Here is a standard emergency department situation, played out all across America today.
Patient X has schizophrenia. He takes medication, but only until he feels better. He is calm when he takes it, but sometimes aggressive and assaultive when out of treatment and off medications.
Patient X decides to leave town and drive somewhere else because he is angry at 1) family 2) significant other 3) health care system 4) situation.
He is found in a store, acting out, frightening customers. He is disheveled, loud and profane, and cannot be easily redirected. He does not harm anyone and makes no overt suicidal or homicidal threats. When confronted by security he walks outside and down the road.
Police are ultimately summoned because he is in and out of stores, acting oddly. X does not engage in any criminal behavior.
He is thus brought to the hospital emergency department. Here, he paces, sometimes yells profanely and is mildly delusional. He has a bag (that nobody bothered to check). He has a cell-phone but does not want to let go of it for the purposes of contacts. He may or may not have ID.
X refuses medication but does not rise to the level of potentially dangerous and (sometimes) illegal chemical or physical restraints. He continues to pace and rant around the already busy department, sometimes sitting in his room. A sitter is arranged who is paid to watch him. The ED continues to sort through confusing presentations of illness and injury, protect privacy, and keep the staff and patients feeling safe amid his behavior.
Law enforcement is contacted again, but point out that he has not committed any crime and that walking around town is not illegal. They do not transport patients like this to other places.
Family is located but are in the next state and have no way to get X. They ask, “Can you just keep him a while?”
The hospital has no funds to transport him anywhere, but recognizes that he is 1) a problem for the ED 2) a danger to discharge but 3) has no reason for a medical admission. (He allowed a lab draw, and everything was normal.)
Mental health is consulted and after assessment, and consideration of his social situation, say that he is indeed schizophrenic but does not rise to the level of involuntary hospitalization.
Ultimately, after five hours, X is angry and says, “I’m leaving this %#@@ place and &%*$ all of you.”
Nursing administration is anxious that he is a danger to himself. But nobody has reason, capacity or funding to do otherwise.
Indeed, he has a very real, very devastating disease. That is not his fault. But the mental health system, too, is diseased. Understaffed and underfunded, stressful and with high turnover, it cannot begin to reach the enormous numbers of people with psychotic disorders, much less those with depression, anxiety, and other issues.
Decades ago, compassionate Americans shuttered state psychiatric hospitals across the land in the belief that they were somehow unfair or oppressive to those hospitalized. Doubtless, there were bad places and bad care. But they were something. They were islands where treatment and safety was available. Now, for the uninsured, hospitalization is next to impossible unless it’s involuntary; and even then it’s brief.
And if a person is already struggling with psychosis, struggling to hold onto reality, consistent outpatient care is often simply not going to happen.
The default, for society, is now “send him to the ER.” Add his inner chaos to the outer chaos and vise-versa. Let all the chaos grow into more and more danger and dysfunction.
What happens after that is nobody else’s problem at all.
But woe to all when, after all options are “weighed in the balance and found wanting,” a bad outcome occurs. Because after all, “something should have been done.”
Yep. But by who?
Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan.
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