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“Imagine this scenario: a busy mom struggles to balance work and parenting during the pandemic when suddenly her teenage son begins to anger. He gets out of control, screams threats, and kicks a hole in the wall. Neighbors call the police, who recommend the family go to the emergency department (ED). When the family arrives at the ED, the stresses of enforced isolation show on their exhausted, tearful faces. And unfortunately, in these extraordinary times, they’re far from alone.”
Gregg Miller and Seth Thomas are emergency physicians.
They share their stories and discuss their KevinMD article, “As the pandemic winds down, another crisis may be looming.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Gregg Miller and Seth Thomas. They are both emergency physicians, and they both wrote the article “As the pandemic winds down, another crisis may be looming.” Gregg and Seth, welcome to the show.
Gregg Miller: Thanks for having us, Kevin.
Kevin Pho: So we’ll get into your article in a little bit, but first I’m going to ask each of you to share your stories and journeys to where you are today. Gregg, why don’t you go first?
Gregg Miller: Yeah, I’m an emergency physician in Washington state, and as an ER doc, we see a lot of mental health and behavioral health issues in the emergency department. So it’s something that we’ve always struggled with and just sort of dealt with, with a sense of learned helplessness.
I think if there was one patient encounter that really made me see that we have to change how we’re approaching mental health in the ED, it was taking care of a 13-year-old who was depressed and suicidal, who ended up boarding in our emergency department for a week waiting for a bed. He just sat in a sterile room, a ligature-free room with nothing in it, wearing a pair of paper scrubs for an entire week. He was not getting the care he needed, and he was obviously very upset. The staff was very upset. The physicians taking care of him shift after shift without getting him the care he needed were very upset. So we realized we really needed a new and different approach to caring for mental health patients in the emergency department.
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Kevin Pho: And Gregg, just to follow up on that case, what was the bottleneck that caused that patient to be in your emergency room for a week?
Gregg Miller: The overwhelmed mental health system. That outpatient and inpatient mental health system is just overwhelmed. There aren’t enough resources out there, there aren’t enough psych beds, and unfortunately that translates into the ED being the safety valve or the place of last resort where people end up when there’s no other place to go.
Kevin Pho: All right. Seth, can you share your story and journey to where you are today?
Seth Thomas: Yeah, thanks, Kevin. I actually don’t think that my story is a lot different than Gregg’s. I think we both experienced the downsides of seeing mental health boarding in our emergency departments, and just realizing that this problem seems to be only getting worse, not better, really motivated me to want to do something different.
I do distinctly remember a case of a young woman who was also boarding in our emergency department for five days and unfortunately ended up having some iatrogenic problems and complications. She ended up developing a DVT and PE and had to be admitted because she was restrained for so long and kept in the back hallway. And I think when a physician who really cares about what they do sees a bad outcome, we want to get motivated. We want to change the way things are.
Kevin Pho: And Seth, over the last 18, 19 months of the pandemic, can you comment on how that has affected what you’re seeing from a behavioral health standpoint in the emergency room?
Seth Thomas: Yeah, I don’t think any emergency physician out there would disagree with me that not only are the raw numbers of patients coming in with a crisis increasing, but we’re finding their acuity going up as well. Four out of every 10 people in the United States are experiencing significant depression and anxiety as a result of the pandemic. We’re also seeing substance abuse go up as well. It’s one of the areas in emergency medicine where we did not see a significant decline in the number of visits in the emergency department, so it’s only getting worse, unfortunately.
Kevin Pho: So both of you talk more about this issue in your KevinMD article, and it’s titled “As the pandemic winds down,” although that’s certainly dubious now, back in late August, “another crisis may be looming.” Now, Gregg, for those who didn’t get a chance to read the article, can you just walk my audience through it and share the story of why you decided to write it?
Gregg Miller: Absolutely. And I think you’re right on. That was an overly optimistic title for that article back in May.
