If you have read the title of today’s blog post, you already know the answer to today’s case. The answer is “Lithium Toxicity.” I could have instead presented a “Can you figure this case out?” type of format. But I did not want to do that because, really, what was causing this particular patient’s symptoms is not obvious, especially early on. This is an introspective learning case. I want you to read the case knowing the answer. The answer is “Lithium Toxicity.” As you read this case presentation, I want you to ask yourself when the possibility of lithium toxicity would have first entered your head and when you would have stopped this patient’s lithium? Continue reading
Here is the clinical scenario: You have an inmate in your facility who is running his head into wall, bull-like, at full speed. He then backs up and does it again. He may be suicidal. He may be high on meth. He may just be a jerk throwing a tantrum. But he will not stop just because you have asked him to.
What would you do in this situation? It seems to me that there are only three options for how to deal with this inmate.
- Do nothing! Let him hurt himself if he wants.
- Physically restrain him in a restraint chair or on a board.
- Administer sedating medications as a form of chemical sedation.
These three responses clearly are different in the risk of a bad outcome. And there are two possible bad outcomes to consider. The first is the medical risk. Which approach is most likely to result in a serious injury to the patient? The second is the legal risk. Which approach is least likely to result in a successful lawsuit?
I hope that no one reading this would opt to do nothing. You simply cannot continue to let this inmate run his head against the wall. The risk of a bad outcome, both medical and legal is just too high. On the medical side, I personally am aware of three cases where inmates running their heads into the wall of their cells fractured their necks. One was left a quadriplegic. The risk of legal action is also high. In fact, this could be Deliberate Indifference: You knew that running his head into the wall could potentially result in serious injury and yet you did nothing to stop him. I will leave the Deliberate Indifference question to the lawyers, but even without this, the threat of a nasty lawsuit following such an injury is almost inevitable.
So the prudent action, both medically and legally, is to restrain this patient in some way. But which method of restraint is safer for the patient? Which method of restraint is safer legally?
In my strongly held opinion, restraint by chemical sedation is safer than prolonged physical restraint for those who are a threat to injuring self or others. I have several reasons for believing this.
- Chemical Sedation is the community standard of care in the other two areas of medicine that also routinely restrain patients who are a threat to self or others. Those two areas are Emergency Medicine and Inpatient Psychiatric medicine.
- Prolonged physical restraint, for example in a restraint chair or board, carries significant risks of injury, including death. Chemical sedation is much safer.
- As long as the chemical sedation is done properly, there is less risk of successful legal action with chemical sedation than with prolonged physical restraint.
Chemical Sedation is the Community Standard of Care
I practiced in a busy emergency department for many years before I came to correctional medicine. There, chemical sedation is routinely practiced. Every Emergency Department does chemical sedation routinely. It is not controversial in ERs at all. I was taught how to do chemical sedation in my ER residency. It is an Emergency Medicine “Core Competency.” Chemical Sedation is discussed in every major Emergency medicine textbook. As a matter of fact, physical restraint is viewed in Emergency Medicine as a tool to facilitate chemical sedation rather than a viable option on its own.
It is a similar situation in inpatient psychiatric hospitals. I have asked several psychiatrists whether they leave dangerous inmates in a psych hospital physically restrained for long periods of time. The typical response is to laugh and say “No. They get sedated.”
I’m not sure why chemical sedation has such a bad reputation in some quarters of the correctional medicine world, because it is the Standard of Care for patients who are an acute danger to self or others elsewhere in medicine. Why is this so? It is because:
Chemical Sedation is Safer than Prolonged Physical Restraint
Unfortunately, I cannot point to any published studies that show that chemical sedation is safer than prolonged physical restraint. That is because there are none. However, I personally know of at least five cases of death from physical restraint. The mechanism of death in these cases has ranged from suffocation to acute pulmonary embolism to “excited delirium.” The point is that prolonged physical restraint carries substantial risks that range from minor (contusions, abrasions, broken bones) to serious (death, loss of limbs from too-tight restraints).
On the other hand, I am not aware of any deaths from chemical sedation, whether in an Emergency Department setting or in corrections. I actually have never heard of any serious complications from chemical sedation. There may have been one somewhere and I am just not aware of it. If you know of such a case, please contact me!
