So there was the time I was hugging a trashcan in the lobby of the community hospital ED just a few blocks from my house. Not because I have a molded plastic fetish or because I like the smell of trash, mind you. I had an itinerant renal calculus, otherwise known as a kidney stone that was moving through my urinary system.

It. Hurt. Like. Hell.

I. Wanted. To. Die.

I was throwing up blood. I was so sick I just wanted someone to kill me so the pain would go away. (Remind me that I need to come back to that re: pain that is so bad that one wants to commit suicide to escape it. There’s a good post there that needs to be written.)

But wait.

My peripatetic pain particle is not the point of this morning’s post. I was sick, yes. I was in terrible pain, yes. I was in the ED because I was seeking help, yes. But that was not the main problem at that instant.

I was made to wait.

In the waiting room.

Waiting for help.

Waiting for relief.

Waiting.

Mental health patients come to the EDs in my state and they want many things. Sympathy. Drugs. Medications. (They’re not the same sometimes, are they?) Counseling. Escape from abuse. Understanding. Housing. Hospital admission.

The common denominator across chief complaints and emergency departments?

Waiting.

These patients usually have to wait.

They come to the ED to get put back on medications that they injudiciously stopped on their own three months before, leading to a serious resurgence in symptoms. They come for detox from heroin. They come for admission to a psychiatric unit because their family wants them to be “put somewhere”.

The problem is, the ED system is a careful, methodical, slow moving glacier of health care provision for these folks, and others too I guess. Now isn’t that strange? You think of all the ED shows you see on television and the action is fast and furious, the pace frenetic, situation after situation life and death. On the brink, hanging on by a thread. Real life in the ED is like that only a fraction of the time. The rest of the time is broken bones, earaches, and anxiety attacks.

Mental  health patients are usually put in isolated rooms or corners of the ED. They are seen briefly and then they wait. In my state, this might mean waiting anywhere from two hours to twenty four hours for a telepsych consult, depending on how backed up we are. Sometimes we have only two consults in the work queue waiting to be seen, but on rare occasions we have had thirty consults, thirty, lined up to be seen. It takes from thirty minutes to two hours to do a telepsych consult. There is always one doctor on shift, and most of the time there are two working together. Do the math.

The patient is told that the telepsych doctor will see them and then make the decision about their going home or not. This is not true. We consult, but we do not discharge or retain directly. That is left up to the attending physician in the ED. Patients get angry when I tell them this. They feel that they have been lied to, especially when they have just smiled at me for thirty minutes and put their best foot forward to get released after a serious suicide attempt that in my mind has just punched their ticket for a hospital admission.

Sometimes they are physically or chemically restrained, a practice that we would like to think went out the door with Cuckoo’s Nest, but is still very much with us today. This process warps their sense of passing time even more, making the waiting that much harder to bear.

Sometimes it is days or weeks before a psychiatric hospital bed opens up. This is complicated by the fact that some patients have insurance to pay for services, some have Medicaid or Medicare, and some are truly indigent and have nothing. More waiting. Finally, the patient becomes so frustrated and upset about waiting in the tiny pale green room with the harsh fluorescent lighting and no stimulation at all they become more depressed, desperate, demanding and agitated, leading to staff pushing for an early discharge that might not be indicated at all.

The waiting truly is the hardest part.

When you’re dancing with a trashcan and throwing up blood.

Or when you’re hallucinating, depressed, and thinking of the easiest way to kill yourself.

Yes. Assessment.

The one-size-fits-all assessment found in most EDs today does not work for mental health patients. At least, not entirely. Yes, a perusal of this completed and often quite lengthy form will fill me in on blood pressure, pulse and temperature. It will let me know about medications taken at home. It will list previous medical diagnoses and oftentimes who is treating those illnesses. It will talk about elimination patterns and intake. It will assure me that the bedrails are in the proper position to prevent falls. All important items to address in an environment that is geared towards rapid global assessment in a safe environment.

We joked, again, in a teleconferenced staff meeting yesterday afternoon about the fact that these assessments will let me know what the patient’s TB testing status is for the last ten years, but will sometimes give me absolutely no clue as to the number of previous serious suicide attempts, even though the consult sent my way asks for an assessment of suicide risk.

Forms follow function.