We talked about how in emergency medicine we really need to take a sense of ownership over our patients who are boarding with mental health crises. This is a problem, like Seth said, that isn’t getting any better, and it’s only going to grow with the pandemic. We’re going to see echoes for months, if not years, after the COVID pandemic ends, with a new pandemic of mental health crises, of behavioral health crises. Like Seth said, opiate visits are higher than ever. Opioid overdoses last year were higher than ever, and we’re seeing a lot more anxiety and depression in teens and young adults and older folks coming through our doors.
So in the emergency department, we need to take a sense of ownership over those patients, and we need to change how we manage those patients. We need to be more assertive and engaged and aggressive when it comes to treating those patients in our EDs, and investing more in our training and in our resources to take care of them.
Kevin Pho: And Gregg, for those who don’t work in the emergency department, give us a sense of what kind of behavioral health support is typically available to you as a physician when someone comes in with an opioid overdose or with a behavioral health issue. Just give us a sense of what the current situation is and what kind of resources you guys typically have.
Gregg Miller: Yeah, I think it really varies, Kevin, from ED to ED, but I’ve worked in a lot of EDs where it’s up to the bedside nurse to make the phone calls, or up to the unit secretary, who’s triaging all the phone calls from patients and consultants, etc., to try to make phone calls to get those patients placed. Some EDs are fortunate enough to have a 24/7 behavioral health social worker in the emergency department. I would say those EDs are few and far between.
Most EDs have access to some type of outpatient mental health crisis team that will come in to evaluate your patient after they’re done evaluating six other patients in six other emergency departments in that county. So usually the wait for a behavioral health crisis team to come into the ED is long. We’ll typically medically clear the patient and say, “OK, this patient is medically stable. They no longer need emergency care. What they need is behavioral health care, mental health care, substance abuse care.” But the gap to get that care can be hours, if not days.
Right now, I was looking at my tracker board, and right now in my emergency department we’ve had a patient waiting for mental health care for more than 200 hours at this point, and two other patients waiting more than 24 hours.
Kevin Pho: And Seth, it sounds like the bottleneck is a lack of inpatient behavioral health beds that you can bring patients to, so they end up boarding in the emergency department. So from your standpoint, from the perspective of an emergency physician, what are some things that you guys can do, given the bottleneck is kind of further downstream?
Seth Thomas: Yeah, I don’t think anybody would argue that the mental health system doesn’t have enough resources. That’s absolutely true. There aren’t enough outpatient clinics, there aren’t enough psychiatrists, counselors, inpatient beds. I agree. But I also think that what Gregg’s alluding to, and what we’re trying to highlight here, is that there’s a gap in care that exists in all of our emergency departments. I don’t care if you’ve got the emergency department that has that 24-hour-a-day social worker who’s trained in mental health or you don’t, there’s still something more that we can do.
I think really the biggest thing for us is to educate ourselves, to get comfortable with caring for these patients. We get so worried about the fact that many of us going through emergency medicine training didn’t get a lot of training in psychiatric emergencies, and that’s true. But we also have a lot of great knowledge in things that are potentially dangerous and life-threatening as well, so airway disasters and trauma and sepsis. We do really well with those things. So this is an area where we can equip ourselves, we can teach ourselves new skills, and we can get comfortable with medications.
We also know that most patients who are there with a crisis don’t really ultimately need inpatient psychiatric care. Anywhere from 60 to 80 percent of those patients can actually go home. So I think we can take ownership of those patients, and we can start treating them, de-escalating them, medicating them, and actually getting them back out to their outpatient appointments.
Kevin Pho: Paint us a picture. Give us a hypothetical scenario of a typical psychiatric emergency where you feel an emergency physician can educate himself or herself to better manage it. So what would be a hypothetical scenario?
Seth Thomas: I think there are a few. I think one that we see pretty frequently would be patients who are using substances, whether it be alcohol or methamphetamines, and they’ve made some comments about feeling depressed or potentially wanting to harm themselves, or they broke up with their girlfriend or boyfriend. As those patients sober up, as we start to talk to them more and really realize the circumstances that went into that scenario, potentially we could get them back home to a safe environment.
