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As I left my night shift yesterday, I signed out 4 different psych patients to the oncoming doctor. One had been there for 4 days, 2 for 2 days, and one was just there for 12 hours. I have to admit, I’m a little bit frustrated with Psych patients in the ER.
I can empathize, to a certain extent with the suicidal patient. As a painfully awkward junior high kid, I remember many times standing at the edge of a cliff and melodramatically imagining plunging off the edge. I can’t imagine the pain of many of the psych patients I see who have truly horrific lives, full of addiction, devoid of true love, barren of healthy friendships, and often absent true meaning.
I think we have made great strides in creating some tools to help with helping people feel more happy. There are some great meds (atypical antipsychotics) that have really helped to calm disorganized thoughts. Psychology has many fascinating insights that help us understand pathologic behavior and feelings.
However, as a whole, the professions of psychiatry and psychology are nearly absent in the ER. What do I have personally to offer in the ER? Some fatherly advice. A willingness to start an antidepressant, or an antipsychotic. A little pull with the local homeless shelter. However, this isn’t enough for the average person. They and their families demand more. Government tells us we owe them more.
Psychiatry and psychology operate as one of the most 9-5 professions in the medical profession. After a decade of being out of residency, I have laid eyes on a psychiatrist a grand total of one time in the ER. Psychologist? NEVER. NEVER. They act like it is an Ebola hot-zone. And so the patients wait. And they wait. The ignorant public cries for more funds to throw at the problem. But the Field of Dreams theme is ever so true that, “If you build it, they will come.” Any new psych bed seems to have 5 occupants vying for it. Any “Mental Health Professional” or whatever they are called in your state has a list of 5 patients who are waiting for them.
While I certainly see true psychiatric emergencies, my perception is that 90 percent of the “psych” in the ER is 50% addiction, and 50% borderline personality disorder. Neither of those diagnoses are generally amenable to forced outside interventions.
I have seen a patient frequently in the ER who is completely borderline. She loves big scenes. She called 911 and when the police showed up, she was holding a knife to her arm. They shot her with a bean bag breaking her hand. We cross a line sometimes as a society in dealing with psych patients. “First do no harm” philosophy in my mind conflicts with giving in to a borderline patient’s demands. We are harming them by giving in to their drama. The best thing in the world to do for them would to take them home and ban them from the ER as a consequence of their nonsensical behavior.
I admit I’m jaded by what feels like an avalanche of chronically suicidal patients, hitting the ER on a weekly basis. After hearing the five hundredth person say that they are suicidal in my career, it has stopped affecting me emotionally. It seems that we just give people a bed to lay in and food, and wait until the emotions wear off and they quit saying the “s” word.
I saw a patient yesterday that had been “suicidal” 40 times this year. He basically lives in ERs and psych facilities. What is worse, he’s a complete jerk about it. If you challenge him on his behavior, he escalates and starts accusing you of “not helping” him. He demands “treatment” but fails to follow up with psychiatry as an out-patient. He has counsellors assigned to him, but he doesn’t go. The problem is, I can’t blame him. I agree with the basic premise of this article:
http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2625374&blobtype=pdf
I saw a patient last week who said she was suicidal. She couldn’t stop the negative thoughts she was having. What were the negative thoughts? She wasn’t pretty enough. (She was very far from ugly). She has an out-patient counsellor who after years, has still been unable to convince her that obsessing about her looks is unhealthy. I didn’t even try. Being more prone to stick my foot in my mouth, I would have probably said something offensive, but completely true like, “I’ve seen people WAY more ugly than you get married and be completely happy.” As I looked down at her med list, I was astounded by the cocktail of 6 different psychiatric drugs that would have given an elephant a permanent grin, even if it were ugly.
Some people just aren’t helped by psychiatry, just as some people aren’t helped by Buddhism, any one of the thousands of sects of Christianity, or a host of other philosophical paradigms. And yet, the government continues to encourage the continued tsunami of sad, crazy, and anxious to crash on the beleaguered shores of Emergency Rooms (where there are almost universally no psychiatrists or psychologists).
