A nightmarish scenario just happened and I'm trying to make it make sense.

[sjLando]

Not a psychiatrist, and person is not related to me.

13 year old boy is being beaten by his father and at school (corporal). Boy is cutting profusely. Grandparents (pediatricians) take him but still let him see his father weekly. Boy sees therapist who says "I could be helping someone now who has some real problems. Cutting is a stupid way to deal with things." Boy sees psychiatrist but only for an ASD dx.

Boy makes attempt with pills and taken to hospital. 72 hours later boy is discharged with an SSRI, state has custody and puts him in what can only be described as one step down from a juvenile detention facility. Boy continues to get no help by the counselors there who are dealing primarily with gang members. Counselors tell boy he can't pursue his dreams of being a musician or a teacher, and that boy will stay here for a long time.

Boy clearly does not belong there, and is youngest of mostly 17 year old gang members. Gang members find out Boy is gay and beat and rape him. Boy taken back to hospital. Now we wait to see what happens next in this exciting tale. Godparents may be given temporary custody.



As someone who is preparing to start a job this year as a psych tech and rotate through peds etc I'm trying to find the motivation and also bringing in to question what happens when I've initiated active rescues on the suicide lines for children, and even my motivation for the career. (This is not the hospital or even state where the above happened).

I've known about bad outcomes in medicine, hell I'm a crisis counselor for God sake, but this thing with the hospital is truly nightmarish and it seems like every step of the way every adult in his life is just shoveling this kids grave another foot deep.

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[annoyedpsychiatrist]

you can not solve the healthcare crisis or americas mental health crisis that has been exacerbated by crap leadership, corruption, economy issues, drugs, poverty, etc.

You can however, make a big difference in individual patient's lives. For those people, THAT is what makes this job worth it, leaving at the end of the day knowning you have helped some people out there, despite not being able to help everyone.

 

[TexasPhysician]

“The hospital is truly nightmarish”? How? From the little provided, the hospital started a valid treatment. Hospitals don’t determine who has custody or where the patient goes after discharge. Hospitals don’t maintain legal power over children.

You are providing minimum details about anything involving psychiatric care.

Even comments from counselors could be taken out of context if you aren’t there listening to every word. If a patient is not participating in counseling and constantly deflects, I could see a counselor stating that you can’t pursue being a teacher or achieving a musical career while in juvenile detention, but you can be developing positive social skills that will forever benefit your life. Let’s focus on today.

 

[sjLando]

“The hospital is truly nightmarish”? How? From the little provided, the hospital started a valid treatment. Hospitals don’t determine who has custody or where the patient goes after discharge. Hospitals don’t maintain legal power over children.

You are providing minimum details about anything involving psychiatric care.

Even comments from counselors could be taken out of context if you aren’t there listening to every word. If a patient is not participating in counseling and constantly deflects, I could see a counselor stating that you can’t pursue being a teacher or achieving a musical career while in juvenile detention, but you can be developing positive social skills that will forever benefit your life. Let’s focus on today.

I was trying to be brief and ultimately I don't have all the details.

The kid needed an actual therapist and to be admitted somewhere that wasn't with hardened criminals. He hadn't done anything wrong. I'm not sure which doctors had him if it was psych or the primary team, but to me this screams why was he not admitted, or if he was admitted did the state force him out of the hospital?

All I know is that he shouldn't have ever left the hospital until there was somewhere adequate for him.

I guess I'm trying to put all the pieces together to try to figure out how everything went so south so quickly.

 

[annoyedpsychiatrist]

I was trying to be brief and ultimately I don't have all the details.

The kid needed an actual therapist and to be admitted somewhere that wasn't with hardened criminals. He hadn't done anything wrong. I'm not sure which doctors had him if it was psych or the primary team, but to me this screams why was he not admitted, or if he was admitted did the state force him out of the hospital?

All I know is that he shouldn't have ever left the hospital until there was somewhere adequate for him.

I guess I'm trying to put all the pieces together to try to figure out how everything went so south so quickly.

psych hospitals don't cure depression, in fact, they can do quite the opposite. They just provide a temporary "relatively" safe place for time to pass if someone was acutely suicidal, and allow for formation of a safety plan/discharge plan. The typical inpatient psych hospital is designed for short term <1 week admissions. You cant fix someones depression/life in a week.