Other ones would be patients who maybe had been using substances or had stopped taking their medications for schizophrenia and have been hearing some voices, but they’re not really a danger to themselves or others, and they aren’t gravely disabled. We can just get them back on their medications and get them home after a brief reevaluation period.
Gregg Miller: I think another great example, if I can, is the patient who comes in who’s depressed, makes some vague suicidal comments, but has a great social safety network. The treatment for that patient is they come in and they get medically cleared, even though from the beginning they’re stable, but that’s a four-hour process to get a urine drug screen and a blood alcohol. And then they get a psychosocial evaluation, which is another six-to-eight-hour process. So by the time this patient who came in with a vague sense of just depression and anxiety is ready to go, it’s been 12 to 24 hours in the emergency department, when, had they been in the right place at the right time at the very beginning, they would have been potentially turned around within an hour if they’d had a team that was comfortable managing behavioral health emergencies.
Kevin Pho: And Gregg, you mentioned that psychosocial evaluation is a six-to-eight-hour process. So for those who aren’t familiar with that process, or just not familiar with the emergency department, why does it take that long?
Gregg Miller: It’s just the resources. There just aren’t. The person who does that evaluation isn’t available immediately. They’re in a different emergency department, they’re at a different facility somewhere, or if they’re in your own emergency department, they’ve got 12 other patients that they’re trying to see at the same time.
Kevin Pho: And Gregg, Seth mentioned that emergency physicians should better educate themselves in terms of managing behavioral health emergencies. So what are some specific ways that they could do that?
Gregg Miller: I think Seth can speak to this too, but I think better risk stratification, recognizing who the low-acuity patients are, and having the pathways. It’s not just a bedside clinician issue. It’s an emergency department leader issue, where medical directors and nurse managers need to set up the right pathways for our bedside clinicians to take these low-acuity patients, put them on the pathway, and get them to a better place without waiting six to eight hours for that formal behavioral health evaluation. So that’s one thing, better risk stratification of low-acuity patients.
Another thing is more familiarity with medications. When I trained in emergency medicine, I learned Haldol and Ativan, and I could give one, I could give the other, or I could give both. So I had three different treatment options, right? And now there are so many other medications out there, including just restarting patients’ own psychiatric medications. That’s sometimes the best thing we can do, and yet we’re uncomfortable doing that because that wasn’t part of our training. And so we can do a whole lot better managing these patients.
Seth Thomas: I concur completely. I think you did a great job summarizing that. I think the other thing to keep in mind is that sometimes we feel like all we can do as emergency physicians is the medical clearance piece, right? That’s what we’ve been trained to do: Evaluate the patient for medical mimics, order a bunch of labs, and then we sort of divorce ourselves from the whole thing and just wait for somebody else to kind of come in and help us.
And then also, I think that we look at a process that is historically very sequential. I do my initial evaluation, we do the medical clearance, then I call somebody, then they come in once everything’s back, and gosh, I hope their blood alcohol level is appropriate enough for me to just have a conversation with them. And so I think if we can take a look at the overall process and start to really break that down, eliminate some of the unnecessary steps, we can start working on parallel processing things. Let’s see them as a team, as Gregg said earlier. Let’s try to get things done in unison, at the same time. That really can cut out a lot of unnecessary waste and delay.
Kevin Pho: And Seth, are you seeing any emergency departments implementing some of the ideas that you and Gregg are talking about?
Seth Thomas: Yeah, we are. And in our experience, initially, some of them come into this and they say, “I don’t know that we can really have an impact.” And then after we work with them for a three-, four-, five-month period, they recognize that they can have a significant impact on these patients. They can change the disposition for a lot of them themselves, and they can really change the performance of the department. So it’s really rewarding to see.
Kevin Pho: And Gregg, I’m a primary internal medicine physician. I have a lot of primary care physicians and clinicians in the audience listening to this. So what’s the role of primary care in terms of helping with some of the issues that you guys discuss?
