CLINICAL HANDBOOK OF SCHIZOPHRENIA

340 V. SYSTEMS OF CAREcare of themselves or a threat to self or others. Because of their condition, they may requiremonitoring on a 24-hour basis inside an inpatient unit.In more severe cases, patients may present themselves to the emergency room withissues such as suicidal or homicidal thoughts; if this occurs, it is important to recognizeand subsequently relay to the patients that their presentation to the emergency room forhelp actually reflects good judgment on their part. Focusing on the positive aspects of thesituation is crucial, because patients are often aware that they are having a setback or exacerbation,which may be upsetting to them, and this upset alone can contribute to theoverall worsening of their condition. By reframing a patient’s visit to the emergency roomas a reflection of his or her good judgment, the physician can be very helpful in contributingto the patient’s recovery from a crisis.However, many patients do not come to emergency settings on their own, but are insteadbrought by family members, board and care operators, conservators, or police. Suchpatients may be reluctant, confused, lacking in insight, and occasionally combative, and oftenare likely to require inpatient stabilization. In these challenging situations, the experienceof the physician is critical to minimize the crisis effectively rather than worsen it.Basic Approaches to Assessment and Treatmentin the Emergency RoomThe most important guiding principle in treatment is safety—for the patient and the staff.Safety begins with the physical structure and layout of the emergency room. To have asingle clinician interview an acutely psychotic patient in a small room that contains sharpobjects, in which the door opens inwardly (and can be shut by the patient and not easilyopened from the outside), invites problems and should be avoided. There should insteadbe easy access for multiple staff to enter and exit, while maintaining the patient’s privacy.Additionally, a system for panic alert, consisting of either buttons or switches physicallyplaced in discreet locations, or as a part of a pager system, is critical. An appropriate codesystem for assaultive behavior is also essential, with a clearly identified team of individualswho have received appropriate training in the management of assaultive behavior. Althoughindividual sites vary in the ways they deal with the possibility that a patient is carryinga weapon, a security system does need to be in place; sometimes this involves theuse of metal detectors or gowning patients upon entry.Another important goal is stabilization of the situation. Again, the structure of theemergency setting can play a role, because it is more difficult to stabilize patients if theyare being evaluated in an area where trauma victims or other extremely intense medicalissues are also being addressed. After the safety of the situation has been optimized, stabilizationgenerally involves addressing whatever led to the exacerbation of illness or thereasons for the emergency room visit. For example, if there has been an acute change inthe patient’s environment or the development of a family crisis, psychosocial or family interventionsalone may allow for stabilization of the situation, without a change in medicationmanagement or a need for admission to a more restrictive environment. In cases inwhich an exacerbation was caused by environmental issues, the structured setting of anemergency room, or simply the change from the previous environment, can sometimesdramatically contribute to the stabilization of the patient.When dealing with patients in acute psychotic states, it is important to be aware ofand take into consideration medical causes. There may be a tendency for clinicians to assumethat an increase in psychosis simply represents a worsening in the underlyingschizophrenic illness. Many patients have an exacerbation related to medical causes however(infections, thyroid problems, etc.). Therefore, a full physical examination should be