 

[sjLando]

psych hospitals don't cure depression, in fact, they can do quite the opposite. They just provide a temporary "relatively" safe place for time to pass if someone was acutely suicidal, and allow for formation of a safety plan/discharge plan. The typical inpatient psych hospital is designed for short term <1 week admissions. You cant fix someones depression/life in a week.

I know, but it seemed like they went to somewhere extremely bad and was not receiving the care they needed.

And now they are right back at the hospital again, worse. What is going to be different this time?

 

[calvnandhobbs68]

I was trying to be brief and ultimately I don't have all the details.

The kid needed an actual therapist and to be admitted somewhere that wasn't with hardened criminals. He hadn't done anything wrong. I'm not sure which doctors had him if it was psych or the primary team, but to me this screams why was he not admitted, or if he was admitted did the state force him out of the hospital?

All I know is that he shouldn't have ever left the hospital until there was somewhere adequate for him.

I guess I'm trying to put all the pieces together to try to figure out how everything went so south so quickly.

Discharge to CPS is a safe and adequate discharge. Hospital doesn’t determine what happens after discharge, just that the minor has someone who seems appropriate to discharge too (and ya can’t really argue it’s not appropriate to discharge to CPS when the state has custody). They can’t help what happens after that.

I know you seem shocked by this but these cases are not terribly uncommon. You can’t expect the medical system to solve overarching system or social problems.

 

[sjLando]

Discharge to CPS is a safe and adequate discharge. Hospital doesn’t determine what happens after discharge, just that the minor has someone who seems appropriate to discharge too (and ya can’t really argue it’s not appropriate to discharge to CPS when the state has custody). They can’t help what happens after that.

I know you seem shocked by this but these cases are not terribly uncommon. You can’t expect the medical system to solve overarching system or social problems.

I expected more, yes. For someone who just swallowed a bottle of pills and has been beaten, to receive more than 3 days of being held in an ED and not admitted.

He was supposed to have been admitted for two weeks initially, but then once custody was switched they discharged him instead.

And it has been confirmed now he is being held at a maximum security juvenile detention center that is supposed to only be for older males. They don't wear jumpsuits or have bar on the windows but this is where he was placed.

I get what you are saying about once discharged it's out of the medical control, but it seems like the decision to discharge was based on the fact that CPS said they had somewhere adequate for him, which clearly they did not.

 

[Merovinge]

I agree pt should have been admitted and not managed in ED over 3 days. I don't feel that would be standard of care for a 13 year old following OD attempt on an entire bottle of pills.

However, saying the hospital should be challenging CPS dispo management is preposterous. We do not control where the state places patients and they are the de facto safest discharge plan when family is known abusers. You are summating two seperate problems, one is the healthcare systems problem (not having beds to admit to, not admitted to gen peds when psych is full) and the other is a massive state/society problem. His sexual assault is tragic but not in anyway related to the healthcare system.

 

[nexus73]

The system is f&*ked. There isn't really a system. As above poster stated, doing the best you can for the patient in front of you is the best you can do. You'll catch some flak because your post comes off as blaming the hospital for not providing the correct care, at least that's how I read it. The problem is not the hospital. It's society not recognizing the importance of mental health and paying for mental health treatment. What does this kid need? A long term residential program with good staff, good psychiatrist, therapist, for several months maybe. A foster care system that isn't screwed up. There are limited if any resources for any of this.

Also, sometimes life situations are just completely horrible, and we don't have a fix for that within healthcare.

 

[sjLando]

The system is f&*ked. There isn't really a system. As above poster stated, doing the best you can for the patient in front of you is the best you can do. You'll catch some flak because your post comes off as blaming the hospital for not providing the correct care, at least that's how I read it. The problem is not the hospital. It's society not recognizing the importance of mental health and paying for mental health treatment. What does this kid need? A long term residential program with good staff, good psychiatrist, therapist, for several months maybe. A foster care system that isn't screwed up. There are limited if any resources for any of this.