Now some ED staff members, especially those wonderful, insightful ED nurses who are my lifeline to what’s really going on with the patient I am about to interview, ask probing and spot-on questions that get to the core reason the person arrived at the hospital. That’s great. Others, stressed to the max, covering too many really sick patients, and pulling their fifth long shift in a row, just don’t have the wherewithal to dig deep for some of the things I’d like to be told or made aware of as a matter of course. I’m not blaming them. It’s just a fact.

I’ll give you an example. A few weeks ago, I was going to see a young man who had supposedly made threats to kill himself and was very paranoid about family members at home. Pretty straight forward, right? I reviewed the records, called the nurse working with this man, asked her how he had been doing in the ED so far, and what her personal assessment of his current symptoms and status was.

She told me that he had been very quiet (spoiler alert-this is usually not good given the history I started you off with just now), a model patient, and had given them no trouble at all. No, she had not heard anything from him about delusions (she had not asked), did not think he had a plan to kill himself, and felt that he would probably be safe to discharge home (one of the primary, if oft-unspoken goals of an emergency room consult, truth be told).

I thanked her for her insights, got the patient on the screen and asked what brought him to the hospital. My first clue was his assertion that the federal government had placed a bug in the back of his head that was tracking his every move, that there were helicopters outside his house, and that he had made very detailed plans that he felt would lead to a successful suicide attempt when he got home. Oh, yes, he had indeed been very quiet and no trouble at all in the ED. He was not acting out, had not required IM medications or restraints, and was not taking up too many of the ED’s resources. The problem? He was very quietly psychotic as hell. I recommended admision for his safety and to treat his “obvious” symptoms. Obvious only if you took the time to really look for them and assess them.

Lastly, all that glitters is not gold. All that hallucinates is not schizophrenia. All that looks sad and flat is not depression. This is a real pet peeve of mine. One of the reasons doctors with medical school and residency training make good psychiatrists is that they know what else to look for. This is  not a cookbook specialty (Oh yeah. DSM-5. My copy has shipped this week and should be here soon. Please don’t get me started. That’s another series of posts for another day, you can be sure of that) and things don’t usually line up neatly as they should. As a matter of fact, in the ED they almost never do. You have to be curious, ask the right questions, dig a little, and when you hear hoofbeats sometimes look for zebras and not the conventional horses as you were taught in medical school.

I have seen hypothyroidism show up to the party as “major depression”, an undiagnosed brain tunor cause “schizophrenia”, and “panic attacks” that were due to hypoxia. One of the most challenging and fun things about psychiatry for me, and ED telepsychiatry is certainly part of it, is that my patients don’t always read the book. Granted, they read it more these days than they used to, but they don’t often read beyond the outlines or the first few paragraphs.

Diagnosis is a challenge. Assessment done right, and thoroughly, is a huge part of that.

What shall we talk about next? Hmm. Maybe what Tom Petty and the Heartbreakers allude to in their song. You know the one I’m talking about.

The Waiting (is the hardest part).

Enjoy. I’ll be back soon.

The ED is a hectic place. 

Sore throats. Heart attacks. Dog bites. Broken bones. Strokes. Major trauma. If you work in an ED, you see it all. And then some. 

Is it any wonder then, with the potential for literally thousands of medical and surgical problems to stumble through the doors of an ED, that hospitals and the bodies that accredit them demand strict, regimented, standard, reproducible emergency assessments and the forms that document them? Of course not. This insures that all the basic questions are asked, that decision trees are followed, that diagnostic criteria are carefully applied, that correct diagnoses are made, and that treatment decisions are made based on evidenced based standards of care, both local and national. 

There are (at least) two wild cards in this process. Health care providers and patients.

Oh, yeah, those. Real people. Stressed people. Tired people. Hurting people. People who are throwing up and having chest pain and screaming and threatening to sue. People who are seeing their hundredth patient at the end of a double shift while trying to focus their eyes on the paperwork in front of them at the same time. Exhausted, sick, frightened, smart, superstitious, trusting, paranoid people. 

Mental health patients are people. Surprised by that, are you? Yeah. They’re people, just like you and me. They just happen to pull out guns to shoot themselves when they get really depressed, or take their clothes off and get hyper-sexual when they’re manic, or put black sheets and duct tape over the windows in their houses when they think the FBI has helicopters hovering outside their house. Other than those little details, they’re pretty normal people just like you and me. 