Gregg Miller: I think understanding what is happening to your patients in the emergency department, number one. When a patient comes into an ED, the standard model has been, “Let’s medically clear them,” and then after that, they just board. They just wait. And so the ED encounter is often not a productive encounter for patients who have acute mental health needs or behavioral health needs with substance use issues, etc. So understanding that the ED is not always the best place for patients who are suffering behavioral health emergencies, and hopefully redirecting patients away from the ED to other outpatient crisis centers that are in the community.
Unfortunately, a lot of times those crisis centers don’t exist. There aren’t the crisis stabilization units or the EmPATH units that have been proven to improve outcomes, and so your only option is the ED. When that’s the case, absolutely, we are here for those patients. We are the safety net for our communities. We want to take care of these patients. And so my message for primary care doctors is: Use us, but understand that we have our limitations.
I think my message really for emergency medicine leaders, though, is you need to be more engaged, you need to be more involved, and you need to create these systems of care within your emergency department so that your bedside nurses, your physicians, and your advanced providers feel a lot more comfortable managing behavioral health patients and are a lot more assertive and interactive with these patients, rather than just kind of brushing your hands off: “OK, they’re medically cleared. Now they’re somebody else’s problem, and I’ll just have them sit in a hallway for 12 hours.” We need to be doing something during those 12 hours, or hopefully avoiding those 12 hours in the first place, to get those patients back to a much more therapeutic environment.
Kevin Pho: We’re talking to Gregg Miller and Seth Thomas. They’re both emergency physicians, and they both wrote the article “As the pandemic winds down, another crisis may be looming.” Gregg and Seth, I’m going to ask each of you for your take-home messages to the KevinMD audience. Seth, why don’t we start with you?
Seth Thomas: Absolutely. Well, I think the one thing that I would want to say is that we have control over the situation, more so than you think. I think that we’ve all been brought up to believe that we really have to stick with the existing program, we have to stick with the existing process, and there’s only one way to take care of these patients in the emergency department. And I really want to change that theory. I want emergency department leaders and physicians to educate themselves, to get comfortable, and to engage with their patients, because I think not only is it going to help the patient, it’s actually going to help them.
There’s nothing more frustrating than trying to take care of a patient when you really don’t have the skill set to do it. You go into work and you see a bunch of these patients boarding there. It’s really frustrating, and it’s draining, and it really attacks our wellness. And so I think that if we can educate ourselves and equip ourselves to take care of these patients, it’s going to provide a much better experience for us as well.
Kevin Pho: And Gregg, let me ask you for your take-home message, and also I’m going to ask you for some resources that interested listeners can follow up on if they’re interested in pursuing some of the ideas that you guys discuss.
Gregg Miller: Yeah, absolutely. So our article talks about our toolkit. It’s called EPI, Emergency Psychiatric Intervention, and so we’ve got content about that on your blog. So please check out the article.
The second, I guess, take-home message, similar to Seth’s, is we need to have a sense of ownership over our patients. But I’ll add something we haven’t talked much about, which is the mental health of our own clinicians right now who are working in acute care, and I’m sure in primary care as well, as we’re dealing with this resurgence of a pandemic. We’re in a place where we never hoped that we’d be in August, and we’re probably going to be in a place that we did not hope we’d be over this winter. And so the mental health issues are acute for everybody, and not just our patients.
And so if there are listeners out there who are acute care physicians or primary care physicians who are going through some issues with depression or anxiety or PTSD or burnout, please reach out and find some help, because you’re not alone. This is the worst, worst time for any of us in the history of our careers to be practicing medicine, and there’s a lot of help out there. And if you are in a good position where you feel like, “Actually, things are going OK for me,” please look around and reach out to somebody who maybe is struggling a little bit, and make that connection. We’re all in this together. We all need to be taking care of each other, and that isn’t just us taking care of our patients. We need to be taking care of each other too.
Kevin Pho: Gregg and Seth, thank you for sharing your time and insight, and thanks again for being on the show.
Gregg Miller: Thanks for having us.
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