Through a Glass Darkly

For now we see through a glass, darkly, but then face to face…

1 Corinthians 13:12


I have been asked one question about my work in telepsychiatry more that any other, hands down.

“Can you really help a mental health patient like that, through a television screen?”

The quick and dirty answer? Yes, absolutely.

The extended answer? Read on.

Psychiatry is an intensely personal specialty. It requires knowing yourself as a doctor, as a therapist, as a consultant, and as a person more than any other kind of medical practice I have ever been exposed to.

It requires four years of residency after four years of medical school to train to become a psychiatrist for a reason. You must not only master the big picture and the fine points of the specialty. You must understand what makes you tick. You must know how you respond to stress, challenge and adversity. Without this knowledge and training, one makes a very marginally competent psychiatrist at best.

As a psychiatric consultant, I ask questions that in normal social discourse would be considered forward, intrusive, even bordering on abusive. I ask about the intimate details of your medical history. I ask about your work history and why you were fired from your last job. I ask about your sexual history and yes, I usually want to know if you’re straight or gay. Not to pry, but because it gives me a tremendous window on your life, how you perceive yourself, and how others perceive you.

I want to know about your legal history. I ask how many DUIs you’ve had and what lead to the Criminal Domestic Violence charge. I want to know the details of your last suicide attempt. Why did you cut yourself instead of overdosing this time? Was your intent to die, or just to reach out and make a statement to someone who had wronged you?

Think about the last really deep conversation you had with a very close friend, a sibling, a parent, a spouse, a lover. What made it special? What made it real? What made it possible for you to let that person have access to a very deep part of you that no one else knows about?

It is the connection, the intimate connection between two people that allows these kinds of conversations to happen. Pure and simple. You know it. I know it. In our friendship, if you are not willing to let me in, to share your hopes, your fears, your dreams with me on the very deepest levels, we might as well be two strangers who met in an airport bar and had a chat during a layover.

Now, several of you have argued with me over the last few years that relationships on social media cannot be real in that sense. You cannot have that kind of deep, emotional and spiritual connection with another human being over Facebook, Twitter or any other social media platform. Many of you have said the same about telepsychiatry. You can’t possibly talk to someone and learn enough about them over a television screen to help them.

All I can tell you is that over the last four years my colleagues and I have done almost fifteen thousand consults via high speed lines and high definition video monitors. Personally, out of the thousands of consults I have completed myself, only two patients that I can recall now refused to talk to me over this medium. Both were very ill and their level of paranoia precluded them connecting on a meaningful level with anyone, in person or via video.

The flip side of that coin? I remember very well, with great pride and a very deep sense of fulfillment, the father of the emotionally sick child I had just interviewed. He was at the end of his rope. His child was suffering, dying in a very real way before his eyes. He did not know what else to do.

After our interview I went over the treatment plan with him. I told him that there were things that could be done to help his child, and that we were going to do them, starting at that very moment. His face changed. He smiled a very weak smile. I could see the hope in his eyes.

Spontaneously, he jumped up out his seat, two hundred miles away from me, and reached out to shake my hand.

I knew at that moment that the medium was powerful, the connection real and the intervention worthwhile.

We had seen each other through a glass darkly, and then face to face.

Miss Personality 2013


So are there other special groups that hit the emergency department on holiday weekends like this?

One of the groups of patients that have a hard time in the regimented world of the ED are the ones with personality disorders. People with things called borderline personality disorder, histrionic personality disorder and avoidant personality disorder don’t mesh well with a place where someone else tells you what to wear, where to sit and stay and when to go to the bathroom.

According to the new DSM-5, a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Let’s break down this DSM-speak for you, dear readers.

Personality disorders show us an enduring pattern of inner experience. It doesn’t matter what the circumstance, what the stress, or what the setting, folks with PDs are going to have a hard time.

