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.
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?
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.
Greg Smith is a psychiatrist who blogs at gregsmithmd.