Chemical Sedation Carries Less Legal Risk Than Does Prolonged Physical Restraint
Again, there are no published studies on the incidence of lawsuits after restraints. I have spoken to several different Risk Management experts on the subject, both in Emergency Medicine and Correctional Medicine, and they have unanimously agreed that chemical sedation of a dangerous patient carries less legal risk than does prolonged physical restraint.
Here is one example. I contacted Rick Bukata and Greg Henry, who together publish Risk Management Monthly, a publication on how to reduce medico-legal risk in Emergency Departments. I asked them about the legal risk of administering chemical sedation to a dangerous patient against his will. This was their response:
“Jeff Keller has malpractice concerns about the patient who is sedated against his/her will. This situation is not likely to be problematic if the patient is being sedated because he or she poses a danger to self or others, and if the reason for sedation is meticulously documented. A physician might be at greater medicolegal risk if he or she fails to sedate a problematic patient who is placing the staff in jeopardy.”
After talking to several Risk Management experts in Correctional Medicine about this subject, I am unaware of any successful lawsuits arising from chemical sedation of an incarcerated inmate who was an acute danger to self or others. Once again, if you are aware of such a lawsuit, I want to know about it! Please contact me!
I believe that the legal risk of restraining an inmate depends on two factors. The first is harm. If a patient has been harmed by the restraints, he is more likely to sue and is more likely to be successful. So the method of restraint least likely to injure the patient is the safest legally. Chemical sedation is safer than prolonged physical restraint and so is safer legally as well.
The second factor is that the sedation was done on the right patient (one who is an acute danger to himself or others) and that this was documented properly.
In fact, chemical sedation is very like administering any medication. You must have the right patient, give the right medications in the right dosages, do the right monitoring and follow-up care, and document in the right way. If you do all of that, your legal risk will be low. More details on that later.
What does your facility do for out-of-control inmates who are a threat to themselves or others? Chemical sedation or prolonged physical restraint? Please comment!
The definition of a “Pearl” is a bit of pithy and insightful information that can be communicated in one or two sentences. Hopefully, it is also something that you have not thought of yet and will change your practice for the better.
I ran into several Pearls at the Essentials conference. Here is a sampling (in no particular order): Continue reading
It is a good idea to check on the current price of medications once in a while. When I do this, I am invariably surprised by price changes since the last time I looked. On the one hand, once a medication goes generic, the price will fall to a small fraction of what it used to cost. This process can occur quickly, say over 6 months, or may take a couple of years until it hits bottom. On the other hand, sometimes drugs that had been cheap, quickly and inexplicably become expensive. The current prices for antipschotics show both trends. Continue reading
A 46 year old man comes to the medical clinic complaining of muscle aches and twitching, which he first noticed two days ago. He had been booked two weeks ago and his prescribed outside medications were continued: sertraline 100mg a day, amitriptyline 100mg at bedtime and lisinopril.
He walks into clinic with a stiff legged gait. His vital signs show a heart rate of 124. He has sweat on his forehead and a noticeable tremor of the hands. His speech is pressured.
So what is going on with this patient? The answer, as you may have guessed from the title, is Serotonin Syndrome. If you tap on his knees, he will have exaggerated reflexes. Fortunately, he has only a mild case.
Serotonin Syndrome is a constellation of symptoms caused by an excess of the neurotransmitter serotonin. It ranges in severity from mild cases (like the one above) to fatal. In my opinion, all medical personnel in correctional facilities should be aware of Serotonin Syndrome. It is not as uncommon as you might have been taught; if you look carefully for it, you will find cases.
Serotonin Syndrome Defined
Serotonin Syndrome is characterized by a trinity of abnormalities:
- Neuromuscular hyperactivity: Muscle twitching, tremor, hyperreflexia.
- Autonomic effects: tachycardia, hypertension, hyperthermia, sweating, shivering.
- Mental status effects: anxiety, agitation, hypomania, confusion, hallucinations.
Mild cases of Serotonin Syndrome may only manifest as tremor, hyperreflexia, tachycardia and sweating and shivering.
Moderately severe patients will additionally have an increased temperature, clonus and agitation.
Severe cases are usually confused and hallucinating, and have very high temperatures (sometimes over 106F) which can lead to all sorts of very bad effects, like rhabdomyolysis, seizures, renal failure, and, yes, death.
