A Bridge Over Troubled Waters – part 2.
Here is the gripping conclusion to the Extreme Psych transport that we heard about from Dr Minh in PArt 1 of “A Bridge Over Troubled Waters?”
It is fair to say that Dr Minh and I have similar but slightly differing views on this difficult and hazardous topic. So here is Minh’s conclusion to the story and his appraoch on the transfer of agitated patients.
As always, Dr Minh’s references and talks are available at the bottom of the blog if you want to know more. Enjoy – over to Minh….
Hi folks. This is the second and final instalment to this case. Where did we leave off? Dilemma? What to do with this involuntary psychiatric patient , intubated in a island hospital without any ICU facilities for the next 8+hours?
There are only two real options. Leave him intubated whilst awaiting retrieval. Or extubate him and observe his behavior whilst awaiting retrieval. It was decided after some discussion to leave him intubated with the GP anaesthetist and nurse in the hospital operating theatre. ALL NIGHT!
Some of my retrieval colleagues have argued that it is riskier to extubate an agitated patient and then try to reintubate again. I admit there is some truth in that but I believe the patient should be given the benefit of the doubt and be allowed a period of observation before embarking on the decision to use intubation and anaesthesia as a form of chemical restraint. The zero tolerance approach to risk in this patient group is inappropriate and violates the legal and ethical principle of least restrictive means that underpins all mental health acts of Australia.
The story gets more complicated. The intubated patient now develops hypotension from presumed sepsis secondary to suspected pulmonary aspiration syndrome. I am not fully aware of all the clinical details that lead to this diagnosis but the patient was commenced on an adrenaline infusion which did correct the hypotension. He was transferred by RFDS the next day but due to more delays not until late in the afternoon. In the end the saga ended the next day after 40 hours of intubation, when the ICU doctor extubated the patient who happily went off to the mental health unit albeit with a sore and hoarse voice having no signs of pulmonary aspiration at all!
Since this unfortunate episode this same patient has been retrieved again in pretty much the same situation. It happened only 3 weeks ago and I spoke to the same treating psychiatrist about how it all went down this time. The difference this time was that we deliberately avoided intubation from the outset as a method of restraint and oral sedation was emphasized at the beginning of the retrieval process. The retrieval team used IV ketamine sedation to good effect and he was happily dropped off to the Cairns Emergency Department as opposed to the ICU!
Primum non nocere, folks!
Dr Minh Le Cong, RFDS Qld
Thanks Minh. This case gets to the crux of the issue with sedation / transfer of severely agitated patients. Timing is everything! If you are the ground Doc, trying to control a dangerous situation you need to know when transfer is likely to occur in order to plan a rational sedation regime. eg, if the plane is landing in an hour or two – sure try some K and see what happens – Minh’s data suggests it is a winner often. However, if the RFDS say they are coming sometime this week… it is tricky, one cannot plan an open-ended sedation regime and leave an aggressive patient either aroused or heavily sedated for more than a few hours without running the risk of either staff being injured or the patient suffering a bad outcome, such as aspiration etc.
So my solution – we need to communicate better and stop making Psych transfer a lower priority than its medical cousins. This may be controversial but I would rather look after the non-STEMI for another day in a small hospital than the Psych guy on heavy sedation.
If I know roughly an ETA for transfer from the time I first assess a Psych patient who needs transfer I think we can come up with a rational sedation package based on the patient’s medical / anaesthetic risk and the safety factors. If you have no time scale – then you end up either giving too much or not enough or inappropriate sedation – and get into trouble.
Communication is KING, we need to talk and stay in touch to know when these often volatile situations change.
Here is my pet suspicion – the reason some folks intubate in this scenario – it forces the flight crew to come sooner, and makes the patient “a medical” transfer thereby shifting the burden / resource to the flight crew. Is this ideal – no, but in small hospitals a single agitated patient can use up all the spare resources quickly.
As Minh says – we need to use the least restrictive / invasive approach, however as the boss on the ground we also have a duty to provide safety for the staff and the patient. Sedation and intubation will remain in the mix, hopefully Minh’s research will give us another “arrow in the quiver” before we reach that point.