These normal people with not so normal chief complaints (“I think the federal government has put a metal bug inside my brain, right back here at the base of my skull, look Doc.”) come into the ED in all sorts of ways as we’ve already discussed here. Here’s the rub. These folks don’t fit the usual medical mold. Not surprised at that either, are you? Good. You shouldn’t be. Why is this a problem?

1. A one-size-fits-all assessment in the ED does not usually address psychiatric and mental health needs fully.
2. Substandard psychiatric histories by health care providers unfamiliar with mental health presentations often lead to the report that “the patient has been fine” and lead to inadequate assessment, diagnosis and treatment. 
3. All that hallucinates is schizophrenia and all that is agitated is bipolar disorder. The problem with that level of reductionism? Hallucinations can come from drugs, brain tumors and iatrogenic medication interactions. Agitation can come from hypoxia, angina, and impending pulmonary embolism. 
4. Patients who hit the ED doors with previously diagnosed psychiatric illness may not get the same attention when they have somatic complaints.  My “live patient” for my psychiatric boards was a middle aged man with schizophrenia who was complaining of atypical chest pain. My examiners expected that I knew schizophrenia backwards and forwards (I did). They wanted to see if I would adequately address these potentially life threatening symptoms in a previously diagnosed psychiatric patient. If I had ignored these issues and focused only on his (relatively stable) delusions and hallucinations, they would have sent me packing. I passed the boards. 

The ED is  often the place that mental health patients, especially if they are indigent, come for both mental health and physical assessment and treatment. Both must be addressed. 

More about this in the next post in this series.

 The first post, from @jordangrumet was titled “Caring 2.0:#HCSM And The Rise Of The Empathic Physician”. Jordan makes several good points, including the fact that nowadays doctors, nurses, pharmacists, patients and advocates can reach not hundreds or thousands but even millions of people online, getting the word out about diseases and treatment and sharing knowledge. He says that knowledge is limited, but maybe caring is not. He says that it’s time to not only tell people what we know, but who were are. 

 He challenges us to move to a Caring 2.0 mindset, a process that involves us showing patients that we are human, that we suffer too, and that we have a lot to offer because of our own life experiences that we will share with them in the collaboration between the patient and the healer. 

 I am rethinking my own blog at gregsmithmd.com. I want to not only share my knowledge and  understanding of mental health, forged in the fires of twenty six years of clinical experience in the field, but to show that I live, love, and suffer too and that these life experiences make me better able to serve my patients. In doing this, I want to become “the doctor my patient really needs”, as Jordan so nicely sums it up.

 Another friend made these feelings manifest in words and pictures in a blog post titled “Let them eat…garbage?” that can be found here. @knotellin speaks of the Jewish tradition and custom of putting out leftover bread in public, sometimes tying it up in plastic bags on the metal outcroppings of rubbish bins so that it may easily be found and harvested by the poor who search for the leavings of those more fortunate than them for daily subsistence. In so doing, the writer goes on to say, “not only is the poor person who has to feed himself or his family debased, but so is the giver. There is no dignity in this transaction for anyone”. 

 My comment to @knotellin about this post was the following:

“I can’t “like” this post, but it certainly makes me think. I am struggling with the same issues in my own field of medicine, psychiatry, in that the medical care that is provided for these “throwaway patients” is often substandard, inferior, and “hung from the metal projections” of the medical hierarchy. What indeed does it say about us as humans that we often provide the neediest among us with the leavings of the richest of us, thinking that we have done out part and washing our hands of any more responsibility than that?”

Thank you, @jordangrumet and @knotellin, for really making me think yesterday. You showed me that we need to move forward to be more transparent in our dealing with our patients as people, and that judicious use of life experience shared makes the therapeutic process richer and the act of healing deeper.

 You also showed me that this sharing can and should occur in a way that is not demeaning to patient or exhalting to clinician, but in a way that lets mutual respect forge a strong partnership that is based on trust, not solely on paternalism and charity.

 Thank you for your writing, your teaching and for touching me in a profound way yesterday.

We doctors who specialize in psychiatry have a sacred trust. We are given the opportunity to talk to people who are hurting every day, people who trust that we will listen to them, try to understand them, not laugh at them, and not think that they are stupid, crazy, or horrible. A tall order, granted, given that we hear stories that sometimes border on the unimaginable, bizarre and otherworldly. This is a privilege. I believe that with all my heart, even on the days that I am the most busy and bone-tired and wondering why I chose to do what I do. My interaction with my patients, that sacred emotional bond between the hurting and the helping, is paramount. If we forfeit that, what do we really have to offer?

