Angry, loud and profane, the young woman was brought in by the police in handcuffs and chains. She had been out of control (as she so often was) and was causing destruction at home.
She had made a passing reference to self-harm in the throes of her meth-induced rage. The police brought her in, saying “she needs help”. If I heard it once, I’ve heard it 10,000 times, and so have you. The patient, barely able to control her frustration, told me that she had no desire to hurt herself or anyone and just wanted to go. I spoke with her father, who expressed a desire for his adult child to be institutionalized.
“I need you to stay with her,” I told the police. She had a history of violent behavior and we had no security. “Sure, doc,” they said, “we can do that.”
Shortly after, when I explained to the patient what was going to happen, she burst into a rage. Then the police said they couldn’t stay. And they didn’t. The patient’s restraints were removed, and she became aggressive and threatening and stormed out. She was brought to the ER for much needed help, but we were, in some ways, powerless to help her.
Advocacy for patients
Then there was the patient with dementia and no family. He wasn’t sick enough to have to stay in his nursing home, so he left. He was also just sick enough that he couldn’t function on the street or in a hotel. So he was taken to the ER, where he spent two weeks living on the ward and the nurses had to manage all of his needs in addition to taking care of normal ward duties like, you know, chest pains , sepsis, strokes, and trauma between changing bedding, getting sodas, and answering the call bell. He also needed help, but not the kind the inpatient side could offer. He needed what so many people seem to need: the kind of help only an emergency can compel to give.
My friend, John, had to defend a young autistic patient who remained in his small emergency department. The patient spent Christmas there during his week-long stay. The care he needed was too much for a group home, but nothing is ever too much for the brave hearts of the emergency department.
We see it again and again: people with dementia, homelessness, drug addicts, psychotics and suicidal people. We don’t mind giving help; we live to help. The problem is that sometimes we just can’t help you. If I can’t hold my patient and no one else can stay with them to hold them, what should I do? I will not fight the dangerous; it is dangerous for all of us, and more precisely, illegal in most cases.
I cannot locate them, including the sweet woman abandoned by her family so she could be cared for in a nursing home. She didn’t meet the admission criteria: she can’t go upstairs and she can’t go to the swing bed.
The violent patient with dementia or the one reported as violent who cannot stand? Geriatric psychiatric beds are like mythical places: we hear stories, but we don’t think they exist. The 5-year-old brought in to enlist because she’s out of control? She was put on legal papers as she sat in the emergency room coloring and eating crackers. Placing it is almost as difficult and in many cases probably unnecessary. The drug user who has no home? Many of them have been in rehab so many times that they have burned all their bridges.
No easy solutions
All of these places, from retirement homes to psychiatric establishments to prisons, have the magic power of “no”. We, on the other hand, have the burden of EMTALA. We cannot deny. We can do nothing but try to offer ‘help’, knowing that our help is anemic, that it is limited in scope and duration, that it is help that will work for a short season until the next time the same patient is brought in again for more help. Our help is mainly warmth and a soft, dry bed, a few meals, and at best some sedation. It’s a kind of help, but it can’t last.
I understand; the police have their own problems. Security is told not to touch anyone. Restraint rules are complex and restrictive. Retirement homes have special admission rules. Psychiatric facilities, rehabilitation centers and homeless shelters are already packed. So everyone will keep bringing people to help us because “something has to be done”, and no one else is able to do it.
Notice, it’s great that we can be there. We are the last hope for so many people. But decades into this madness, I’m sick of being where the buck stops. And I wonder, I really wonder, when we’ve done everything, who can we call to help us?
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Dr Leappractices emergency medicine in rural South Carolina and is an opinion columnist for the Greenville News. He is also the author of four booksLife in Emergistan, available athttps://amzn.to/2T60WET, and Work knights, cats don’t work, and The practical test, all available onwww.booklocker.com, and a blog, http://edwinleap.com. Read his past columns onhttp://bit.ly/EMN-Emergistan.