Psychiatric Disorder

In the chaos of the ER, patients with mental or behavioral problems receive scant attention

Unless you love the person and see the effects. One St. Louis woman has made seven trips to private-hospital ERs with a family member who has a serious mental illness. "I don't remember ever getting in in under five hours," she says. "For someone with a mental illness, this is traumatic. If they're having delusions or hallucinations, large groups of people are very unnerving. Everyone's a stranger, and if people are speaking loudly, they hear it even more loudly; there's no filtering of the noises. So, in a long wait, you see the rocking, the fetal position, turning away from people, facing the wall to filter out some of the stimuli.

"It appears to us, watching and waiting, that anyone who comes in with blood on gets immediate attention," she admits. "Mental illness is invisible." Unless the person is psychotic, in which case "you go to their 'safe room.' Blank walls and a steel door and an uncovered mattress pad. It's very cold. But," she adds wryly, "it does get you out of the waiting room." She pauses. "It's very hard to realize, secondhand, the torment someone with a mental illness is going through. If we had any idea, I don't think we would do the process like this."

What do you need to make an ER easier on psych patients? "You mean besides respect?" retorts Dr. Margaret Nelson (not her real name), a St. Louis psychiatrist who has covered ERs here and in another state. "If someone is a street-looking person, especially if they smell of alcohol or act a little goofy, some ERs will automatically assume it's psych and not do any kind of a medical check." The converse is true, too: According to a July 1997 article in the Journal of Emergency Medicine, about 30 percent of patients who come to the ER for chest pain but don't have a cardiac problem are actually suffering from panic disorder. And in January 1997, the Annals of Emergency Medicine reported a study in which only 4 percent of teenagers coming to an ER with physical complaints (chest pain, weakness, dizziness, hyperventilation) were screened, as they should have been, for depression.

"I've had patients who were demented, and the nurse circled 'yes' on the form that asked if they were alert andcontinued on next pagecontinued from previous pageoriented," groans Nelson. "I once had a nice, long conversation with a woman who was about 100. Then I asked where she lived, and she said with her mother. So I asked her what year it was, and she said 1957! Some nurses will assume that if the patient can speak, they're alert and oriented. And often a doctor will say someone is demented when in fact they are delirious, which means fluctuating levels of consciousness and is a medical emergency, often signaling something toxic or metabolic.

"If I had all the money in the world?" Nelson asks abruptly. "I'd set up an ER where you get greeted at the desk, have your vital signs checked, get thoroughly interviewed by an RN, nurse practitioner or social worker." (Quoted Sherman's comment that they're all busy telling people their loved ones are dying, she retorts, "How many deaths are they having a night?") "In terms of space," she resumes, "you need that open area, so if someone crashes you can get there. But around the perimeter, a series of little treatment rooms with walls, for any procedure deserving of privacy. A lot of places will still interview psych patients out in the open, right in the hallway. That's wrong. They have to be able to trust you.

"People say, 'We don't have enough money,'" Nelson mimics. "I think that's bullshit. Unfortunately, the money's tied up elsewhere. As a result, we have shortages of staff, overworked staff, burned-out staff. And ER psych is a shortage specialty. The average time till burnout for any ER doctor is 10 years. One described the work to me as 'long periods of boredom interrupted by moments of sheer terror.'"

What about the territoriality and detachment Stratton observed? "You're not my patient," Nelson explains swiftly, familiar with the syndrome. "If you are not my patient, I don't take care of you. Right now I might have a break." She sighs. "You're put in a setting where you have no help, you get harried and you burn out. You never know what's going to walk through that door or, in extreme cases, drive through that door. You never know what's coming. And if you have a really terrible night, the patients who come next are going to catch that, because you're not going to dump it on someone who arrested three times and you revived them and sent them upstairs.

"Bottom line, there's not enough staff. Their weeks need to be shortened, not lengthened. There needs to be a coordinator with a backup shift. But they don't do that. You go on; you just keep doing it, no matter what. And the way you go on is the same way soldiers go on in combat: You dissociate. Feelings are not important; people are not important. The only thing that's important is your job. And if your job is to draw blood, it doesn't matter if you're drawing it from a distraught elderly lady with thin veins -- your job is to get that blood.

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