That being said, there is a horrendous breakdown in this trust between the hurting and the healing in the emergency departments where many mental health patients are forced by default to go for acute and  chronic care. We make jokes about the TSA and the indignity of passing through the obligatory minefield of airports large and small since 9-11, but the same indignities are being visited on the mentally ill of America every day.

When a person is picked up by the local sheriff’s department executing a probate court order for transport for mental health evaluation, one of the first things that often happens is that the patient is handcuffed. Keep in mind that this person has not been arrested or charged with any crime. They are simply being transported for a medical evaluation. I have heard patients with trauma histories talk about how they are triggered to the point of hysteria by this practice, as some of them have been bound, assaulted, even tortured in the past.

Can you imagine? You are scared, maybe strung out on drugs, already paranoid, and the police come to your front porch, seize you bodily, handcuff you, and put you in the back of a cruiser. This very first step, the very first contact with a system designed to help the mentally ill, scares some of these patients so badly that they never go back for treatment again.

This is only the beginning. When patients arrive at the ED, they are stripped of all personal possessions, clothing, jewelry, money, everything. No keeping an iPod that might be playing the very music that calms you and makes the voices fade into the background just enough to make them manageable. No keeping a Timex that might help you stay oriented during the next few days when you will be held in a nondescript room with no windows or clocks to help you know what time of day it is.

In some hospital EDs, personal health information is gathered and discussed in open cubicles or behind flimsy curtains that do little to address HIPAA regulations. The person next to you is having belly pain and is likely to have an appendectomy presently. You are hearing voices that tell you to kill yourself. Now everybody knows about both of you.

Security guards are used as sitters outside your door once you are committed for treatment. You can’t take walk down the hall to stretch your legs. You can only take a shower when allowed, and no razors are given to shave beards or legs. You can’t smoke, something that may not be in your best interest but that has strong implications among psychiatric patients. As my patient said last week, “this feels worse than prison, Doc”.

We talk about treating people with mental illnesses with compassion and gentleness. We talk about people being more than a diagnosis, more than a diagnostic code. More than just another case or “the bipolar in Bed 2”.

It’s time we start doing instead of talking. It’s time we start treating people who come to the emergency department for help with mental illness with dignity.

Next: treatment issues.

So you’re in the emergency department, probably in a small, windowless room, dressed in paper (or, if you’re lucky, crazy green cotton cloth) scrubs. You’re lying in a bed with a plastic mattress and scratchy sheets staring across the room at the door that has a small chicken-wire reinforced tempered glass windowlette in it and is ajar just enough to let you see the shiny black shoe of the security guard who keeps watch over you.

The room is either hotter than blazes or cold as ice, in which case you reach down for the thin blanket. They’ve taken your blood, leaving a little round bruised area in the bend of your left arm (“I write with my right hand-can you stick me in the left arm, please?”). You’re lucky, because the tech that was on early this morning is good and got a purple top, two red tops and a speckled all filled after just one stick. She was the first person you’ve seen since about five AM. A conversation partner who sticks you with a needle is better than no one at all, you suppose.

Now, you think that the morning will have to be better than the dead of night, when you answered questions until your eyes crossed and your voice croaked, you were banded and poked and prodded and had blood pressures taken and sticks stuck down your throat and a doctor briefly listened to your chest and said “hmm” to himself. You’ll get to see your family this morning and everybody will understand that this was all just a huge mistake and you’ll get to go home.

Except that’s not how it goes.

Many hospital EDs have rules that say you can’t have any contact with anybody, including family members, for the first twenty four hours of your stay, maybe as much as seventy two. Safety, security, blah, blah, blah. Now, I’ll grant you that sometimes seeing the family member who took out the probate court order of detention that got you picked up and hauled in here in the first place might be a little dicey. You are, after all, confused and not a little preturbed that Aunt Millicent would do this to you. Seeing her might cause you to rise up and try to comandeer the medication cart and go wheeling down the hall toward the door, wreaking havoc through the corridors. Best that she stay away. Unbeknownst to you, she feels horribly guilty for what she did, even though it was the right thing and you need this evaluation.