Prime example: you know very well that if you go the ED for your health care that you are likely to wait. And wait. And wait. And wait some more.  A man with Narcisisstic PD will most likely respond to this “normal” stress by loudly proclaiming to the triage nurse that his illness is  much more important than anyone else’s, that his time is more valuable, and that his as-yet-undiagnosed condition will probably be worthy of publication in several juried medical journals. This is his inner world. He is more important than you. He is more interesting than you. He should be bumped ahead of you in line. Even though he might be indigent, he should be given the very best care there is. Just beacuse he’s, well, HIM.

The fact that these PDs start in teenage years or early adulthood is a problem, in that the patient with PD will learn very earily on how to get the system to respond. A woman with Borderline PD comes to the ED with moderate symptoms of depression and anxiety. All of her lab work and studies are normal, her physical exam is unchanged from the last one documented and she is bascially ready for discharge to outpatient followup. Her doctor, who she has already put on a very high pedestal, comes in to tell her that she is being released. In purely medical terms, she flips out. The doctor immediately falls off his pedestal, hard, and becomes the worst practitioner in the entire world, stupid and ignorant and incapable of seeing what kind of care she needs. She fusses. She fumes. She might show inappropriate, intense anger at being discharged (remember, she has just been told that she is basically okay, something most of us would be happy to hear in the ED as we are being sent home).

PDs are stable over time. From one ED visit to the next, the woman with Histrionic PD will show the same pattern of excessive emotionality, attention seeking, and dramatic acting out that will most likely lead many ED staff to shun her (not always consciously, mind you). This is the patient who opens her gown just a little too wide at the top, exposing her ample bosom to the male nurses or doctors when not necessary for examination. She is the one who will always have every hair in place, perfect makeup, and freshened bright red lipstick even though she has just reported abdominal pain that is “10 out of 10” and excruciating. She sexualizes the encounter, manipulates the staff, and if her perceived needs are not met she may have a dramatic fainting spell, pseudoseizure, or bizarre migraine out of the blue just as her discharge paperwork is being completed.

It is difficult enough to sort through the myriad symptoms, lab values, scans, x-rays, histories and old records to come up with a solid working diagnosis in the ED and get a patient triaged, diagnosed, treated and out the door. Add to that the pressure of working in the context of personality disorders, which are not uncommon in patients who present to the ED for treatment, and the ED staff may find themselves in a hell of a mess.

The trick here?

Stay cool.

Remember your training.

Use your head.

Don’t rise to the bait.

These folks are sick just like anyone else. It’s just that the way they respond to medical stress is the same way they respond to changes in their love life, a broken water pump in their car, or a clogged toilet in their bathroom.

See past that, to what the real issue of the moment is, and you’re halfway home.

Ya’ll Come Back Now, Ya Hear?


“I can stop drinking any time I want to, Doc. I’ve done it a hundred times!”

”I don’t need my lithium any more. I have the strength of ten men. I’m smarter than anybody in my family. Why would I need to take medication?”

“God told me to stop getting the injections. He talks to me every day. Don’t you, God?” (looking over toward the empty exam room chair in the corner)


The scourge of the ED. The scourge of medicine in general.

Why do we ALL (and I sheepishly but with full disclosure include myself in this camp) continue to do the things that we know give us problems, make us sick, and land us back in the doctor’s office, the exam room, the ED, or a hospital bed?

Why? It makes no sense.

Psychiatric patients are sometimes unceremoniously called “frequent fliers” in the business (as are, of course, other medical patients who visit the ED with greater than expected regularity). This is not derogatory in my personal opinion, but it is damn sure descriptive. How many? Hundreds, thousands. In and out of treatment. In and out of acute care hospital beds, which are now scarcer than hens’ teeth. On medications, then off medications, Therapeutic blood levels of medications this week, then a level of zero next week. (Noncompliance is now a non-PC word, but there you have it. Call it whatever you like.) Repeated blood alcohol levels of 200, 300, 400.