Also, sometimes life situations are just completely horrible, and we don't have a fix for that within healthcare.

It was kind of 50/50 I was under the impression people who did thos would end up with longer than a 72 hour care at the hospital, but as you and everyone else said I understand that what happens afterwords and the societal issues are outside the scope.

Considering I'm slated to start working as a psych tech and had visions of this being my career, yeah, I'm trying to use this as a gauge to see if I would fit in if this is what happens every day.

 

[sjLando]

I agree pt should have been admitted and not managed in ED over 3 days. I don't feel that would be standard of care for a 13 year old following OD attempt on an entire bottle of pills.

However, saying the hospital should be challenging CPS dispo management is preposterous. We do not control where the state places patients and they are the de facto safest discharge plan when family is known abusers. You are summating two seperate problems, one is the healthcare systems problem (not having beds to admit to, not admitted to gen peds when psych is full) and the other is a massive state/society problem. His sexual assault is tragic but not in anyway related to the healthcare system.

Thank you for helping me clear this up I am trying to learn and put all the pieces together because I am ignorant and hence why I'm starting a job in it soon before med school to see if this is really where I belong or not.

 

[WisNeuro]

I agree pt should have been admitted and not managed in ED over 3 days. I don't feel that would be standard of care for a 13 year old following OD attempt on an entire bottle of pills.

However, saying the hospital should be challenging CPS dispo management is preposterous. We do not control where the state places patients and they are the de facto safest discharge plan when family is known abusers. You are summating two seperate problems, one is the healthcare systems problem (not having beds to admit to, not admitted to gen peds when psych is full) and the other is a massive state/society problem. His sexual assault is tragic but not in anyway related to the healthcare system.

Probably depends on the area. Our metro IP bed capacity for peds is alarmingly small. ED management for crisis is almost the norm as opposed to the exception. There's simply nowhere else for them to go after the ED.

 

[Merovinge]

Thank you for helping me clear this up I am trying to learn and put all the pieces together because I am ignorant and hence why I'm starting a job in it soon before med school to see if this is really where I belong or not.

If you can be happy lightening the load of 1 (or a dozen) people for a day and sleep well at night knowing that's a day well lived (which it absolutely is in my opinion), then the field of mental health is amazing. If you see a broken system and think it needs to be built from scratch from the ground up, then you will not be happy and should do public health/policy or law school.

 

[Merovinge]

Probably depends on the area. Our metro IP bed capacity for peds is alarmingly small. ED management for crisis is almost the norm as opposed to the exception. There's simply nowhere else for them to go after the ED.

That doesn't make it the standard of care. It might be the only option possible in your area (I kind of doubt it) and standard of your area, but that doesn't make it standard. Even if the CAP beds are not accessible, the the CAP team should be working with peds to bring these kids onto a portion of the med/surg floors and create pseudoprograming for them with longer length of stays. If that's not possible, they should leave the job instead of signing off on bad care. The buck stops with us as subspecialists and it's a very vulnerable child's life we are holding. If we aren't willing to stand up for them, clearly no one else is in the system.

 

[WisNeuro]

That doesn't make it the standard of care. It might be the only option possible in your area (I kind of doubt it) and standard of your area, but that doesn't make it standard. Even if the CAP beds are not accessible, the the CAP team should be working with peds to bring these kids onto a portion of the med/surg floors and create pseudoprograming for them with longer length of stays. If that's not possible, they should leave the job instead of signing off on bad care. The buck stops with us as subspecialists and it's a very vulnerable child's life we are holding. If we aren't willing to stand up for them, clearly no one else is in the system.

I agree that it shouldn't be the SoC, but many hospital systems who are already hemorrhaging money aren't exactly looking to expand/create more loss leader units in their settings. I think it's a larger system and the failure of MH parity, personally.

 

[sjLando]

I agree that it shouldn't be the SoC, but many hospital systems who are already hemorrhaging money aren't exactly looking to expand/create more loss leader units in their settings. I think it's a larger system and the failure of MH parity, personally.

I had heard they only discharged him because when the state got custody it was cheaper to put him in the correctional facility than to pay the hospital for the admit and that was the reason CPS asked for a discharge.