I have heard tell of family who come bringing gifts of drugs and other contraband to ease the suffering of their hostage kin. I have seen parents who get their teeneaged daughters brought to the ED for help, then sit in the room with them and browbeat them to the point that they are asked to leave. I have seen mothers who sit by the bed of their child in the ED day and night and absolutely refuse to leave until some disposition is made. I have seen other mothers who drop the problem child off with these white-coated strangers, sign a paper, turn on a dime and hightail it out the door, never to return.

So hey, in the ED, family visits are sometimes good, sometimes bad. Sometimes helpful, sometimes not so helpful.

Oh, you’ll see other people this morning. Techs, cleaning people, maintenance people, support staff, admin (sign here and here and here, please), consultants, psych liaisons, staff nurses, charge nurses and maybe even a doctor. It takes a lot of people to run a hospital and an ED, and they pass through in a steady stream all day long, doing their thing, getting their jobs done, all in the service of the organism.

Oh, the doctor and nurse thing? Let me tell you a little something about that. Well. maybe just the doctor part since I am a doctor and can speak directly from my own experience.

If you’re a psych patient in an ED, doctors will treat you kindly and efficiently and do what they have to do to assess you, but that’s all. They are basically uncomfortable around you. Sometimes, they are afraid of you. Sometimes they are bothered by the fact that you are even there, especially if the mental health assessment gig is new for their hospital and ED.

Now, to be clear, I am not doctor bashing. I AM a doctor. It’s as though I, a psychiatrist and, I think, a good one, walked into a modern-day cardiac ICU and was assigned a sixty-year-old man who had just had his third myocardial infarction and was being kept alive on a ventilator. I’d be able to handle most of the rudimentary procedures necessary to keep him alive. I can still do a competent physical examination, review and interpret lab results, and see evidence of congestive failure or pneumonia on a chest x-ray. However, I am not comfortable taking care of someone suffering the effects of a massive heart attack. It’s not what I’ve been doing the past twenty six years. Give me antipsychotics and hallucinations and depression and panic attacks. I’m at home in that landscape. You get my drift?

Even when it feels like you’re being avoided by the doctors and nurses in the ED, I just can’t imagine that this is ever done out of spite or neglect or malice. Healthcare providers are not wired that way. We want to help people. But, like the plumber who knows his pipes and the electrician who knows junction boxes and wire, each of us has a body of knowledge, learned and honed and fine tuned over years of clinical experience after that initial rudimentary medical education we all get. We know what we know, and we avoid what we don’t know how to do. It’s training, but it’s also human nature.

When you have an encounter with an emergency department after a serious suicide attempt, you don’t ft the established mold. You can’t be sutured. You can’t be set and casted. You can’t be TPA’d.

You don’t fit an established medical protocol.

Hey, you already knew that, didn’t you?

Next, what happens to your dignity when you come to the emergency department seeking help for a mental health problem?

One last thing.

Happy Mother’s Day to all the mothers out there. My mother was one of my first readers back in the day, and she encouraged me to keep writing and creating.

Thanks, Mom.

Now, you have volunteered to come in, you have been picked up by the police, or you have been coerced by your family into coming to the emergency department tonight. You could have gotten to this point any number of ways. It’s three AM. The fact is, you’re being triaged by a very tired night nurse who is looking forward to seven AM report and freedom. Not blaming her for that. Not at all.

You are subjected to what is a pretty standard assessment nowadays in most EDs, including questions about your presenting complaint, your past history, the medications you take at home, and suicidal ideation or previous suicide attempts, and a substance abuse history. You might be screened for various illnesses, and if you say that you’re suicidal you get a few extra questions that allows the ED staff to assign a number value to your risk for self harm. At this point, or sometime soon after, a telepsycyh consult will be ordered for you if you are in one of the SC hospitals that is part of the SC Department of Mental Health Telepsychiatry Project. Funny thing is, up to this point you’re treated pretty much the same as the patient with congestive heart failure, poorly controlled diabetes mellitus or a hangnail. It’s after you are identified as a psych patient that things start to get a little restrictive. Well, a lot restrictive actually. Downright borderline abusive, if you ask me. But what do I know? I’m only a psychiatrist with twenty six years of clinical experience in the field. Ahem.

