Info@PsychPodcast.com Or visit us at PsychEdPodcast.org Thank you so much for listening. Catch you next time.