Saturday, May 07, 2011
That End of the Hall
The ER where I volunteer has a particular set of rooms often used for psychiatric cases. They feature things like steel shutters that pull down over equipment panels, so someone who's acting out can't destroy medical gizmos. Even without such special features, the staff tends to cluster the psych patients close together so that sitters -- staff charged to watch them -- and/or security have only one area to cover.
The rooms were lively today. One patient kept begging to use the cell phones of passersby, and ultimately got into a yelling match with a doctor while security guards and nurses looked on. (It's hard to say who was more frustrated, the doctor or the patient.) Another patient wound up in four-point restraint. "One arm up, one down!" the nurse instructed the security guards who'd be trussing up the patient. She later told me that if both arms are down, the patient can still head-butt someone who, for instance, is changing an IV. If one arm's down at the patient's side and another's over the patient's head, movement's much more restricted. And then we had a frequent flyer, someone notorious in the department and whom I've met at least twice over the last few years, who had already been in two other times this week.
Psych patients have to be medically cleared before they can be sent to psych hospitals (and have to wait for beds to become available in those facilities). They also have to be evaluated by a psychologist, psychiatrist or psychiatric social worker. These individuals aren't dedicated to one department, or even one hospital. They're on call and float among all the hospitals in the area, which means that it can take hours for them to show up.
When you add all these factors together, some psych patients wind up being held in the ER for forty-eight hours. This would be nearly intolerable for any patient, but psych patients are, by definition, already emotionally unstable. Nobody likes waiting in an ER; psych patients are probably less able to handle long wait times than anyone else, and they wind up with the longest wait times of all.
Let's do a thought experiment. Imagine an average citizen who isn't already depressed, paranoid, or feeling violent towards self or others. Maybe you're picturing yourself; maybe you're picturing someone you think is better adjusted than you are. Now, stick this person in a small white room. Deprive this person of all clothing and other personal possessions -- since just about anything you can imagine could conceivably become an instrument of destruction -- and give your patient a humiliating hospital gown instead. Outside the door, park an aide or nurse who peers in at regular intervals.
Your patient will be given food and warm blankets, and may even have a private bathroom. A chaplain may stop by for a chat. Doctors and nurses will show up for a medical evaluation early on, but after that, no one can tell the patient how soon the person performing the psych evaluation will arrive, because no one knows. Once the psych evaluation has taken place, no one can tell the patient how soon a bed will be available at the facility across town. Once a bed opens up, it's anyone's guess when transport will show up. If the patient wants to leave, she or he will be told, "No, you're on a legal hold." Everyone will try to be as nice as possible, but if the patient starts getting cranky, the attitude of the staff is likely to go downhill fast. In most cases -- for reasons I don't entirely understand myself -- the patient won't have access to whatever medication he or she was taking (or not taking) at home. And all of this could go on for up to two days.
At the end of those two days, is your average citizen feeling depressed or paranoid yet? Fighting an urge to scream at people? Looking for things to throw?
Yeah. I thought so.
This system would drive the sanest of us bonkers, and the people subjected to it are already fragile. It stinks. Patients and staff both hate it, and too often vent their frustration on each other as the easiest accessible targets. Patients don't understand why they can't get their meds: they're in a hospital, aren't they? Providers don't understand why patients can't be more reasonable, and resent bad behavior even when that behavior's a symptom of the condition for which the patient is seeking treatment. It certainly doesn't help if the bad behavior involves attempted violence to staff. Even patients (psych or otherwise) who've walked into the hospital tend to start getting rebellious after ten or twelve hours; people who've been brought in against their will are even more unhappy.
Nobody was happy today. I usually like psych patients, but I found this bunch as exhausting as everyone else did (although my heart breaks for our frequent flyer, who's a very sad case). I was on the fringes of a staff kvetch-fest that featured people offering passionate rants about how much they hate dealing with psych patients. They want to be sympathetic; they try to be sympathetic. But they're overworked and have a million other urgent tasks to perform for patients for whom the ER is the front line, not a way station.
"The system's broken," I said. "It's like taking somebody with a broken leg and saying, 'Okay, we're gonna make you stand in a corner for forty-eight hours, on your broken leg, and we're not gonna give you pain meds.'"
People laughed. "That's pretty good, for a chaplain," said one of the docs. (We chaplains are a slow bunch, but we catch on eventually.) A case manager said, "You're right. The system is broken. Can you think of ways to fix it? Would you work on that?" (I think she was being serious, not sarcastic, although I may have missed some nuances in the general haze of fatigue and exasperation. Gary's response, when I told him about this later, was, "Are they paying you a consulting fee?")
"I think what we need is a dedicated psych ER," I said, "and that won't happen." The case manager sighed, nodded, and walked away.
Actually, we don't even need a dedicated psych ER. We do need a few ER staff who are dedicated to psych patients and who'll attend to their needs as quickly as everyone else attends to the purely medical cases. And, most of all, we need a ton more community mental-health resources. If we had those, some of these patients wouldn't wind up in the ER at all, and others would have more options about where to go post-ER.
None of that's going to happen, either, not in this economy. Those kinds of services are the things that get cut when money's tight. (And I've done enough research to know that the conditions I'm describing aren't limited to our area.) And, of course, many psychiatric patients can't pay for their care, which makes everything worse.
One patient today wound up being discharged, a huge relief for everybody. The frequent flyer asked me solemnly if I loved Jesus, and when I smiled and nodded, sang me a song he wrote about being friends with God. Then he rolled over to take a nap, which was probably the most sensible way for him to spend his time. I don't know what happened to the patient in restraints. For all I know, he and the frequent flyer are still in their respective small white rooms, all these hours later, frustrating a new shift of medical staff.
Really, there's got to be a way to do better by these folks. The question is how to do it without spending extra money. If anyone has any idea how to answer that, please let me know.