Arrivals

Good morning, folks. Let’s talk about access today, shall we?

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.

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