Medicine in Psychiatry: What Do We Need to Know?

Physical disorders are present in at least 50% of psychiatric patients, and a consensus exists that they are underrecognized, misdiagnosed, and suboptimally treated (Felker et al. 1996; Marder et al. 2004). These undesirable outcomes have been explained in terms of systemic obstacles to health care, behavioral aspects of psychiatric disorders, physical consequenc es of mental illnesses, and side effects of psychotropic drugs (Goldman 2000). However, psychiatrist-related reasons are clearly just as important and include inadequate history taking and premature diagnostic closure (Sternberg 1986), as well as a reluctance to perform physical assessments (Krummel and Kathol 1987). The requirements for certification in psychiatry in the United States include 4 months of medical training but do not specify knowledge objectives (Accreditation Council for Graduate Medical Education 2000). The traditional setting for this training has been the medical ward of a teaching hospital, where psychiatry residents work alongside medical residents involved in the care of patients with acute myocardial infarction, congestive heart failure, pneumonia, respiratory failure, septicemia, phlebitis, cirrhosis, and malignancies (Thompson and Byyny 1982). We lack empirical data that show how this type of knowledge is used in psychiatric settings. What we do know is that life-threatening and terminal diseases are both infrequently encountered by and beyond the scope of care of the professional staff and support services of a self-standing psychiatric hospital. Our discussions with hundreds of psychiatry residents and attending physicians indicated their perception that the traditional training has not prepared them well for the medical problems of psychiatric patients and has not decreased their reliance on medical consultatio n to address symptoms of acute illnesses, side effects of psychotropic drugs, and manifestations of chronic degenerative disorders. What do psychiatrists need to know about physical illnesses? To begin to answer this question, we performed a retrospective analysis of inmediately ca ll for help. In the community, the emergency medical service should be activated by calling 911; in the hospital, one should initiate a code and ask for the crash cart and automated external defibrillator (AED), if one is available. Early CPR begins with proper positioning of the patient and the rescuer. If the patient is not positioned on a hard surface, every attempt should be made to gently move the patient onto his or her back with a firm support such as a backboard. If there is any question of cervical spine injury, the goal is to maintain the head, neck, and trunk in line without applying any traction while moving the patient. After the patient is properly positioned, the primary survey, including evaluation of the ABCDs (airway, breathing, circulation, defibrillation), is conducted. Airway The first step should be to open the patient s mouth and inspect the airway for any foreign body. The basic head tilt and chin lift maneuver involves putting one hand on the patient s forehead and placing two fingers of the other hand under the bony part of the chin and gently lifting up. This movement lifts the tongue off the airway and allows air to pass unobstructed (Allied Mobile Health Training 2004). If there is concern about cervical spine injury, the rescuer must provide the jaw-thrust maneuver by grasping the mandible of the jaw with the fingertips while the hands are placed on the sides of the patient s face. The mandible is then lifted forward to relieve any obstruction (Cummins 1997). Breathing The rescuer then looks, listens, and feels for any respirations by looking at the patient s chest to see if it is rising and falling, listening for sounds of breathing, and feeling the patient s breath on his or her cheek. All

three steps should be done simultaneously (Allied Mobile Health Training 2004). If no respirations are detected or if they are agonal and sporadic, the rescuer should provide positive pressure ventilations to the patient either by using a bag-valve-mask device or by pinching the nose and delivering two slow, full breaths over a period of 2 seconds each. When a bag-valve-mask device is used, caution must be exercised to ensure a tight seal around the patient s nose and mouth to minimize gastric distention and the chance for regurgitation and aspiration of stomach contents. The adequacy of ventilations can be gauged by the symmetric rise and fall of the chest cavity.