Management of Self-Inflicted Nonaccidental Amputations of the Upper Extremity: Systematic Review.

PURPOSE: Clinicians assessing patients with deliberate self-inflicted amputations face a problem of whether or not to replant. The objective of this study was to summarize the literature on this topic and provide recommendations regarding the acute management of patients following self-inflicted amputations in the upper extremity. METHODS: Two reviewers searched four databases using the keywords "Upper extremity," "Amputation," and "Self-Inflicted." The reviewers systematically screened and collected data on publications reporting cases of self-inflicted upper-extremity amputations. The findings then were summarized in a narrative fashion. RESULTS: Twenty-four studies were included. Twenty-nine cases of self-inflicted upper-extremity amputations were reported. There were 25 unilateral and four bilateral extremity amputations. Amputations were most commonly at the hand/wrist (18 patients) and forearm level (6 patients). The amputations were most commonly performed with a saw (9 patients) or a knife (8 patients). Reasons for amputation included psychosis (10 cases), suicide attempt (7 cases), depression (5 cases), and body integrity identity disorder (four cases). Fifteen replantations were performed; all were successful. Reasons for not pursuing replantation were related to injury factors (ie, multilevel injury, prolonged ischemia, damaged part) rather than patient-level factors. Two patients with replantable extremities declined replantation, both of whom had body integrity identity disorder. Of the patients who underwent replantation, none expressed regret. CONCLUSIONS: The literature shows that patients experiencing psychosis or depression committed self-harm during an acute psychiatric decompensation, and once medically and psychiatrically stabilized, expressed satisfaction with their replanted limb. Surgeons should not consider psychiatric decompensation a contraindication to replantation and should be aware of patients with body integrity identity disorder who consciously may elect to undergo revision amputation. When presented with patients experiencing psychiatric decompensation who refuse replantation/are not competent, surgeons should seek emergency assistance from the psychiatry team to determine the best management of a self-inflicted amputation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapy/Prevention/Etiology/Harm V.

A Tough Case to Crack: Diagnostic, Ethical, and Legal Considerations in Treating Compulsive Neck Cracking.

Compulsive behaviors rarely lead to significant physical injury, but when they do, they can introduce challenges in treatment secondary to diagnostic uncertainty and introduce ethical and legal dilemmas when trying to optimize patient care. We discuss the clinical complexities in treating a patient with compulsive neck cracking as she navigates various clinical settings in hopes of alleviating the anxiety and pain that lead to her behaviors. Ultimately, the principles of beneficence and autonomy must be weighed when determining whether someone with a chronic risk of serious physical harm from compulsive behaviors requires involuntary psychiatric treatment.

Consultation-Liaison Case Conference: Psychiatric Evaluation and Management Following Gunshot Injury.

We present the case of a 23-year-old female presenting to consultation-liaison psychiatry after admission for multiple gunshot wounds. Top experts in the consultation-liaison field provide guidance for this commonly encountered clinical case based on their experience and a review of the available literature. Key teaching topics include risk factors for gun violence victimization, assessment of psychiatric diagnoses associated with gunshot injury, and management challenges including access to psychiatric care. Specifically, we highlight the high prevalence of trauma-related disorders, substance use disorders, and functional impairment after gunshot injury. We also provide practical guidance on issues of lethality assessment, trauma-informed care, psychiatric management, and community resources that support recovery.

Limitations of Traditional Models for Medical Decision-Making Capacity and Ethical Clinical Practice in Light of the SARS-CoV-2 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has upended psychiatric practice and poses unprecedented challenges for maintaining access to quality care. We discuss the ethical challenges of treating a patient with schizophrenia in need of hospitalization but who declined severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surveillance testing. The traditional framework of capacity assessment depends on the patient's ability to weigh risks and benefits, but this framework is of limited utility in context of the COVID-19 pandemic; the personal benefits of testing for the patient are unclear and in fact may not outweigh the risk of being declined psychiatric care. Moreover, classic capacity assessment does not well account for physicians' obligations to other patients and the public health. We conclude that physicians cannot coerce surveillance testing, and we consider the implications of requiring SARS-CoV-2 testing for accessing mental health treatment.