Telling everyone that you want to commit suicide seems to be the modern, accepted way to throw a tantrum. It’s an extremely manipulative abuse that happens so many times in modern relationships. You get everyone’s attention. They all tell bend over backwards to give you your way. I always want to whisper to the poor partner at the bedside, who is holding hands with the suicidal patient… “Run!”
I find the epidemic of suicide in Micronesia telling. Prior to the 70’s, suicide was virtually non-existent, far lower than Western countries. Subsequently, the rates sky-rocketed to rates double that of Western countries. http://www.nytimes.com/1983/03/06/us/micronesia-s-male-suicide-rate-defies-solution.html
Our modern society has had a similar pattern:
What is my point? I think that just as suicide is a behavior that is subject to epidemics, suicidal threats are occurring in the same fashion. The 60’s and 70’s were the golden era of psychiatry and psychology, with the legitimization of the fields and spending on treatments as a society that sky-rocketed. Did that prevent the tripling of suicide? Has psychiatry failed?
http://content.healthaffairs.org/content/early/2016/05/13/hlthaff.2015.1659
201 billion dollars are spent annually in the US. Are we happier? More functional? Less crazy as a society? One shudders to think what would happen if the modern opiate of the people were taken away. I’m increasingly wondering why I’m even involved in the process.
What would I do different? I guess I would make detaining people against their will against the law if the reason is that they are a danger to themselves. If a loved one wants to stop them, fine, that is their prerogative. However, it seems to be unconstitutional to take away someone’s right to liberty if they are competent and want to kill themselves. We all are guaranteed the right to life, liberty and the pursuit of happiness. What if death is the thing that makes the most sense to you in your pursuit of happiness? There is an increasingly popular movement to legalize suicide in terminal patients. Is psychiatric suffering any less real than physical pain?
Once we got out from under the ridiculousness of restraining, sedating against their will, and physically assaulting patients in an attempt to “help” them, we could switch the procedure for psych patients. We currently spend billions on a useless bureaucracy of psychiatric assessment that does nothing for patients other than take away their rights and generate paperwork. In a different legal climate, every hospital could offer a psychiatrist and a psychologist to prescribe meds and offer counselling to those who desire it in a 9-5 fashion. No more of this sitting around for days, taking away a room for medical patients.
Regarding the psychotic, perhaps we’ve done some good in that arena. Or not. Consider the following graph:
I can empathize, to a certain extent with the suicidal patient. As a painfully awkward junior high kid, I remember many times standing at the edge of a cliff and melodramatically imagining plunging off the edge. I can’t imagine the pain of many of the psych patients I see who have truly horrific lives, full of addiction, devoid of true love, barren of healthy friendships, and often absent true meaning.
I think we have made great strides in creating some tools to help with helping people feel more happy. There are some great meds (atypical antipsychotics) that have really helped to calm disorganized thoughts. Psychology has many fascinating insights that help us understand pathologic behavior and feelings.
However, as a whole, the professions of psychiatry and psychology are nearly absent in the ER. What do I have personally to offer in the ER? Some fatherly advice. A willingness to start an antidepressant, or an antipsychotic. A little pull with the local homeless shelter. However, this isn’t enough for the average person. They and their families demand more. Government tells us we owe them more.
Psychiatry and psychology operate as one of the most 9-5 professions in the medical profession. After a decade of being out of residency, I have laid eyes on a psychiatrist a grand total of one time in the ER. Psychologist? NEVER. NEVER. They act like it is an Ebola hot-zone. And so the patients wait. And they wait. The ignorant public cries for more funds to throw at the problem. But the Field of Dreams theme is ever so true that, “If you build it, they will come.” Any new psych bed seems to have 5 occupants vying for it. Any “Mental Health Professional” or whatever they are called in your state has a list of 5 patients who are waiting for them.
While I certainly see true psychiatric emergencies, my perception is that 90 percent of the “psych” in the ER is 50% addiction, and 50% borderline personality disorder. Neither of those diagnoses are generally amenable to forced outside interventions.
I have seen a patient frequently in the ER who is completely borderline. She loves big scenes. She called 911 and when the police showed up, she was holding a knife to her arm. They shot her with a bean bag breaking her hand. We cross a line sometimes as a society in dealing with psych patients. “First do no harm” philosophy in my mind conflicts with giving in to a borderline patient’s demands. We are harming them by giving in to their drama. The best thing in the world to do for them would to take them home and ban them from the ER as a consequence of their nonsensical behavior.