What happens to you next? What is done to you, without any input from you? You are wanded to make sure you have no weapons or contraband on your person. Then you are asked to remove all your personal clothing and dress in standard issue scrubs. Now granted, some hospitals have nice blue or green or purple scrubs if you’re into color, but still. Paper scrubs. Pretty flimsy and non-substantial. Your clothes and personal items are inventoried and put away for safe keeping. You cannot keep a watch, a cell phone or any other personal effects in most cases. You would be surprised, as I have been, how many people are not able to give me a contact number for family or even for their own spouse because the number is stored in their cell phone and they don’t know what it is! In most hospitals you are not allowed any visitors at all, even close family, for at least the first twenty four hours if not longer. You are pretty much cut off from everyone that might help you to feel safe, at a time when you are likely the most out of control you have been in some time. Make sense to you? Me neither.

You are then most likely put into a cubicle or bay or room that is isolated from other patients. Some of these rooms for psych patients have only a bed, or maybe even a gurney, to lie down on, no television, no reading material, no stimulation of any kind. Patients are constantly complaining to me about “staring at the four walls” especially if they have to wait in the ED for a psych bed to open up somewhere so they can get some actual treatment. Put a patient who is paranoid, agitated, hallucinating and frightened into a small windowless room, cut off from all communication with others and given nothing to distract him and what happens? That’s right. You guessed it.

Worse yet to me, many of these folks are told to get into the hospital bed or gurney, pull the sheets up, and lie there passively waiting for their assessment to be completed. That is perfecty fine if you have a kidney stone, have just been given narcotics and don’t want to move (yes, been there, done that a few times, thank you for asking), but if you are an agitated mental health patient, or if you are depressed out of your mind, lying passively in a hospital bed for hours or days is the worst possible thing you can be told to do. You should be up, dressed, stimulated appropriately, and distracted as much as possible from the symptoms that brought you into the ED in the first place. Most all of these mental health patients are not IV-in-arm, lie in this bed and don’t move kinds of patients.

Now granted, I understand full well that the hospital EDs must maintain a safe environment for both patients and staff. Patients who are truly suicidal and have expressed plans or are even at risk of acting on these urges in the ED must be kept safe. This often involves restrictions. But the vast majoriy of patients I see for consults in the ED are not like this. They do not need this level of restriction, and in my humble opinion I think it might be detrimental to them overall.

The bottom line here for me? Hospital EDs are so worried about controlling, restricting, and limiting mental health patients during their assesment and in the wating tme afterward that the issues that brought them in are exacerbated and actually harder to control. Anxiety gets worse, depression and despair deepen, hopelessness is heightened, and the patient who initially wanted help is thinking of nothing else but how to escape the prison that he now feels he is trapped in. “This is like being in jail, Doc. Sitting here looking at these four walls, no TV, can’t call my family. This is worse than jail.”

Do I have any opinions about solutions to this problem? You’re kidding, right? We’ll get there. I’ve got a lot more to tell you about before we get to potential solutions.

Stay with me.

I’ve had family members call me before and ask about how to handle a pretty common situation. Their daughter or mother or husband have stopped taking their psychiatric medication, or they are drinking heavily again, or they are responding to voices or other hallucinations to the detriment of their day to day functioning. What to do? How to help?

If the family member or other person so afflicted is willing and able to go voluntarily to their local physician, counselor or mental health system, that’s a good start. Oftentimes seeing someone, ironing out any issues with adherence to a pre-existing treatment plan or getting new prescriptions written rights the ship and nothing more is needed. That is the best case scenario.

If the person gets to the facility and a clinician feels that they are not able to help on an outpatient basis, they might recommend that family take the next step and proceed to the local emergency department for further evaluation. Now, if the patient is willing to do this, no problem. If not, mental health center clinicians or other providers have the option to fill out what is usually known as Part I of a commitment form, authorizing the involuntary transport of the person to the ED. There, the ED physician and possibly a psychiatrist or telepsychiatrist gets involved and the evaluation moves forward.

Another way this can happen is that the family or other concerned person may go to the local probate court and petition for an involuntary pickup order that will force the person to be transported to the ED for the evaluation. When faced with this possibility while working in the clinics, I would almost always want the family members themselves to do this, versus someone from the mental health center, as the family usually had a much more intimate knowledge of how the patient was functioning and if an involuntary admission was likely to be needed. Oddly, even if they were worried sick about their loved ones or in some cases even being abused by them, family members would be hesitant about doing this, fearing the wrath of the detained patient or having extreme feelings of guilt about “having him put away”. With gentle encouragement, they would usually go to the court and proceed.

South Carolina utilizes two models for civil commitment, a police powers model and a parens patriae model. Both require a commitment hearing in a probate court in the county where the person is located. The police powers model allows for immediate detention, as I referred to above.

