NUBE 2024

We will walk through the case of a 10 year old child with a psychiatric history of complex PTSD, ADHD and DMDD presenting to the emergency department for “aggression”. The patient spent 20+ days boarding until a residential placement was found. In those days, there were more than 30 workplace violence injuries, 50 violent restraint episodes, and countless brainstorming sessions. When the “going got tough” and the facilities' process, resiliency, and resources were challenged, “the tough got going”. A multi-disciplinary team came together to optimize pharmacotherapy, behavior modification, therapies, and other modalities to remain true to our mission and “do what is right for kids”.

Learning Objectives:

Identify pharmacologic options for agitation.

Self report increase knowledge related to care of complex pediatric patients.

Self report increase in knowledge of non-pharmacologic agents of behavioral change.

Ethical issues, particularly those involving respect for patient autonomy, arise in emergency psychiatry practice all the time. Most clinicians working in this setting recognize that there is an ethical component when a patient is committed or determined to lack capacity to make their own medical decisions. In these cases we determine there is a good reason to override the person’s autonomy. Yet, the ethical issues are woven into the clinical care so tightly when the illness is directly impacting the patient’s ability to make decisions for themselves, that we often simply do not think about them. We think of ethics as the discussion of the complicated cases that cause disagreement among staff or catch media attention and we do not examine the ethics of the small decisions we make all of the time. If we did recognize and take a few minutes to explore these small decisions in everyday practice, we might discover that some are driven by systemic issues of bias toward our patients that have been written into our processes and procedures. Recognizing this may be the first step we can take in working toward change.

As an emergency psychiatrist who has recently completed a degree in bioethics, I now notice the small things we do every day that have ethical ramifications and deserve our attention. And I see how some of the dilemmas we face are created by how we do our work. Can we change? Maybe, but first we must see the problems. We are all busy doing our day-to-day work and stepping back to examine underlying ethical concerns is difficult. Thinking of ethics in the context of everyday work rather than as something separate and associated with only the complicated cases may help us provide better and more ethical care.

In this brief “rapid fire” presentation, I want to encourage audience members to recognize and begin to examine the small things, the “microethics” of our everyday practice. I will start by reviewing the concept of what is referred to as micro or everyday ethics in medical practice and will then use a case or two to further illustrate my points. This will be followed by a few minutes for audience members to share their own stories of every day ethical decisions. My hope is that this presentation and brief discussion will simply be a first step in beginning to think about ethics in our everyday interactions, while considering how this information can help us address procedural issues.

Learning Objectives:

Define microethics, the ethics of everyday clinical practice.

Identify an ethical issue in your everyday practice and explain why it is an ethical issue.

Explain how recognizing a microethics issue can help you identify underlying processes and procedures that may need critical reexamination.

As an ER nurse for twenty years and now a psychiatric nurse practitioner, I have never had a case impact my practice as much as Amanda's. I took care of Amanda as an ED nurse in May 2024. I want to share this fascinating and impactful case with conference attendees. It is a case full of assumptions.

A homeless 40-year-old female, Amanda, comes to the ED via ambulance after people living in a home became worried about "a woman lying in their backyard on a mattress, incontinent to urine and without pants for three days". The patient is severely sunburned (Phoenix in May), has a temperature of 103 degrees, but is alert and oriented. Pt denies mental health and substance abuse. No medical history and takes no medications. No old records are found. Basic labs and UA ordered, fluids hung, and ice packs applied to the neck and groin. Through conversation, it is discovered that Amanda has her master's degree in accounting and lost her job one year ago. She has two children she sees occasionally, and when asked what she does during the day, she replies, "I am a ho on the streets." As the patient's RN, I could not reconcile her situation with her presentation. I left my shift that night with a strong feeling toward this patient. I felt so strongly at one point that I even half-heartedly considered taking her home! I came back to work four days later and learned that Amanda had been admitted to the hospital with Hyponatremia and discharged the day before. She was discharged with a ride home but instead fell asleep on hospital grounds in a bush. I raised concern about her condition to multiple parties, and upon a more extensive review of her medical record, it was discovered that she had been diagnosed with a brain tumor on her front lobe in 2021 and even admitted to our facility in the Neuro ICU in 2021. After being sent to her mother's apartment and trespassed by police there, A "BOLO" is issued for Amanda to all charge nurses in the ED, and amazingly, she appears that same night again via EMS for nausea and vomiting. A head CT is done on her second trip to the ED, and doctors discover that her tumor is now the size of a softball on her frontal lobe, and it is impacting her decision-making. She is taken to the ICU and has a craniotomy four days later. A day after surgery, she is alert, oriented, and trying to rebuild a life with family members who had given up on her. This story has many twists and turns that make it even more compelling. All types of medical professionals (doctors, nurses, social workers) who participated in Amanda's story made assumptions about her in some way. It tells a story of how we can mistakenly view patients in the ED judgmentally and perhaps how changing our mindset can and will save a life just like Amanda's.

Learning Objectives:

Listen to a fantastic and heart warming story from an ED nurse who took care of a homeless patient (5/24) and changed both of their lives forever. This story is extremely relevant to all conference attendees.

Describe educational initiatives related to this case.

Discover how this case was presented to the “ER Behavioral Core team” to inspire participation and ignite a passion for improving the care of behavioral health patients in our ED.