Treatment of Serotonin Syndrome
The most important treatment of Serotonin Syndrome is to immediately stop all of the serotonergic drugs the patient is taking! Benzodiazepines are helpful in treating the agitation and neuromuscular effects of moderate cases. Severe cases, of course, need to go to the ER for big time supportive care and treatment.
Causes of Serotonin Syndrome
So what causes Serotonin Syndrome? The answer is that Serotonin Syndrome is caused by drugs that act by increasing serotonin levels. These are mostly psychiatric drugs, of course. The Big Three Categories of serotonergic drugs are:
- Selective Serotonin Reuptake Inhibitors (SSRIs). There are lots of these. I won’t list them; you know what they are.
- Tricyclic antidepressants (TCAs), which act by blocking serotonin reuptake as well as norepinephrine reuptake. The ones I see used most are amitriptyline, imipramine and doxepin.
- Serotonin-norepinephrine Reuptake Inhibitors (SNRIs). This group includes Trazodone Venlafaxine and desvenlafaxine (Effexor and Pristiq), and duloxetine (Cymbalta).
You should memorize that list! However, many other drugs increase serotonin levels besides those in The Big Three Categories. Interesting examples include amphetamines, Buspirone, Tramadol and tryptans.
There are two main ways that the drugs in the Big Three Categories can cause Serotonin Syndrome. One way is just to use large doses of a serotonergic agent, usually an SSRI. Big dosing of SSRIs was done in the past more than it is now. My psychiatrist mentor here in Boise, Dr. Estess, told me that when Prozac was first introduced and doctors were experimenting with big doses, like 80mg a day, he used to see lots of mild-moderate cases of Serotonin Syndrome. It is less common to see large doses of SSRIs used nowadays, since it has been pretty well established that you get little, if any, additional anti-depressant benefit from SSRIs by using big doses. But still, occasionally, someone will arrive at one of my jails taking, say, 200mg a day of sertraline. If you see a patient like that, check their reflexes and look carefully for a tremor and you may indeed find evidence of systemic serotonin effect.
However, the more important cause of Serotonin Syndrome, by far, is by combining agents from two different categories. This practice is very common; I see this all the time. For example an SSRI is prescribed along with Trazodone as a sleeper or an SSRI is combined with a tri-cyclic antidepressant like amitriptyline on the dubious premise that two anti-depressants are better than one. However, try this: plug an SSRI and a TCA or trazodone into a drug interaction checker (like this one that I like to use). A big red stop sign will pop up saying (approximately) “Major potential drug interaction! Risk of Serotonin Syndrome! Do you really want to do this?” And the risk here is real.
Serotonin Syndrome Develops Quickly
One thing that I did not mention yet about full-blown Serotonin Syndrome is that it tends to develop quickly. I personally learned this the hard way. I had a patient in one of my jails die from Serotonin Syndrome. Dead. The patient was a middle-aged man who came to the jail taking Paxil and Imipramine prescribed by his outside psychiatrist. I continued these medications. A couple of months into his incarceration, in the middle of the night, he developed agitation, hallucinations and vomiting. He became unresponsive. An ambulance was called. At the ER, he had a temp of 107F, intense muscle rigidity, and full blown shock. He died there in the ER.
This tragic case occurred early in my correctional medicine career. It has made me vigilant in looking for evidence of Serotonin Syndrome—and I have found a few mild-moderate cases since. It also made me question whether the benefit of combining two serotonergic agents in one patient ever outweighs the risk. I personally don’t believe so.
Whether you agree or disagree with this conclusion, please remember the danger of Serotonin Syndrome when you combine serotonergic agents. You may have used this combination a hundred times and have never seen ill effects. That does not mean you never will. Consider whether the benefit of the drug combination you are considering truly outweigh the risk of Serotonin Syndrome.
Have you had a case of Serotonin Syndrome in your facility?
What is your opinion of combining serotonergic drugs?
A mental health professional recently referred a patient to the medical clinic “for consideration of a mood stabilizer.” Continue reading
Like most physicians, I subscribe to several medical education and CME sites. One of my favorites is Primary Care Medical Abstracts. PCMA chooses 30 papers a month of interest to primary care physicians and then these papers are reviewed by two physicians (usually Rick Bukata and Jerry Hoffman). The reviews are insightful and funny and pretty fun to listen to. These guys have no problem calling B.S. when they review certain papers. I like that! (By the way, I have no affiliation with PCMA). Continue reading