I wish I had all the correct details but that's part of the post is me trying to figure out what is actually going on and put the pieces together so I can have an understanding.

 

[sjLando]

That doesn't make it the standard of care. It might be the only option possible in your area (I kind of doubt it) and standard of your area, but that doesn't make it standard. Even if the CAP beds are not accessible, the the CAP team should be working with peds to bring these kids onto a portion of the med/surg floors and create pseudoprograming for them with longer length of stays. If that's not possible, they should leave the job instead of signing off on bad care. The buck stops with us as subspecialists and it's a very vulnerable child's life we are holding. If we aren't willing to stand up for them, clearly no one else is in the system.

This is what I wanted to hear and makes me think I'm not entirely crazy and disillusioned.

 

[calvnandhobbs68]

I had heard they only discharged him because when the state got custody it was cheaper to put him in the correctional facility than to pay the hospital for the admit and that was the reason CPS asked for a discharge.

I wish I had all the correct details but that's part of the post is me trying to figure out what is actually going on and put the pieces together so I can have an understanding.

No, this is highly unlikely to be the actual reason. I think you're getting random bits of this from other people and don't have the whole picture here. Are you hearing this stuff from a friend or someone related to this person or something?

CPS doesn't ask for kids to be discharged because it's "more expensive" to admit them to the hospital. These kids are covered by the state Medicaid insurance plan and CPS has nothing to do with paying with a hospital stay in any way. In fact, putting some kid in a residential or (as you say) correctional setting for an extended period is almost certainly more expensive than being in an inpatient psych unit for a week. Almost every single time I've had a kid in state custody who was admitted CPS would actually prefer they stay admitted cause then they don't have to deal with placing them and we usually had to tell CPS "no this kid can go home so you need to find some place for him to go".

Now, what could have happened is the hospital said they don't have an inpatient bed for this kid or he might wait in the ED for days looking for a bed and CPS asked if they'd be okay with discharging back to CPS from a safety standpoint. Which seems to have been a fine decision here, as no suicide seems to have occurred in the time period since hospital discharge and now readmission for the assault at this placement (which has nothing to do with the hospital determining he was a low enough risk of suicide to discharge back to supervised custody). Lots of state agencies have been getting flak for kids in state custody ending up in the ER waiting days or weeks for placement.

 

[nexus73]

That doesn't make it the standard of care. It might be the only option possible in your area (I kind of doubt it) and standard of your area, but that doesn't make it standard. Even if the CAP beds are not accessible, the the CAP team should be working with peds to bring these kids onto a portion of the med/surg floors and create pseudoprograming for them with longer length of stays. If that's not possible, they should leave the job instead of signing off on bad care. The buck stops with us as subspecialists and it's a very vulnerable child's life we are holding. If we aren't willing to stand up for them, clearly no one else is in the system.

Psych is crisis standards many many places, just not recognized as crisis standards.

 

[whopper]

I hope you take into consideration, especially in areas that are on the battlezone front lines such as ERs, hospitals in the worst area of town, jails, prisons that some people are pretty much as bad as you'd expect them to be in The Walking Dead.

I've seen someone who sold her infant to be sexually slaved for drugs. I've seen men who've just been raped by other men within the hour of it happening, women raped by men within the hour of it happening, women stalked by sexual predators and the police did nothing to help the woman while it went on and on and on.

No, this is highly unlikely to be the actual reason. I think you're getting random bits of this from other people and don't have the whole picture here. Are you hearing this stuff from a friend or someone related to this person or something?

This situation stated by the original writer-it highly varies per area. I'm in Missouri. Seriously-you can't afford a lawyer you'll be put on a 10 month waiting list for one. Tell that to someone else in any of the other 49 states they'll say that's bull$hit, cause in their state it isn't happening and they can't fathom it being different than their 1 state despite that there's 49 others, and Missouri is on the bottom of the list in terms of following these allegedly Constitutional mandatory rules.

My own county had a forced labor jail until just about 2 years ago. Serious. These poor fools in this jail weren't even found guilty by a court of law, put on a 10 month waiting list for a lawyer and while in jail are forced to do labor. Well hey they said it was voluntary, cause if you didn't do the work they put you in a heat-box but that's besides the point....

