Clinical Case 011: Psych Transfer in extremis
June 2, 2011
This is a true case that occurred in NW WA over a few years and highlights lots of areas of error. However, I think it is a good “worst case scenario” to illustrate the difficulty we face in sedation in Psychiatric patients here in remote Australia.
We will call the patient Mr Rex, 38 yo Pilbara resident.
•Psych history:
–Diagnosed @ 25 yo with “maniform psychosis”
–Readmitted to Graylands at 26 with amphetamine-induced psychosis. Dx: bipolar affective disorder
–Managed as outpatient on Olanzapine with variable compliance
•Medical History:
–Morbid obesity – wt ~ 150 kg / BMI 52.
–Severe obstructive sleep apneoa, could not afford / tolerate CPAP machine
–Heavy smoker with chronic lung disease / ?asthma
–Heavy Alcohol intake
–Gastro-oesophageal reflux – untreated
–Hypertension – no treatment
–Intermittent amphetamine use
–No other regular medications
•Social History:
–Living in a small mining town with defacto partner
–Extended family live in SW WA
My first encounter with Mr Rex….
•Arrived @ Karratha ED for my night shift
–Parking outside = 2x police cars, 1 ambulance, 1 x fire-engine
–Inside – 1 x very large man snoring loudly
– 1 x large police officer with deformed humerus – broken in struggle to remove him from the wagon
–a gang of confused volunteer fire officers, Mr Rex smashed an alarm button in the flurry of wrestling in ED
•Mr Rex was sedated using a combination of midazolam, clonazepam and diazepam by various routes over the first hour in ED
–Admitted under Mental Health Act and RFDS alerted, advised a prolonged time to transport, therefore moved to a ward bed “near nurse’s station”
•Later that night – increasing agitation despite benzos, therefore given a dose of IM haloperidol just prior to nurse handover.
•SMO walked past and noted hypoxia on SpO2 monitor, then cardiac pause – precordial thump, then CPR
•Called duty Anaesthetist – Mr Rex “surprisingly easily” intubated but had clearly aspirated.
•RFDS alerted – flew to Royal Perth ICU overnight
•30 day admission – slow to wean off ventilator, required tracheostomy
•Discharged to Graylands (Psych hospital in Perth)
•Returned to Pilbara on CTO.
The following are excerpts from a letter to the Pilbara Hospital from the RFDS following this transport.
•Please be aware that the patient poses a significant transport problem and should probably not be transported by RFDS by air for acute mental health problems (unless he has arrested or been intubated for medical problems.) Any transport attempt will result in a dilemma of either excellent sedation with Olanzapine and midazolam resulting in no airway OR no sedation, a good airway but a combative large individual.
•Discussion with specialist anaesthetists and Chief Psychiatrist came to the conclusion that it was inappropriate to consider intubation for air transport and that he posed too great a risk to fly unsedated or sedated but unintubated.
So about a month after discharge…
•Mr. Rex went on another amphetamine bender resulting in psychosis:
•Symptoms: increasing insomnia, pouring drinks on his head, urinating in the house, dropping lit cigarettes indoors, stealing money from friends, walking around front yard naked, using chainsaw to threaten neighbours, set fire to fence and pouring petrol over his head at service station.
•Not complying with his CTO / medications
•Decision was taken to transport Mr Rex, by road to Perth, 1600 km over 18 hours…
–2 Police officers in a “paddy wagon”
–1 nurse
–3 stages – in 3 days
–Staying in similar regional hospitals en route
–Arrived at Graylands safely
•Was this a success?
–Least restrictive?
–Best use of resources?
–Safe?
