It’s a Family Affair

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Is there a place for family members in the emergency department?

Yeah. 

“Go down the hall, take a right, go through those double doors, behind the vending machine, against the far wall. There’s a double row of hard plastic blue seats where you can sit. Coffee machine down the hall from there. Gift shop on the first floor. We’ll call you when you can see Aunt Mary.”

Of course. We’ve all been there, done that. I’ve spent some time in those egg-shaped butt-numbing receptacles, as have you. That’s not exactly what I’m talking about, though. 

How do families fit in when mental health patients come to the ED seeking help for the suicidal thoughts, the voices, the depression that plague them?

First of all, right out of the gate, family can be invaluable in providing information that the mental health patient cannot or will not give up themselves. 

Some patients are simply too distraught, too disorganized and too psychotic to give any meaningful narrative of how and why they showed up. They are too preoccupied with seeing dead people to speak with live people. They are too deeply focused on themselves and their pain to turn their focus outward on the doctor who is asking what seems like an endless stream of silly questions. 

I can’t make a meaningful diagnosis or recommend anything helpful to an ED attending physician if I have incomplete information. This is why my consult procedure more often than not involves making at least one phone call after I finish the patient interview. A spouse can give me insight into this new-onset psychosis in a seventy year old. Mother knows best when separating acting out from mental disturbance in a six year old. A father has a different perspective on a teenager’s angst than a mother does. 

Families can be calming in times of crisis. 

The ED is a scary place, full of hustle and bustle and lights and portable x-ray machines and lab techs and white-coated scary people. Having one’s clothes and valuables taken away, given air-conditioned scrubs to don, and being placed on a gurney and told to stay there and not move can be very uncomfortable and downright upsetting to a person who is already panicking and contemplating suicide. 

A family member at the bedside, when allowed and appropriate, can be better than Q 4 hour injections of Haldol and Ativan any day. A kind word from mom, a firm hand from dad, or confirmation from a spouse that everything will be okay are balms for the raw nerves and grating irritation that is the emergency department. 

Now, you know as well as I do that this is not always the case. Supportive, loving families are wonderful and helpful in the ED, but there are other times that having family members in the vicinity of the mental health patient is nothing but trouble. Sometimes, it can be a disaster. 

Take for example the nine year old who presents with abdominal pain. Workup is negative. There is nothing “wrong” physically with the child, but the ED doc, rightly so, feels one of those gut checks that tells her to go further. The child is anxious, fearful, more so than would be expected in a normal ED encounter for belly pain. She is anxious, scans the room, cowers and shrinks away when touched. She has a couple of bruises, incidental findings on an otherwise completely normal physical examination. 

The doc calls for a mental health evaluation and a social work consult. During this process, the child’s father, nowhere to be found on initial presentation, shows up at the triage desk demanding to see little Suzy. He is big, scary, belligerent and smells strongly of alcohol. He demands that she be released and says that he is taking her home. There’s nothing wrong with her, he insists, a little too forcefully. 

You know where this is headed. Social services, psychiatry and child advocacy get involved as afternoon turns to evening to night and shift change in the ED comes and goes. This little child, who came in complaining  of belly pain, has a pain in her heart and an injury to her soul that her abusive father does not want made public in this place of healing. While a sanctuary to the abused little girl, the ED points an accusing finger squarely at the man who is the abuser. He knows, even in his intoxicated state, what it will mean if this history sees the light of day. So does the ED staff, who are charged with keeping the child safe.

I have seen other family members abuse the system of mental health evaluation by taking out what are nothing more than false probate court orders to have a patient picked up and brought to the ED for certification for admission to a psychiatric hospital, even when they clearly don’t need it. This might be because of a deep-seated family feud over money or land. It might be a controlling husband looking to have his wife “put away” in a mental institution (something that thankfully doesn’t happen today as it did years ago). This abuse of power by one family member over another, whether or not they have a true mental illness that needs treatment or not, can be frightening to the patient and eye-opening to the hospital staff, who are not accustomed to being pawns in this kind of game.

As a second-year trainee many years ago, I had a supervisor in the outpatient clinic who was a child analyst. Dr. Finch told me something one day that has stuck with me for almost thirty years. 

“Dr. Smith,” he told me in his gruff but smooth bass voice, “you cannot, you will not see this child for therapy unless the family agrees to be here, to be active, and to be involved in his treatment. Period.” 

That lesson from my old clinic supervisor is just as valid for me today as I see ED patients as it was when I was learning to do play therapy with emotionally disturbed children. 

I can talk to families and glean valuable information, good and bad, positive and negative, and do a better job of helping the suffering soul in front of me.

Or, I can ignore input from family members, tuning out the very people who know my patient and her struggles the most intimately. 

I do the former because it is good practice and is best for my patient.

I do the latter at my peril.

 

 

 

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