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srk

alcohol on medical wards

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Hi there,

Everytime iam on call I get called to see agressive patient on a medical ward. and it turns out that the pt is alcohol dependent,the medics insist that the pt is medically fit.( the recent bloods show raised lfts, no signs of infection though). anybody has any thoughts how to deal with this situation where you feel that you are bullied to take the patient over just because he has been aggrssive?

thanks.

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Unless they have a psychiatric illness, if they are medically fit then they should be discharged, or the police should be called to arrest them if the aggression continues.

What is it that the medics are wanting you to do with these referrals?

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i think you need to clarify if they are aggressive because they are intoxicated...which should hopefully not be the case if they have been on the ward for a bit...if this is the case, risk assessment and there should be a hospital policy for dealing with aggressive patients...OR...are they in withdrawal because they have been on the ward for a few days and not been topping themselves up...a good history is necessary as alcohol withdrawal can be dangerous due to possible seizures, DTs etc...if this is the case, then there is strong argument that this be managed jointly on the medical ward...if this is happening...there needs to be formal education and working links set up...at the end of the day, when it feels like everyone is at you and dumping on you...try to focus on the needs of the patient...what is the best care for them

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Unless they have a psychiatric illness, if they are medically fit then they should be discharged, or the police should be called to arrest them if the aggression continues.

What is it that the medics are wanting you to do with these referrals?

I totally agree...

I suggest you go with a breathalyser (it is available in most psychiatric inpatient wards) and record...  if the patient is drunk, ask them to call the police...

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Alcohol intoxication or alcohol withdrawal is always clinical diagnosis and breath analyser has no role. Obviously you can substantiate your finding with breath analyser. If it is alcohol withdrawal ( including DT) or alcohol intoxication, It is best patient be under the care of medics.

When referred some aggressive patients, we need to rule out mental illness i.e. patient behaviour is not due to hallucination, delusion, mania or depression.

We need to be very clear that the patients are not admitted for emergency detoxification in Psychiatric ward. It is done only in medical ward, and in most of the times, even medics well aware of the fact and they are just bellying you.

You should give your help in managing aggressive and confused patients such as nursing in quite room, well lit room, familiar staff, managing risk such as jumping and throwing things around and more importantly, rapid tranquilisation protocol. Medics can sometime really dangerous in giving combination or haloperidol, lorazepam and Olanzapine altogether so that occasionally patient get more confused.

Always rule out Korsokoff’s and Wernickes encephalopathy. Prescribe Thiamine and Vitamin.

Always include close observation in the management plan (possibly with a RMN). It is the responsibility of the medical ward manager to book a RMN. There is a possibility they bully you in saying to arrange for RMN.

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I'd have to disagree that diagnosis is always a clinical one. How can you be certain that they are intoxicated with alcohol purely by clinical picture, especially if uncooperative or refusing to give a history? How can you be sure that it is not due to intoxication with other substances or a delirium? Given the ease of use of breathalysers and of urine toxicology testing I am not sure why you wouldn't first confirm what you are dealing with, before giving advice on management.

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Unless they have a psychiatric illness, if they are medically fit then they should be discharged, or the police should be called to arrest them if the aggression continues.

What is it that the medics are wanting you to do with these referrals?

I totally agree...

I suggest you go with a breathalyser (it is available in most psychiatric inpatient wards) and record... if the patient is drunk, ask them to call the police...

I have discharged Sec 136 in the past with clear advise to the police to arrest if they feel appropriate, till the peson is sober. Of course it is easier ina section assessment than in a referral from the medics!!! ;)

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I had an interesting discussion with a friend. He's a medical str somewhere near newcastle, and was venting out his frustration at the 'unhelpful' psy SHO whom he'ld called.

Fraom my experience, liaison work often boils down in someone talking to the patient and to the irate staff without showing countertransference. We need to understand that as the psy on call, sometimes all we need to do is liaise, and contain the anxiety of the med sho, who probably has a ward full of psychologically disabled staff on his / her back!

If nothing else works, even if u go and assess the patient and come back, that helps.

But before that, it might be helpful to think that while they are asking you to come and assess, they probably only need to be told that -

- if intoxicated, you could not do a MSA anyway.

- if it's mental illness + alcohol, the medical reasons for being admitted to the ward have to be prioritised.

- if they want you to come and section the patient, unless they want u to make the section using an axe, a section would have to be done by the RMO of the patient or their nominee. Familiarize yourself with your local policy: in some hospitals, it would not be permissable to do a section in a medical ward as you come from a different trust! Most SHO would only be able to do a Section 5[2], and would that be helpful in managing the patient??

- are they actually asking about what medication the patient can be given in order to tranquillize him?

- are they calling you because the patient is probably pulling out his catheter / iv line every other minute and the SHO is getting pissed off? In which case is reinserting that line every minute really that necessary, or can it wait. If it's that critical - have they considered using the common law?

- yes he might be schizophrenic on a coctail of antispsychotics. Does that necessarily mean he does not have capacity to refuse a certain treatment, or cannot take responsibility for his actions?

- try to use the 'will not assess until medically cleared[tm]' explanation when everyhting elwe fails.

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I was recently in the section 12 course and were clearly told that the responsibility of detaining a patient on the medical ward is on the RMO who woul dbe the consultant on the medical ward and that this is a NON DELEGATABLE job ie that this job cannot be nominated to a deputy.

The other offshoot of the above discussion is the issue of capacity. If our chap who is an alcoholic admitted on the medical as he had gone yellow with a raised bilirubin is recieving medical treatment and during the course of this decides to suddenly take his own discharge when he is clearly not medically fit. To add to the confusion, he suffers from a mental illness and in the process of the assessment has a mental illness; what is the plan of action??

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