So now skip forward 2 years…
Mr Rex was ‘on holidays’ in Broome, Police called to McDs where he was creating a scene at 04:00
Told Police he had torched his car outside of town and walked into Broome
•No shoes or shirt. Taken to the local ED by Police
•Advised ED staff he had been in Graylands and had sleep apnoea
•Pressured speech, pacing in ED, attempted to approach another unconscious patient
•Police assisted in getting him back to his bed and had IV sited, threatened with Taser
•Placed under the Mental Health Act – for transport etc
Info sought from Pilbara Hospital, the following info was faxed : “allergic to Haloperidol” “Laryngeal spasm”
•Given IV midazolam + 20 mg oral olanzapine
•Settled and was monitored 2:1 nurse
•Continuous oximetry showed variable low 90’s readings, though he responded to verbal stimulation
•Took deep breaths to command
•At 06:55 – 3 mg IV midazolam
•DMO also ordered IV esomeprazole for aspiration risk
•Nurses noted him to be cyanotic at 07:05, Unresponsive – CPR commenced, adrenaline etc
•30 mins of bag-mask / LMA ventilation – unsucessful, declared dead.
•No shoes or shirt. Taken to the local ED by Police
•Advised ED staff he had been in Graylands and had sleep apnoea
•Pressured speech, pacing in ED, attempted to approach another unconscious patient
•Police assisted in getting him back to his bed and had IV sited, threatened with Taser
•Placed under the Mental Health Act – for transport etc
Info sought from Pilbara Hospital, the following info was faxed : “allergic to Haloperidol” “Laryngeal spasm”
•Given IV midazolam + 20 mg oral olanzapine
•Settled and was monitored 2:1 nurse
•Continuous oximetry showed variable low 90’s readings, though he responded to verbal stimulation
•Took deep breaths to command
•At 06:55 – 3 mg IV midazolam
•DMO also ordered IV esomeprazole for aspiration risk
•Nurses noted him to be cyanotic at 07:05, Unresponsive – CPR commenced, adrenaline etc
•30 mins of bag-mask / LMA ventilation – unsucessful, declared dead.
Duty Anaesthetic DMO arrived as he was eventually called – noted he had a Grade 1 laryngeal view
Now this case is clearly tragic – an extremely sad mix of medical errors. I put it up so that we can see the “worst case scenario” and contemplate how we would all deal with such a challenging situation. I hope to generate a bit of debate.
Coming soon a post which I hope will answer some of the questions posed by Mr Rex… comments please!
Clinical Case 061: Colle’s sans Xray
Clinical Case 037: finding fevers’ focus
Ectopic pregnancy – HCG hiccups, some older evidence
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
4 Comments
A very sad but interesting case. I think there are a couple of perspectives that you can look at this from; 1) The management of the complex comorbid psychiatric and medically ill patient. 2) The management of the difficult patient who specialists dislike and don’t wish to get involved with.
In terms of #1 it sounds like there may have been incomplete information at the time of treatment as is common with the psychiatric patient. Certainly there are alternative de-escalation strategies that could be used if the history of hypoxic arrest in response to sedation were known.
In terms of #2 this is a constant issue. Difficult patients present hard thankless work to our specialists and getting them involved is often difficult. A patient with organically caused delerium requiring large doses of benzodiazipine will invariably be on a monitor and admitted to an ICU, while a patient with a psychiatric or substance abuse diagnosis requiring the same meds will often be found in a quiet room or even a locked seclusion room. Whether it is a patient with florid delerium tremens, or psychosis comorbid with a serious medical condition often the patient is not the problem of anyone but the emergency department (no one will transport them, no one will accept them, they are someone elses problem-‘get their medical condition cleared’, ‘get their psych condition cleared’).
I think it is very helpful to always think that these are high risk patients, who provide incomplete history and who have a great capacity for premature death. I find that helpful when I am being cursed out by a manic patient, possibly also septic, meningitic, etc. Though my insistence on aggressive monitoring and management wins me no friends, particularly when suspicions are not borne out.
Dr. J
Thanks Dr J. I know what you mean. One of the best aspects of being a Broome Doc is the absence of “departmentalism” – basically one covers all the patients, so the florid DT and the aggressive schizophrenic all come under the same banner and get equal treatment in my shop! This does require us to break with the big hospital traditions of “somebody else’s problem” and the “buff and turf”.
Working in a small hospital – you come to realise that buffing is the same as delaying – you could do the easy thing now, or turf it to someone else – but then, I am the Anaesthetic guy that has to sort it out when it all goes pear-shaped. So better to anticipate problems and deal with them rather than avoid and delay!
