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Managing and medicating the psychotic patient
the second Orange County study, which is as yet unpublished. In any event, in using this illustration he restates my point exactly. That is, we must take avery close look at any data before making our commitments. After all, how can we commit strained resources to a problem we have not yet defined? When we develop data, coroners' records alone simply are not reliable enough to formulate plans. I am certain that in some counties a detailed and analytical coroner's report is the norm; i n others it is the exception. The clinical record is the only reliable document by which we can judge trauma care, or medical care of any kind. Until these kinds of data are forthcoming the medical community is unlikely to accept any conclusions, and the cooperation of the medical community is essential in the implementation of any trauma plan. Dr. Trunkey's third point leaves me in even greater confusion. He has mixed up the cost of maintenance of trauma centers with the suggestion that the author would prefer to let trauma victims die since it is much cheaper that way. I can agree on only one point: it is Certainly much cheaper to let people die. However, both Dr. Trunkey and I have dedicated our entire professional careers to saving lives, not burying patients. Hence his inflammatory implication makes my point exactly. That is, evangelical fervor is no substitute for careful planning. Dr. Trunkey's conclusions regarding West Germany are impressive. Unfortunately, like the iceberg, seven-eighths of the problem is beneath the surface. In point of fact, between 1970 and 1980 West Germany for the first time imposed a motor vehicle speed limit on principal (non-Autobahn) highways, and required for the first time passive restraint devices for automobiles. At the same t i m e West Germany was enjoying its new prosperity, and the population was driving bigger and safer cars; Finally, in the period described West Germany was the 0nly developed nation in the world to experience an absolute numerical population drop. Consequently, the residual population was predictably older and perhaps saner in its driving habits. Obviously the cause for the drop in highway fatalities was multifactorial, and orga-
nized trauma care can take only limited credit for these dramatic results. I enter a plea that we use our data honorably. "Stay Alive at 55" has been our watchword since 1973. During the period from 1970 tO 1980 the number of licensed drivers in the United States increased from 111,000,000 to I46,000,000. A t the same time the number of highway fatalities dropped from 52,627 to 51,077. This translates to a fall from 47.4 highway fatalities per 100,000 licensed drivers in 1970 to 35 fatalities per 100,000 licensed drivers in 1980, for an overall reduction of 26%. One can hardly conclude that trauma centers in the United States account for this dramatic fall in fatalities. The final paragraph of Dr. Trunkey's commentary is fascinating: "Failure to implement effective local and regional systems of care is widely recognized due to local economic and political self-interest . . . . " I am not so sure that there are any such "failures," nor is there any "widely recognized local and political self-interest . . . . " I n fact, I can't think of a statement better calculated to provoke resentment among physicians who have heretofore dedicated a substantial portion of their practices to the care of patient s Dr. Trunkey describes. In short, I believe Dr. Trunkey has totally misread the conscience of physicians in America. He manages a trauma system with a single receiving hospital covering a relatively small geographic area. Other physicians (myself included) deal in catchment areas of hundreds of square miles with several highly qualified hospitals. Our problems are not so simple, particularly in view of the diversity of needs , circumstances, and resources of every community. My message is the same. Organize your medical community, take the.time and effort necessary to measure your data alongside national statistics, and draw your own conclusions. Then, aggressively attack your local trauma problem with data in hand. Improved trauma care i s mandatory when data indicate the trauma victims are n o t provided with every possible chance for survival. Roland B. Clark, MD San Diego
Managing and Medicating the Psychotic Patient To the Editor: Dr. Dubin's evaluation and management of violent patients (,10:481-484, September 1981)was informative and thorough. EVery persofl needs to develop his own strategy for dealing with the potentially violent patient. I have found some Of the following suggestions helpfuI in dealing with violence in the emergency department. While the interviewer should be closer to the door than the patient, it is less threatening if the interviewer is not between the patient and the door. By interviewing from a Position midway between the door and the patient, but not on a direct lIne of sight, with the door ajar, rarely will the patient feel trapped. Body language speaks louder than words; a well-practiced, non-threatening posture can cool off the patient. When the physician deliberately slouches and keeps his hands in the 11:5 May 1982
