Mental Illness In The ER
3 unglamorous details that medical shows leave out
There’s a reason why emergency physicians are commonly called ‘jack of all trades’ or ‘master of none’. I see a lot of different things in the emergency department, but we’re (surprise, surprise) primarily focused on preventing your emergent death. The process of triage helps ER staff focus on who needs what and how soon, which can explain long wait-times (it’s frustrating, I know — I’m sorry). But the prioritization of patients — although undoubtedly necessary for emergencies — can result in the neglect of ER patients seeking treatment for psychiatric emergencies. We must create a more empathetic culture where the severity of mental illness is on par with that of a broken leg or, say, even a heart attack. I’m not saying we should start a therapy session when someone’s coding next door. But it’s clear to me that we need a new approach in how we treat patients with mental illness in the ER, especially when they’re the only patients who feel compelled to say ‘sorry’ for the help they receive.
Let’s make one thing clear: Yes, psychiatric emergencies are medical emergencies. It makes no difference if you’re depressed or suicidal, suffering from substance use withdrawals, having a panic attack, or hallucinating: You belong in the ER just as much as someone with a gunshot wound does — don’t let anyone tell you otherwise. I promise you don’t have to apologize for coming in. No, you’re neither “an inconvenience” nor are you wasting my time (as some of my patients have told me).
I truly wish more healthcare providers would champion for mental health. Many systems throughout the United States are simply incapable of providing efficient care to an already marginalized patient population. Mental illness is still stigmatized in the United States and abroad; I know I’m not alone in thinking this. No matter how small, I hope these three personal experiences contribute to both the destigmatization of mental illness as well as the humanization of its deserving sufferers.
1. Everything is taken from a patient.
I always feel complicit in something evil when I have to tell a patient they can’t have anything in their bare, windowless room — not even their clothes — but I do understand the intention is purely precautionary. When they arrive, they’ll be stripped out of the clothes they came in and will be required to wear paper scrubs. I haven’t worn them before, but just handling them with my fingers tells me I wouldn’t want to wear them for 12+ hours. After their belongings are locked away and they’re ‘settled-in’ as best as possible, a patient must contend with, in addition to what brought them in, not having a cellphone, wearing scratchy paper garments, and finding solace with whatever is on TV at two in the morning. It’s understandably a tough situation to be in, but one that I don’t truly understand completely. To make matters worse, however, this is the quickest part of the entire process.
2. Many patients wait an extremely long time.
Shifts in our emergency department last 12 hours. I work the night shift, so I show up before 7 pm and leave sometime after 7 am. When I arrive, there are usually 2–3 patients already roomed who are seeking help for some form of mental illness. Most of them, if not all, have been waiting for over an hour by the time I arrive. Exactly what or who are they waiting for? Well, it’s a two-part waiting process, one that can take more than 12 hours. It’s not uncommon that I’ll go home in the morning, sleep for a couple of hours, only to return in the evening to see a patient from the night before in the same room! The first round of waiting is for a behavioral health clinician to call the ER and say they’re ready to speak with the patient; a nurse or medic will then wheel in a cart on wheels to conduct a virtual chat akin to a FaceTime call. During the call, the behavioral clinician will ask the patient if he or she would like to be transferred to a psychiatric facility. Irrespective of her answer, there will be even more waiting: Answering ‘Yes’ will put the patient in the queue for medical transport; answering ‘No’ will require clinicians to coordinate with a magistrate to determine if the patient can be safely released. Here are two hypothetical, yet realistic timelines of both responses:
‘Yes’ Timeline
- 10:00 pm — Patient admitted to emergency department
- 01:00 am—Telehealth call
- 01:30 am — Patient placed in transport queue
- 06:00 am — Transport arrives
- 07:45 am — Patient arrives at closest psychiatric facility
[Total elapsed time: 9 hours, 45 minutes]
‘No’ Timeline
- 10:00 pm — Patient admitted to emergency department
- 01:00 am — Telehealth call
- 02:00 am—Magistrate is called, no response (sleeping?)
- 03:00 am — Magistrate returns call
- 03:30 am — Patient can be discharged
- 04:00 am — Patient receives discharge papers
[Total elapsed time: 6 hours]
Please note that these are the waiting times that I’m generally accustomed to at my hospital. Mind you, we serve in-state and out-of-state patients alike in the most populous city in the state. A lot of other uncontrollable factors like being short-staffed, full capacity at psychiatric facilities, and low transport availability will further delay the process. Hopefully, not all hospitals will share these long waiting times; hopefully, some have even better systems that I could help implement in my city…
3. Patients have no privacy whatsoever.
Let’s suppose you start experiencing symptoms of psychosis — like hearing voices — and decide to go to the ER. Good news: I’ll commend you for taking care of yourself when something’s amiss with your health (too many people don’t). Bad news: In addition to not having your belongings and having to deal with an absurd waiting time, you will also be monitored during your entire time. Someone will be assigned as your care partner and ensure you’re safe by continuous monitoring — even in the bathroom. Again, all of these policies were enacted for a reason, I get it. It’s well-documented that mental illness sufferers use points of transition (e.g. bathrooms) to harm themselves. But there surely must be a better, more dignified method where patient/provider safety is guaranteed while patient comfort and autonomy are preserved … right?
I have monitored many psychiatric patients; I’ve even sat with some for an entire 12-hour shift. Sure, 12 hours is a lot of time in one day; however, it’s absolutely minuscule compared to some of the life stories that I have heard while sitting with some patients. It’s both truly amazing and humbling that in just 12 short hours, someone can go from a stranger to someone whose life story you’ve heard, reflected upon, and maybe even related to. We must treat patients with mental illnesses for who they are, and this is who they are: Regular people like you and me who have just so happened to trip in the marathon that is life. Some get back up quicker than others, but everyone will inevitably need a helping hand at some point. It takes a village; no man is an island—please, be kind to one another.