Oh, and wen it comes to mortality – in my part of the world – psychosis and mental health are just as bigger killers as ACS or sepsis. In my mind this means that these patient’s get priority treatment and ideally the Aeromedical team should feel the same way?
Thanks Casey for sharing the case. It certainly highlights the dangers of sedation in the agitated mental health patient in remote locations. Regarding the issues of urgent aeromedical transport I tend to agree that if it is unsafe to leave a remote patient where they are, its better to plan and send a full retrieval response for an early assessment with the capacity to provide procedural sedation and/or general anaesthesia with tracheal intubation.
In general the aeromedical teaching is to delay an air transport of an acutely agitated patient for several days if need be to allow regular sedation to work and more complete assessment to occur. Certainly REGA international Swiss retrieval service do international retrievals of psychiatric patients and that is their experience as to a best approach.
IN remote Australia, as you and I have discovered, there is no Best practice approach to this patient group and no one has come up with any decent published data or research to support what is the best approach. Lots of people think they have the correct approach but are not willing to publish it. For example, with intubation, no service is willing to publish the advice that this is a standard recommendation for this patient group in air transport. My service for a few years did have such a published guideline but I had that reversed 12 months ago when we revised the protocols.
This case you have presented bears some similarities with a case presented by Dr Bowie of Christchurch ICU at the 2010 Aeromedical society scientific meeting. Please review his talk at
http://www.isas.org.au/img.ashx?f=f&p=christchurch_2010%2fExtreme+Psychiatric+Patient+-+David+Bowie.pdf
Hi again, Casey and forum
I wanted to comment on the road transfer of this patient on the second occasion. Clearly this was a safer approach. Why? Because it avoided the dangers of rapid sedation and the risks in the back of an aircraft. Adequate security was utilised and there was no need to rush the process. Was it textbook perfect? Well no because it tied up a lot of resources for 3 days. Is it a sustainable strategy for this patient in future exarcebations? Its uncertain really? How many 1600km road transfers are you going to do before you realise this is getting too costly and resource intensive? And there are still dangers..I recall a prisoner death in the back of a transport vehicle in north WA only a few years back.
So why did it go pear shaped on the third and fatal occasion for this patient? Why did he get brought in at 0400 by police , alive and at 0705 he is dead after midazolam was given?
Sadly this is not the first time something like this has happened in Australia. It even happened in a big tertiary hospital ED in Brisbane.. refer to coroners report for 2005 Adam Fernandez
http://www.courts.qld.gov.au/Fernandez_Adam.pdf
I would suggest a couple of things to improve safety in these high risk sedation patients. As Casey has pointed out in his SAFE sedation risk matrix, it might be better to keep police at the bedside and keep the physical security element at a high level. Secondly, you should sedate these obese patients in a sitting up position to maximise respiration and monitor their ETCO2 noninvasively. You can assemble a non invasive ETCO2 mask system if you have an inline ETCO2 detector providing waveform capnography for ETT. We do it all the time with our ketamine sedations and it works fine. A consistently low ETCO2 reading and waveform or a consistently high ETCO2 or rise in the level are markers of early respiratory depression and risk for significant hypoxia, well before SAO2.
SO in this case knowing what his ETCO2 was at prior to giving that IV 3mg midazolam bolus might have helped adjust the dose or timing of it, if for example the ETCO2 was 60. IF you don’t trust the ETCO2 you can always draw a venous blood gas from his IV for a pCO2 reading.
Also what sedation level was being targeted for this patient? THis is an area of sedation management that we should really be trying to improve. In the protocols I wrote, the RASS scoring system was chosen. You can even just use GCS if you want, although that is not validated for sedation of patients. Point is we should target a safe range and try to stick to that.
And probably in these high risk sedation patients, IV sedation should be carried out by an anaesthetic trained doctor present along with an airway assistant. YOu could just try to continue with oral sedation which is safer for general trained nurses to administer but the principle should be that no IV sedation is given unless there are two providers present who can rescue the patient from oversedation..in other words IV sedation should be done by two people not solo.