Psychiatric Disorder

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

One Sunday evening, Eileen Stratton (not her real name) found herself sobbing uncontrollably for no apparent reason. "I was shaking, my heart felt weird, I was getting very agitated and very upset." She called her therapist, who was out of town, and then her medical doctor, because she has a history of rapid heartbeat. The doctor's partner took the call and agreed that she should go to the emergency room.

Stratton drove herself 45 minutes to Jewish Hospital. They shuttled her over to the Barnes ER, accompanied by a silent young man. When they arrived, families were clustered around the desk, and the nurse was visibly harried. The young man, eager to depart, pressed Stratton's papers on the nurse. "Shit!" she snapped. "Can't you see I'm busy?"

He tossed the papers on the desk and left, says Stratton. The nurse yelled at the families, "Look, if you don't want to get run over, you better move, because I've got helicopters coming in!" Another nurse came out, and Stratton got the impression the two were fighting. She sat down, still shaking, amid the general turmoil.

Three hours later, her name was called on the PA. She hesitated at a sign that read, "Stop Here for Security." Stratton says that she "stood there with my heart beating like it was coming out of my chest. Two guards were standing around eating sandwiches. Finally one said, 'Go ahead.'

"A young nurse took my blood pressure and asked why I was there. I said, 'I don't know how to identify it -- my heart's racing, I feel overwhelmed, I've been crying uncontrollably. I'm on medication for my heart, so I don't know if I'm having a drug reaction.' She said, 'Oh, depression.'"

Stratton heard another staff person, walking by a man who thought he was having a heart attack, loudly describe an accident victim across the room as "just about the grossest thing I've ever seen." Meanwhile, a nurse was yelling directions for suppositories at a frail, elderly woman in a wheelchair: "'You put 'em where you poop!' Another woman wet her bed and was crying that she was all wet and they were complaining about her. There was no dignity."

Later Stratton overheard someone call, "Anybody seen the depressed lady yet?" but she says it wasn't until 6:15 the next morning when a psychiatrist showed up and asked brusquely, "What is your problem?"

"We were out in the middle of everybody, too, so I'm only glad I didn't have to have suppositories," she says ruefully. "I tried to explain, and he said, 'This is an emergency room.' I said, 'I see that.' He said, 'Well, are you going to kill yourself?' I said, 'I don't think so, but I don't know what that would feel like. My father committed suicide and -- ' He said, 'I don't really have time to talk to you here. You need to find yourself a psychiatrist who has time to fit you in.' Then he said, 'You must be very tired. You look tired. I'm going to prescribe sleeping pills for you,' and came back with two weeks' worth." (She later learned they were anti-depressants, which can help with sleep.)

"He couldn't wait to get rid of me," sums up Stratton. "I'm bright enough to know weekend nights are probably terrible there, and I realize I don't have a gunshot wound or a broken neck. I'm not trying to be pushy. But it was almost like people were laughing at the patients. They were totally detached, and everyone was telling you how busy they were, but there were still people standing around visiting. Like it's their territory, and they don't really want you there." She went home more shaken than before, and all she could think was, "We are getting to be such a cruel society."

"A hospital emergency ward can be as loud as a Spice Girls concert and just about as soothing."

-- Health magazine, December 1998

ER trips are hellish, no matter what. "It's difficult to do a lot of niceties down there," says Dr. Laura K. Sherman, chief psychiatry resident at Barnes. "People are dying." Still, she'd hate to see a separate ER for psychiatric cases, because she's tired of psych patients' not getting full medical care.

"It would be nice to have more space, so we'd have a quiet area," she says. "Barnes is building a bigger ER." Quiet would help; so would some basic kindness. Any chance of a pastoral-care or social worker helping out with that? "It's almost impossible," Sherman replies. "They are typically very busy doing things like telling people that their loved one is dying. And to make that determination of 'Hey, maybe we can have someone go back and sit with this person' -- well, triage would have to do that, and I don't think that's really part of their job."

Should Eileen Stratton have simply stayed home? "Oh, no," Sherman says. "My philosophy is, if you don't know where to go, err on the safe side and go to the ER. Someone might be shaky and vulnerable, but, damn, they might also be suicidal. It's very difficult to know." Does all the stress, anxiety, bloody trauma and fatigue ever destabilize them further? "There is no way of gauging that," she shrugs helplessly.

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.

"Administrators encourage divisiveness," she adds. "They don't encourage support groups of ER doctors and nurses, because imagine what would happen if they started talking about all the things that were wrong with the system and what needs to be done to correct it. Right now, it's hard to say, 'I need some time, and I need to not be punished for it.'

From the patient's perspective, is any real harm done? "I think it is," she says. "It hurts to be that vulnerable. It hurts to wait seven hours and see everybody else get taken. The message is, 'What is wrong with you doesn't matter.' And what you see while you wait! Yeah, I think it does do harm.

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