pockets of a long white coat, the patient will not expect any harm. Traditionally, doctors never scuffle with patients, and so must not become involyed with t h e restraining procedure should it become necessary, although clearly executing the order to do so. In defusing the already violent patient, logic should not be used; rarely is the patient in sufficient control to understand an appeal to reason. Instead, seemingly ridiculous questions will often take a patient by surprise and cause him to hesitate. At this point the interviewer has the patient's attention, and can attempt the talk-down. Acknowledging one's own fear is essential; machismo has no place in managing the violent patient. Informing a patient that you are scared of him allows him to realize, often for the first time, that he is being perceived as threat-
Annals of EmergencyMedicine
283/9:1
CORRESPONDENCE
ening by the staff. Again, a seemingly innocent question, "You aren't going to hurt me are you?" will help the patient know what the interviewer is feeling. The patient may respond by asking if the interviewer is going to hurt him, allowing the staff to realize how frightened the patient has become. The rule of "three-big-men" should be utilized in managIng the threatening male patient. Even psychotic men realize the likely outcome of an encounter with three big men, and Will usually calm down. Women, however, do not universally respond to this approach, and even a small woman may take on a room full of security guards. One must demand that security send three big men if the rule is to be invoked. As each antipsychotic has its own spectrum of side effects, the choice of any one over the others may be impor-
rant. It is helpful to note that low-potency antipsychotics are more likely to cause hypotension than are higherpotency medications. Conversely, the higher-potency agents cause more extrapyramidal symptoms. This being the case, rapid tranquilization with Thorazine ® provides a greater margin of safety for the staff, as the patient often is posturally hypotensive, and therefore cannot get out of bed to attack. Extrapyramidal symptoms such as cogwheel rigidity will make throwing a punch very difficult under the influence of a high-potency medication.
B. Eliot Cole, MD Department of Psychiatry Bowman Gray School of Medicine Winston-Salem, North Carolina
Author's Reply In general I agree with all of Dr. Cole's points, except for his last statement concerning the use of antipsychotic medications. I strongly disagree with his assertion that "rapid tranquilization with Thorazine ® provides a greater margin of safety for the staff as the patient often is posturally hypotensive . . . . " In my opinion, the concept of rendering a patient hypotensive so that he cannot get out of bed and attack staff is clinically unsound. Many patients that require rapid tranquilization are delirious or intoxicated with drugs and/or alcohol. Thorazine ® has very strong anticholinergic action and is one of the most sedating of the antipsychotic drugs. In drug and alcohol intoxication, these side effects can be potentiated and could worsen the patient's clinical problem. FurthermOre, it would seem to be most undesirable to sedate and/or render hypotensive a patient with a eVA, a subdural, a myocardial infarction, and a number of other medical illnesses which frequently present in an emergency department with a predominance of psychiatric symptoms.
In a busy emergency department, there may be several patients who are too sedated and/or too hypotensive to move, and therefore create a bottleneck which impedes clinical care.
I feel that optima] patient care occurs when the patient's anxiety, uncooperativeness, and agitation can be minimized by rapid tranquilization, without preventing the patient from being able to participate and cooperate in his evaluation and treatment. Therefore, I believe that a high potency neuroleptic, such as Navane ~, is still the first drug of choice. The high-potency drugs may cause extrapyramidal symptoms (though in a current study we have seen no EPS with Navane ® in rapid tranquilization). EPS symptoms are much less problematic than hypotension and much more readily treatable.
William R. Dubin, MD Assistant Professor of Psychiatry Jefferson Medical College Philadelphia
Orthostatic Tachycardia and Ectopic Pregnancy To the Editor: Two women recently came to our emergency department with severe abdominal pain from ruptured ectopic pregnancies. Both were pale and hypotensive and had more than a liter of intraperitoneal blood on laparotomy, but neither had tachycardia. Both had pulse rates in the 70 to 100 range during repeated observations. Neither patient was on any beta blocking medications, nor did either have an unusually slow resting pulse or any evidence of SA or AV nodal disease after recovery. We ordinarily rely on resting or orthostatic tachycardia as the most sensitive clinical indicator of hypovolemia, 1 but I wonder if the visceral irritation of the expanding tubal pregnancies in these patients produced a vagal reflex which blunted the usual sympathetic tachycardia. Absent tachy92/284
cardia in hypovolemic patients with heart disease, autonomic dysfunction, or beta blocking medications is no surprise, but surgeons and obstetricians I have asked are not acquainted with such a phenomenon with ruptured ectopic pregnancies or other conditions. I wonder if other readers have seen similar patients or defined other settings in which tachycardia is a less:than-usually-reliable indicator of hypovolemia.