Under the police powers model, a probate judge, after receiving an affidavit from a family member or another party concerned about a person’s welfare, may issue a detention order that allows police to pick up the alleged mentally ill person and take him to a local mental health center or emergency room for evaluation, as I outlined above. After evaluation, the person may be immediately detained in a psychiatric hospital if the certain criteria are met.

There is a written affidavit sworn by a witness (the family member alluded to above is ideal in my opinion) stating their concern that the person is mentally ill and that because of that, the person is likely to cause serious harm to himself or others if not immediately hospitalized; the specific type of serious harm thought probable (what is the person likely to do if not treated); and the factual basis for this belief (what has the petitioner actually seen the person do, such as taking out a gun, loading it, and making a threat to shoot himself).

Also, certification by a licensed physician may come into play here. This written statement by the doctor must say that the person is mentally ill and that because of his mental illness, he is likely to harm himself through neglect, inability to care for himself, personal injury, or otherwise, or to harm others if not immediately hospitalized. (We take care of our own, so to speak, if they cannot take good care of themselves) The certification must contain the grounds for the opinion.

Read more about this process in the state of South Carolina, and how probate court judges play a vital role in it, here.

So, we’ve looked at several ways that a person may end up in the local emergency department. I see patients in two dozen EDs around the state. Some are very good at handling mental health emergencies and evaluations. Some are not so good.

Next, we’ll  take a look inside, pulling back the curtain of the ED bay, opening the door of the holding room and feeling just what it is like to be held against one’s will in a hustling, bustling hospital ED.

I think it might surprise you.

So, how do people get to the Emergency Department (ED) seeking mental health treatment in the first place? Do they just wander in off the street? Sometimes, sometimes not.

Of course, a particular patient may decide that he needs something and walk in under his own power. Notice that I said something. Here is one of the first branches in the decision tree for the ED physician, and by extension the ED psychiatrist or telepsychiatrist in my case. This patient may be ill, know he is ill and want to seek help. That often happens when a person has been in treatment somewhere, misses a few appointments, has his case closed by the mental health center (MHC), runs out of medications, and then becomes symptomatic again. Read more about mental health problems and relapse here. If he knows that the voices are getting worse, the depression is coming back, and he is becoming suicidal, he may be savvy enough to know that if he does not seek help soon, things will get out of control and one of the other scenarios below will play out for him soon. That’s good. He comes in, gets seen, gets treated, and may be able to go home straight from the ED. This is a win-win. Patient gets what he needs, ED provides a reasonable and necessary service, patient does not sit in the ED for days or weeks, and that ED bed is freed up for the next patient presenting with chest pain or trauma.

Of course, there are other reasons for someone presenting to an ED. Sometimes this person is not mentally ill at all, but is faking, actually faking, symptoms with some particular goal in mind. What kind of goal? Oh, I don’t know, maybe something as simple as getting what is referred to as “three hots and a cot” because he has been homeless for six months and truly has no place to go. You see this a lot in EDs, and by extension in psychiatric hospitals, around the holidays. It’s hard to find turkey and dressing in the back alleys. You don’t wake up with a stocking full of Christmas goodies when you sleep on a park bench. Can you blame someone who is homeless and cold and hungry for seeking help under the big red ED sign? Of course not. Is this the best use of our staggeringly overtaxed health care system? Of course not.

Other “patients” start to see little green men (a wonderfully rare symptom in “real” psychiatric practice) when they are three or four days out from a child support hearing or a court date to address their marijuana possession charge. You mean, people bring themselves into a hospital to get poked and prodded and pumped full of medications just so they won’t have to go to court? Uh, yes. All the time.

