Had a difficult case today, and I'm not sure how I should have handled it.
I (emerg doc, midsize community hospital) had a 40 something year old man who came to the ED complaining of homicidal and suicidal ideation. He said he had auditory, visual command hallucinations telling him to kill himself and others. Says he's felt this way for years, but it is now worse in some way that he can't specify, for some duration he can't specify. He endorsed pretty much every psychiatric symptom under the sun. Says he was diagnosed with schizophrenia, chart actually says substance induced psychosis, episode 8 years ago. Chart review shows he is undomiciled, and this morning burned yet another bridge regarding social housing. Denies drug use. Saying he needs to be "institutionalized" because he's a risk to himself and the public.
No formed plan for suicide. No specific target or mechanism for homicide.
His thoughts are linear and logical otherwise. Affect euthymic. Not terribly forthcoming.
At this point I'm pretty sure he's malingering. Social worker tries everything to get him a bed somewhere but he has burned every bridge in town. Figuring that he may well have substance use, mood, or personality disorders, I get all set to discharge him with an outpatient psyc referral. He goes ballistic. He is throwing stuff around the room, very physically aggressive, we call security but he settles down before we have to chemically sedate or restrain him.
Then I caved. I figured that, despite not being psychotic, the chance of him hurting someone was actually significant. He had a recent prison sentence for a very violent crime, and he seemed actually potentially desperate enough to hurt someone to convince someone (us or even the police) to institutionalize him. Although I didn't think he was psychotic, he probably did have some degree of mental disorder/psychiatric illness. In order to discharge him, I'd have to call the police to drag him out. Then he turns around and tells the police he's going to kill someone because the voices in his head tell him to – and the police will bring him right back to my ED (I've seen this happen before). If he does actually leave after being dragged out by security, and then beats some little old lady, imagine the headlines: "Man with known psychotic history presents to ED requesting help because voices are telling him to commit murder, then commits murder after being dragged out of the hospital against his will, without any treatment, by Dr. Gursky". And, even if he hurts someone because he's an asshole, not because he's mentally ill, I have to live with that guilt. I figure that if I'm on the fence about the degree of danger and whether he's got a mental disorder, then presumably I should ask someone with more expertise about these issues.
So I consulted psychiatry. Which means he will sit in my ED taking up a bed overnight, be a pain in the ass to the night emerg docs, then see psychiatry and get discharged in the morning. I feel guilty because I feel I'm wasting resources and kicking the can down the road. I'm basically forcing this uncomfortable decision on my psychiatry colleague. And I pretty much know that they're going to send him home.
Has anyone found any other creative solutions for this type of situation? Psychiatrists, how would you feel about getting a consult like this?
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