Thomas Stair, MD Emergency Department Georgetown University Hospital Washington DC 1. Knopp R, Claypool R, Leonardi D: Use of the tilt test in measuring acute blood loss. Ann Emerg Med 9:29-32, 1980.
Annals of Emergency Medicine
11:5 May 1982
nized trauma care can take only limited credit for these dramatic results. I enter a plea that we use our data honorably. "Stay Alive at 55" has been our watchword since 1973. During the period from 1970 tO 1980 the number of licensed drivers in the United States increased from 111,000,000 to I46,000,000. A t the same time the number of highway fatalities dropped from 52,627 to 51,077. This translates to a fall from 47.4 highway fatalities per 100,000 licensed drivers in 1970 to 35 fatalities per 100,000 licensed drivers in 1980, for an overall reduction of 26%. One can hardly conclude that trauma centers in the United States account for this dramatic fall in fatalities. The final paragraph of Dr. Trunkey's commentary is fascinating: "Failure to implement effective local and regional systems of care is widely recognized due to local economic and political self-interest . . . . " I am not so sure that there are any such "failures," nor is there any "widely recognized local and political self-interest . . . . " I n fact, I can't think of a statement better calculated to provoke resentment among physicians who have heretofore dedicated a substantial portion of their practices to the care of patient s Dr. Trunkey describes. In short, I believe Dr. Trunkey has totally misread the conscience of physicians in America. He manages a trauma system with a single receiving hospital covering a relatively small geographic area. Other physicians (myself included) deal in catchment areas of hundreds of square miles with several highly qualified hospitals. Our problems are not so simple, particularly in view of the diversity of needs , circumstances, and resources of every community. My message is the same. Organize your medical community, take the.time and effort necessary to measure your data alongside national statistics, and draw your own conclusions. Then, aggressively attack your local trauma problem with data in hand. Improved trauma care i s mandatory when data indicate the trauma victims are n o t provided with every possible chance for survival. Roland B. Clark, MD San Diego
Managing and Medicating the Psychotic Patient To the Editor: Dr. Dubin's evaluation and management of violent patients (,10:481-484, September 1981)was informative and thorough. EVery persofl needs to develop his own strategy for dealing with the potentially violent patient. I have found some Of the following suggestions helpfuI in dealing with violence in the emergency department. While the interviewer should be closer to the door than the patient, it is less threatening if the interviewer is not between the patient and the door. By interviewing from a Position midway between the door and the patient, but not on a direct lIne of sight, with the door ajar, rarely will the patient feel trapped. Body language speaks louder than words; a well-practiced, non-threatening posture can cool off the patient. When the physician deliberately slouches and keeps his hands in the 11:5 May 1982
pockets of a long white coat, the patient will not expect any harm. Traditionally, doctors never scuffle with patients, and so must not become involyed with t h e restraining procedure should it become necessary, although clearly executing the order to do so. In defusing the already violent patient, logic should not be used; rarely is the patient in sufficient control to understand an appeal to reason. Instead, seemingly ridiculous questions will often take a patient by surprise and cause him to hesitate. At this point the interviewer has the patient's attention, and can attempt the talk-down. Acknowledging one's own fear is essential; machismo has no place in managing the violent patient. Informing a patient that you are scared of him allows him to realize, often for the first time, that he is being perceived as threat-
Annals of EmergencyMedicine
283/9:1
CORRESPONDENCE
ening by the staff. Again, a seemingly innocent question, "You aren't going to hurt me are you?" will help the patient know what the interviewer is feeling. The patient may respond by asking if the interviewer is going to hurt him, allowing the staff to realize how frightened the patient has become. The rule of "three-big-men" should be utilized in managIng the threatening male patient. Even psychotic men realize the likely outcome of an encounter with three big men, and Will usually calm down. Women, however, do not universally respond to this approach, and even a small woman may take on a room full of security guards. One must demand that security send three big men if the rule is to be invoked. As each antipsychotic has its own spectrum of side effects, the choice of any one over the others may be impor-
rant. It is helpful to note that low-potency antipsychotics are more likely to cause hypotension than are higherpotency medications. Conversely, the higher-potency agents cause more extrapyramidal symptoms. This being the case, rapid tranquilization with Thorazine ® provides a greater margin of safety for the staff, as the patient often is posturally hypotensive, and therefore cannot get out of bed to attack. Extrapyramidal symptoms such as cogwheel rigidity will make throwing a punch very difficult under the influence of a high-potency medication.
