Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Crisis
Crisis - Key Features
1. Take the necessary time to assist patients in crisis, as they often present unexpectedly.
Reassure that you are available to help. Commend them for seeking help and validate their experience. Establish rapport and use active-listening skills.
2. Identify your patient’s personal resources for support (e.g., family, friends) as part of your management of patients facing crisis.
3. Offer appropriate community resources (e.g., counselor) as part of your ongoing management of patients with a crisis.
4. Assess suicidality in patients facing crisis.
5. Use psychoactive medication rationally to assist patients in crisis.
6. Inquire about unhealthy coping methods (e.g., drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis.
7. Ask your patient if there are others needing help as a consequence of the crisis.
8. Negotiate a follow-up plan with patients facing crisis.
9. Be careful not to cross boundaries when treating patients in crisis (e.g., lending money, appointments outside regular hours).
10. Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
11. When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia),
a) Assess the environment for needed resources (people, material).
b) Be calm and methodical. c) Ask for the help you need.
Overview
a. Initial supportive assessment and safe environment, validate experience focus on rapport, open communication
b. Evaluate medical (nutrition, injury related pain) needs and then psychiatric care (suicide, homicide)
c. History taking: detailed history of events and previous traumatic events. Screen for comorbid depression and anxiety
d. Develop action plan: include emotional stability and personal feelings of control of situation, have list of resources (personal and community)
e. Follow-up to assess progress. Resources for support can include internal ones (e.g., exploration of effective coping mechanisms and constructive thinking patterns.)
Preparation
Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
Establish office policies for managing agitated/dangerous patients
Prepare for common emergencies encountered in the office setting (e.g. in general, asthma, anaphylaxis, shock, seizures, and cardiac arrest).
Purchase equipment / medications for anticipated emergencies
Familiarize all staff with equipment and local protocols
When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia):
- Assess the environment for needed resources (people, material).
- Assign roles / delegate
- Anticipate equipment needs.
Management
Be calm and methodical.
ABC’s, vitals, etc.
Reassess frequently
Communicate your assessments and thought process to team
Use closed-loop communication when giving orders
Ask for the help you need.
Offer appropriate community resources (e.g., counselor) as part of your ongoing management of patients with a crisis.
If mental and psychiatric statuses are not stable, this may include psychiatric referral, hospitalization, or involuntary commitment.
Enquire about unhealthy coping methods (e.g., drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis.
Ask your patient if there are others needing help as a consequence of the crisis.
Assess suicidality in patients facing crisis:
- See priority topic Suicide
- Thought of death, degree of intention, lethality of methods
- Availability of means (firearms)
- Prep attempts, nature, and family hex of suicide
- Response to crisis may be self-harming behaviors
Homicidality?
- Legally mandated duty to warn if there is a clear risk to identifiable person(s) that could cause serious and imminent harm.
Suspected child abuse?
- Statutory requirement to report to public authorities
Victim of abuse?
- Encourage them to remove themselves (and others) from dangerous situations.
"Medications:"
Use psychoactive medication rationally to assist patients in crisis.
Provide rx for physical pain or for sleep
Take into account previous medications and responses to medications in the past and comorbid illnesses
No evidence in acute setting 0-72hrs
Assessment of duration of crisis (once, cumulative or ongoing)
Goal of medication is to
- 1. Decrease symptoms of re-experiencing, avoidance/numbness or hyper-arousal
- 2. Help with comorbid illness
- 3. Reduce suicidal, impulsive and aggressive behavior
First Line:
- SSRI for 8-12 weeks, first week reduction in anger/irritability, 2-4wk for rx effect, fluoxetine has been studied, fluvoxamine may have better sleep related improvements
- TCA- some studies of effectiveness of amitriptyline in male combat veterans Benzodiazepines-help with anxiety and sleep, addictive potential
- Beta-blockers- propranolol acutely may reduce later symptoms of post-traumatic stress disorder
Follow-up
Reassess status/safety, reinforce positive efforts Immediacy should fit clinical scenario (seriousness of crisis, reliability of patient). Higher level of care indicated if failure to improve with current treatment.
"Things to Avoid"
Take care not to cross boundaries when treating patients in crisis
Exchanging gifts, services, and money may cause feelings of obligation or imply a dual relationship.
Appointments outside of regular hours (especially unchaperoned) are associated with additional boundary violations and cases of misconduct.
Excessive self-disclosure can strain rapport.
Physical contact (e.g. hugs, kisses, arm stroking, etc.) can be misinterpreted and blur relationship boundaries.