I saw a patient recently who was sitting up, reasonably lucid, talking to me and was pissed as hell that I would not order strong narcotics for his thirty-year-old back and hip pain. His blood alcohol level? 479. For reference, at 100, you’re drunk.

You can’t go home again.

Well, of course, you can, if your home is the ED of a local hospital or a publicly funded clinic that has little choice but to take you back, muttering soto voce about it but doing it nonetheless. You know it, and they know it.

Why are there repeat offenders (against themselves and their own health) in the medical world?

Chronic illness is just that. It’s chronic. Unrelenting. Painful. Hard to live with. Sometimes we want to give up. I was diagnosed with polymyalgia rheumatica a few years back. It’s under good control now, but some days I wake up feeling like I slept under a Sherman Tank. I’m stiff. I hurt. My body says “no” and I say “but I have to get to work by eight if I want to eat”. I go back to the doctor when I have to. When I need to. When I need some help. Not often, but I go.

Mental illness is a little different. Are you catching that drift from me as we go through this exercise together, you and I? Mental illness takes away our ability to process things normally, to make good decisions and to do things that are in our own best interest. We stop taking medications, we drink more and more, we drop out of service at the clinic, and we take a few more pills each day to keep us going. Pills off the street. Illegal drugs. “Legal drugs” like spice that don’t show up as THC in a random urine drug screen but that I’ve seen make pretty normal people bat shit crazy in an emergency department.

Which kinds of mental health problems show up most often in the ED for evaluation? If you look at my log of consults done, something I keep at the end of each shift, every day that I work, you would see a long column of reasons. Danger to self outshines them all. Intoxication is well represented. Danger to others pops up. Unable to care for self has its moments. Yes, there are patterns.

It has astounded me, truly astounded me, how big a part substance abuse plays in the presentation to the ED for mental health evaluation. I may as well go ahead and check off “marijuana” on your forms before I even talk to you because eighty per cent of the time I know you smoke it. And, please, don’t even try to go there with me. We can argue until the cows come home about whether the drug should be legalized or not, whether it’s just like alcohol or not, whether it’s a gateway drug or not, whether it calms your nerves better than Xanax or not, ad infinitum. In SC, using marijuana is illegal. If you get a random screen pulled and you “piss positive”, you get fired. Deal with it. I’m not going to argue with you about it at midnight in the ED when your blood alcohol level is also 300. Move to Colorado.

Mi dispiace. Got carried away there. (Sitting up straight and straightening tie, if I still wore one, which I usually don’t).

Is it ever safe to just say, “no more”? To say to the patient, “Look, you don’t want treatment, that’s obvious, so why don’t we call it even? I’ll discharge you if you promise to never come back to my ED ever again. Deal?”

That’s a struggle for any of us who took the Hippocratic Oath (yes, we really did) and basically had it beaten into us as medical students and residents that we HELP people. We TREAT people. Sick people. People who don’t think clearly and who do not make good decisions. That’s what we do. Yeah, but to the point of personal abuse?

I think I need to come back to this, what do you think? This is important stuff, but I’m at a thousand words already and your eyes are glazing over.

Tough issue, this one.

So we muddle through.

You come in. You’re sick.

We patch you up, send you out.

You come back in. You’re sick. Same sickness.

We patch you up, send you out.

I seem to remember something from Greek mythology about a guy named Sisyphus.


Let’s shift gears next time and talk about some special populations that I see in the ED for mental health evaluation nowadays. Sound good to you?


See you back here soon.

Would you give me a hand with this rock? Thanks.

The Waiting Game


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.


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?


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.

Don’t Bug Me!

Now, where was I?

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.

If the Dog Bites, If the Bee Stings, If I’m Feeling Sad



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.


Close Encounters of the Emergency Kind


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.

You’re Surrounded!

Okay, so I want you to imagine that you’re a mental health patient in crisis. C’mon, you can do it.

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.

Court Is In Session

iStock_000001647199_SmallGood morning.

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.