What about the patient who comes to the ED because family tells him he must, or they will have him arrested or will kick him out of the house or some such. Does coercion play a part in getting patients in the front door for treatment, for better or for ill? Yes, it does. Read a little more about this topic here. From this MacArthur study, we find that patients who believe they have been allowed “voice” and treated by family and clinical staff with respect, concern, and good faith in the process of hospital admission report experiencing significantly less coercion than patients not so treated. This holds true even for legally “involuntary” patients and for patients who report being pressured to be hospitalized. If a patient is forced into a treatment situation, especially one as potentially traumatic as an ED (see later posts in this series), he may completely rebel and decide that not cooperating with the assessment and treatment is his new primary goal. This is a lose-lose situation. Patient is not cooperative, ED staff is frustrated, nobody may provide treatment that is accepted by anybody, and the ED bed is tied up for days. All treatment issues aside, there are times that the family simply wants the patient out of the way and sends him to the ED with the hope that he will be “sent somewhere” for a week, a month, or forever. Thankfully, that does not happen as it used to in the days of the huge psychiatric hospital snake pits, where someone was sent to remain locked up in “treatment” sometimes for their entire life. That being said, families do try to have patients “put away” even today because of money issues, squabbles over land, and for old grudges that simply will not die. It is the job of the ED physician and psychiatrist to make sure that trumped up symptoms and histories are exposed for what they are, and that people who do not need to be committed to state hospitals and other facilities are sent home.

One of the more gratifying scenarios for me in this business is the patient who is brought to the ED by EMS (emergency services workers of various kinds, or the police) for a mental health emergency that then turns out to be a previously undiagnosed medical problem that can be assessed and treated. I have seen this play out when a child who was acting out in school turned out to have undiagnosed petit mal seizures. I have seen mood changes and physically aggressive and assaultive behavior that are thought to be due to bipolar mania lead to a new diagnosis of a treatable brain tumor. I’ve seen severe and deep depression with physical manifestations point to a diagnosis of hypothyroidism. All that glitters is not gold, and all that hallucinates is not schizophrenia.

One of the really nice things I see nowadays is that police officers are being trained to quickly spot mental health problems and deal with them in specific, nonthreatening ways that lead to de-escalation and assistance for the person involved, as opposed to tasering, flexicuffs (more on that later, too) and a police car ride to jail. It is a longstanding truism that out largest mental health facilities are our prisons and jails, and that often plays out locally as well. Sometimes when confronted with a person who is out of control and potentially dangerous, it is obviously easier for law enforcement to fall back on previous training, subdue, charge, and transport to jail. Thank goodness many fine police officers today see agitation as a potential response to drug use, threats as possible attempts to act out suicide by cop and yelling and screaming as cries for help, not assaults on the cops themselves. These patients are then brought to the ED for appropriate evaluation and treatment of any mental health or substance abuse problem that might exist.

There are a few other ways that patients can arrive at the ED. We’ll continue with those in the next post.

All that to say that I am not, or have not been to this point, a very well educated man. 

I decided to take a job doing telepsychiatry a little over three years ago. The lure of the technology (shiny!) and the cutting edge aspects of seeing patients in emergency departments (EDs) hundreds of miles away by using slick technology, high speed data lines and multiple computers was just too much to resist. My team mates and I have now seen patients in up to twenty five hospitals (the number fluctuates from time to time), and we have done over fourteen thousand consults in the last four years, give or take. I am basically an ED psychiatrist, albeit a virtual one. The sixteen hour shifts are just as long and draining as if I were really there in body as well as soul, maybe more so. The work is isolating. The constant stream of suicidal patients and the assessment of risk is daunting and exhausting. Like any emergency department job, it is exhilarating and heartbreaking work.

I have learned more, in some ways, in the ED over the last three years than all the years that went before. I have learned how we treat our own people and how we see the sickest of the sick. I have seen how we respond to substance abuse, and how we meet our own mortality every day when we give Narcan to a woman who has just swallowed pills or sew up the wrist of someone who knew how to cut “the right way” and was almost successful in bleeding out. I have learned how helpless you feel when you realize that a patient is set on suicide. I have struggled with wanting to give up on the alcoholic who comes into the ED with a blood alcohol level of almost five hundred (that would basically kill you or me) for the fifteenth time, swearing that he can quit any time and that he does not want treatment of any kind. 

I am being educated every day. There is not a day that goes by that I don’t hear of a new story, a new excuse, a new type of substance to abuse, a new way to be abused, or a new way to die. 

Besides the privilege of being there to help take care of patients, I am also seeing some of the very worst things that are wrong with our health care system, specifically as it pertains to the evaluation and treatment of the mentally ill, some of our most vulnerable citizens. I would like to share some of these observations with you over the next little while. I hope that you will read them, think about them and that they will stimulate discussion and debate. We do a lot of good in the health care business these days. We help a lot of people. We also work in a system that is broken, and that desperately needs a long acting depot injection of compassion, common sense and change to insure its viability into the future.

Come with me, and I will open your eyes.