CPS doesn't ask for kids to be discharged because it's "more expensive" to admit them to the hospital.

Just like the legal system in criminal defense is horrendous in Missouri, add CPS too. Now I got no idea where the original author is but I now wouldn't be surprised with any tale of woe with CPS in this state. I reported a case to CPS where a sex worker was going to introduce her minor daughter to the trade, I called CPS and CPS did nothing despite that there was photographic evidence backing up what I wrote.

 

[calvnandhobbs68]

Just like the legal system in criminal defense is horrendous in Missouri, add CPS too. Now I got no idea where the original author is but I now wouldn't be surprised with any tale of woe with CPS in this state. I reported a case to CPS where a sex worker was going to introduce her minor daughter to the trade, I called CPS and CPS did nothing despite that there was photographic evidence backing up what I wrote.

I'll just say I'm familiar with CPS in multiple states (including your own state) and although I too have seen problems with competence with CPS, I have never run into a situation where CPS wants to take a patient from the hospital or ED because it's "cheaper". Again, those are completely separate pots of money and CPS couldn't care less what Medicaid is spending on the kid for any type of medical care. I can actually give multiple examples of kids I've taken care of personally who were in state custody and LIVED on an inpatient medical or psychiatric unit for MONTHS because they couldn't place them...nobody from CPS was taking them away cause it was "too expensive".

I'm not saying that (most) of the fact actually happened with this kid aren't true. I'm sure he does have a ****ty home life. I'm sure he actually was cutting. I'm sure he did actually have an intentional overdose and I could absolutely buy that he was discharged from the ED after being observed for 3 days. I'm sure he did get discharged to CPS who certainly could have put him in some probably crappy residential or borderline detention center placement that's mostly for "bad" kids cause that makes up a decent chunk of who is in the system with CPS and I'm not at all disputing some other kids beat on him and sexually assaulted him.

The issue people are having with OP is where the blame is being placed here, OP's second hand info about what therapists have been saying to this kid and OP's implied or inferred reasons for decision making in this process. For instance, if CPS takes custody and says they can place this patient in a residential monitored placement immediately, then yeah that could certainly seem like a reasonable placement situation from the hospital's standpoint. It's not the hospital or psychiatrists job to try to figure out "is this a place full of gangs where people are gonna beat this kid up?".

 

[TexasPhysician]

I had heard they only discharged him because when the state got custody it was cheaper to put him in the correctional facility than to pay the hospital for the admit and that was the reason CPS asked for a discharge.

I wish I had all the correct details but that's part of the post is me trying to figure out what is actually going on and put the pieces together so I can have an understanding.

That didn’t happen. CPS doesn’t pay for the hospitalization, and in general CPS is very ineffective. In my experience, CPS tries to do absolutely nothing.

It is 1000x more likely that after a few days in holding that the child was no longer actively suicidal. Once you are no longer suicidal, you don’t need to continue waiting for a bed. It is discharge time.

Come discharge time, why was the kid going with CPS? Where were the grandparents? Why does the state have custody? No other family came forward? So you are saying that the father, grandparents, and remaining family all declined this child? If that is the case, what is the temporary alternative to what happened? I’m not saying this is an ideal system we have here, but we can’t see the future and family doesn’t appear to want him.

Not only have I had professional experience with CPS, I have personal experience. My mother was a teacher. My mother finds a child that she knows from her school wandering the neighborhood at night. Police are contacted. The child’s parents were intoxicated and mother had taken a bat to father. Mother arrested and father in the hospital. Police and CPS say that since we “know” the child, we can keep the child a few days until they can figure things out. Our system would rather leave a child temporarily with unrelated people while they sort things out than create placement.

 

[Old&InTheWay]

I don't understand why this conversation is taking place on this forum? The topic is really only tangentially related to psychiatry and few of the opinions offered here are actually grounded in the expertise and training of psychiatrists...it's essentially just people's opinions and speculation in response to the initial post which appears to be little more than gossip. It's a bad look and it takes away from the usefulness of this site for residents and physicians (who are the intended audience).