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(PSYCHIATRIC TIMES) - A 24-year-old veteran of Operation Iraqi Freedom (OIF) presents to the ED mid-morning on a weekday. While the veteran is waiting to be triaged, other patients alert staff that he appears to be talking to himself and pacing around the waiting room. A nurse tries to escort the veteran to an ED examination room. Multiple attempts by the ED staff and hospital police—several of whom are themselves OIF veterans—are unsuccessful in calming the patient or persuading him to enter a room.

The increased attention escalates the patient’s behavior and he begins to run around the ED. At one point he hides under instrument trays, yelling out “Incoming! We have to get them before they get us! The enemy is coming for us!” He then runs to another location, as if taking fire.

A quick general status evaluation shows a young man with several days’ growth of beard in jeans and T-shirt who looks sleep-deprived. The veteran’s speech is rapid and staccato; he displays hyperactive movements, with frequent scanning of the environment, terrified affect, and loss of contact with the immediate hospital reality.

An experienced female emergency psychiatrist quickly arrives but is unable to orient the patient or convince him to accept medical intervention. All questions regarding his current status are answered with phrases indicating the patient is re-experiencing combat in Iraq. His behavior is increasingly unpredictable and aggressive, leading the ED physician and psychiatrist to be concerned about the safety not only of the veteran but also of other patients and staff. All involved wish to avoid use of force if at all possible, certain this will retraumatize the patient and reinforce his dissociative state.

The ED physician, an older man, tells the psychiatrist that he is an Army veteran and a colonel in the Reserves, and suggests that it might help if he addressed the soldier as an officer. The psychiatrist agrees that this approach is worth a try but emphasizes the need to use the military hierarchy to reassure the veteran he is not in Iraq or in any danger and without either challenging or affirming the patient’s belief he is in a combat setting.

The soldier responds quickly and with obvious relief to the physician’s instruction to “Stand down . . . we are not in Iraq . . . all your buddies are okay . . . this is a secure hospital area and I need to examine you.” He follows the physician’s orders to go into the examination room and sit on the gurney and allows 1 mg of lorazepam and 1 mg of risperidone to be administered. The medication further calms the patient who then cooperates with a physical examination, blood draw, and toxicology screen. There are no physical abnormalities and results of the toxicology screen are negative. After medical clearance, the veteran is admitted voluntarily to an inpatient psychiatry ward for safety and further stabilization where active pharmacological and psychotherapeutic treatment of his PTSD is initiated.

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