B. Eliot Cole, MD Department of Psychiatry Bowman Gray School of Medicine Winston-Salem, North Carolina
Author's Reply In general I agree with all of Dr. Cole's points, except for his last statement concerning the use of antipsychotic medications. I strongly disagree with his assertion that "rapid tranquilization with Thorazine ® provides a greater margin of safety for the staff as the patient often is posturally hypotensive . . . . " In my opinion, the concept of rendering a patient hypotensive so that he cannot get out of bed and attack staff is clinically unsound. Many patients that require rapid tranquilization are delirious or intoxicated with drugs and/or alcohol. Thorazine ® has very strong anticholinergic action and is one of the most sedating of the antipsychotic drugs. In drug and alcohol intoxication, these side effects can be potentiated and could worsen the patient's clinical problem. FurthermOre, it would seem to be most undesirable to sedate and/or render hypotensive a patient with a eVA, a subdural, a myocardial infarction, and a number of other medical illnesses which frequently present in an emergency department with a predominance of psychiatric symptoms.
In a busy emergency department, there may be several patients who are too sedated and/or too hypotensive to move, and therefore create a bottleneck which impedes clinical care.
I feel that optima] patient care occurs when the patient's anxiety, uncooperativeness, and agitation can be minimized by rapid tranquilization, without preventing the patient from being able to participate and cooperate in his evaluation and treatment. Therefore, I believe that a high potency neuroleptic, such as Navane ~, is still the first drug of choice. The high-potency drugs may cause extrapyramidal symptoms (though in a current study we have seen no EPS with Navane ® in rapid tranquilization). EPS symptoms are much less problematic than hypotension and much more readily treatable.
William R. Dubin, MD Assistant Professor of Psychiatry Jefferson Medical College Philadelphia
Orthostatic Tachycardia and Ectopic Pregnancy To the Editor: Two women recently came to our emergency department with severe abdominal pain from ruptured ectopic pregnancies. Both were pale and hypotensive and had more than a liter of intraperitoneal blood on laparotomy, but neither had tachycardia. Both had pulse rates in the 70 to 100 range during repeated observations. Neither patient was on any beta blocking medications, nor did either have an unusually slow resting pulse or any evidence of SA or AV nodal disease after recovery. We ordinarily rely on resting or orthostatic tachycardia as the most sensitive clinical indicator of hypovolemia, 1 but I wonder if the visceral irritation of the expanding tubal pregnancies in these patients produced a vagal reflex which blunted the usual sympathetic tachycardia. Absent tachy92/284
cardia in hypovolemic patients with heart disease, autonomic dysfunction, or beta blocking medications is no surprise, but surgeons and obstetricians I have asked are not acquainted with such a phenomenon with ruptured ectopic pregnancies or other conditions. I wonder if other readers have seen similar patients or defined other settings in which tachycardia is a less:than-usually-reliable indicator of hypovolemia.
Thomas Stair, MD Emergency Department Georgetown University Hospital Washington DC 1. Knopp R, Claypool R, Leonardi D: Use of the tilt test in measuring acute blood loss. Ann Emerg Med 9:29-32, 1980.
Annals of Emergency Medicine
11:5 May 1982