I admit I’m jaded by what feels like an avalanche of chronically suicidal patients, hitting the ER on a weekly basis. After hearing the five hundredth person say that they are suicidal in my career, it has stopped affecting me emotionally. It seems that we just give people a bed to lay in and food, and wait until the emotions wear off and they quit saying the “s” word.
I saw a patient yesterday that had been “suicidal” 40 times this year. He basically lives in ERs and psych facilities. What is worse, he’s a complete jerk about it. If you challenge him on his behavior, he escalates and starts accusing you of “not helping” him. He demands “treatment” but fails to follow up with psychiatry as an out-patient. He has counsellors assigned to him, but he doesn’t go. The problem is, I can’t blame him. I agree with the basic premise of this article:
http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2625374&blobtype=pdf
I saw a patient last week who said she was suicidal. She couldn’t stop the negative thoughts she was having. What were the negative thoughts? She wasn’t pretty enough. (She was very far from ugly). She has an out-patient counsellor who after years, has still been unable to convince her that obsessing about her looks is unhealthy. I didn’t even try. Being more prone to stick my foot in my mouth, I would have probably said something offensive, but completely true like, “I’ve seen people WAY more ugly than you get married and be completely happy.” As I looked down at her med list, I was astounded by the cocktail of 6 different psychiatric drugs that would have given an elephant a permanent grin, even if it were ugly.
Some people just aren’t helped by psychiatry, just as some people aren’t helped by Buddhism, any one of the thousands of sects of Christianity, or a host of other philosophical paradigms. And yet, the government continues to encourage the continued tsunami of sad, crazy, and anxious to crash on the beleaguered shores of Emergency Rooms (where there are almost universally no psychiatrists or psychologists).
Telling everyone that you want to commit suicide seems to be the modern, accepted way to throw a tantrum. It’s an extremely manipulative abuse that happens so many times in modern relationships. You get everyone’s attention. They all tell bend over backwards to give you your way. I always want to whisper to the poor partner at the bedside, who is holding hands with the suicidal patient… “Run!”
I find the epidemic of suicide in Micronesia telling. Prior to the 70’s, suicide was virtually non-existent, far lower than Western countries. Subsequently, the rates sky-rocketed to rates double that of Western countries. http://www.nytimes.com/1983/03/06/us/micronesia-s-male-suicide-rate-defies-solution.html
Our modern society has had a similar pattern:
What is my point? I think that just as suicide is a behavior that is subject to epidemics, suicidal threats are occurring in the same fashion. The 60’s and 70’s were the golden era of psychiatry and psychology, with the legitimization of the fields and spending on treatments as a society that sky-rocketed. Did that prevent the tripling of suicide? Has psychiatry failed?
http://content.healthaffairs.org/content/early/2016/05/13/hlthaff.2015.1659
201 billion dollars are spent annually in the US. Are we happier? More functional? Less crazy as a society? One shudders to think what would happen if the modern opiate of the people were taken away. I’m increasingly wondering why I’m even involved in the process.
What would I do different? I guess I would make detaining people against their will against the law if the reason is that they are a danger to themselves. If a loved one wants to stop them, fine, that is their prerogative. However, it seems to be unconstitutional to take away someone’s right to liberty if they are competent and want to kill themselves. We all are guaranteed the right to life, liberty and the pursuit of happiness. What if death is the thing that makes the most sense to you in your pursuit of happiness? There is an increasingly popular movement to legalize suicide in terminal patients. Is psychiatric suffering any less real than physical pain?
Once we got out from under the ridiculousness of restraining, sedating against their will, and physically assaulting patients in an attempt to “help” them, we could switch the procedure for psych patients. We currently spend billions on a useless bureaucracy of psychiatric assessment that does nothing for patients other than take away their rights and generate paperwork. In a different legal climate, every hospital could offer a psychiatrist and a psychologist to prescribe meds and offer counselling to those who desire it in a 9-5 fashion. No more of this sitting around for days, taking away a room for medical patients.
Regarding the psychotic, perhaps we’ve done some good in that arena. Or not. Consider the following graph:
