(022) Multidisciplinary Approach to Managing Deliberate Foreign Body Ingestion on the Medical Floor

Abstract: Background/Significance: Intentional foreign body ingestion (IFBI) accounts for 1500 deaths per year, 92% of which are deliberate. This incurs approximately $6,000 per hospital visit in the United States, with an average hospital stay of 5.66 days. The disorder has a complex pathophysiology, often co-morbid with severe personality disorders, PTSD, and some psychotic disorders. We will expand on the multidisciplinary aspects of management and offer recommendations for approaches for a patient with IFBI in the inpatient setting. Perspectives from emergency medicine, gastroenterology, and a Behavioral Resource Team will be included in our discussion.

Case: NH is a 29-year-old patient with past psychiatric history of borderline personality disorder, PTSD, and extensive self-harm history who presented to the hospital after ingestion of 30 thumb tacks and two batteries impulsively due to acute distress. She was admitted with plan for serial daily imaging to ensure passage of all objects. The patient's psychiatric history is significant for several prior inpatient hospitalizations, and a long history of self-harm including medication overdose, cutting, head-banging, prolonged refusal to eat, vaginal-packing and prolonged refusal of voiding. The patient has extensive sexual abuse history as well. The patient’s medical admission was complicated by the repeated swallowing of mask wires and popsicle sticks, minimal oral intake and repeat vaginal packing all with a constant companion present. She required several gynecological exams for impaction, medical management of her dehydration and continued follow-up by gastroenterology for various ingestions, including repeated EGD and imaging. After two months in the hospital, the patient repeatedly denied suicidal ideation and was discharged home.

Discussion: Consistent with prior research on this disorder, effective treatment approaches to IFBI are multidisciplinary. The decision to pursue placement in an inpatient psychiatric unit should be carefully weighed against the potential for impairing treatment progress. A care plan can be developed among providers in emergency medicine, psychiatry, gastroenterology and potentially the hospital bioethics board. Additionally, poison control may also become involved. Shared management across providers, including the consultation-liaison psychiatrist, can help alleviate symptoms of physician burnout and facilitate comprehensive and patient-centered care.

Conclusion/Implications: Treatment approaches to IFBI should be multidisciplinary. Little is known about the psychiatric management of this behavior and additional studies are needed to outline best practices around IFBI in the hospital setting. A comprehensive, multidisciplinary plan which outlines treatment strategies and specialty-specific challenges will ultimately provider the best patient centered care for this very challenging patient population. Furthermore, developing a treatment care plan can be vital in protecting the patient and managing staff expectations and countertransference; it may also have financial benefits due to shorter duration of admission.