Dr. Dan Barkhuff: Just send ‘them’ all to the ED, and let the ED figure it out
This commentary is by Dan Barkhuff, one of the physicians at the UVM Medical Center emergency department.
“Yeah, I know him,” I say to the off-going attending physician during signout, the 30 minutes-or-so period in between shifts at the University of Vermont emergency department where we discuss patients who — either through time of check-in to the emergency department, medical complexity, or, most commonly, lack of inpatient psychiatric beds — require multiple 8-10 hour chunks of care.
“What’s going on today?”
Sometimes, with the psychiatric patient population, the issue is a recent suicide attempt, or a gesture, or pervasive thoughts. Sometimes they’re manic. Sometimes they’re awaiting a consult from our overbooked CRISIS team of caseworkers.
All too often, they’ve overdosed on the cheaply available heroin/fentanyl that has indirectly led to five homicides in the city of Burlington in the last year. We, the ED staff, cracked a couple of their chests in a last-ditch bloody effort to save their lives. I had only one of them, but he was shot in the head, so we didn’t perform the thoracotomy “cracking a chest” refers to.
I glance at the per-patient “time in the ED tab” on the computer screen. “126 hours, 27 hours, 328 hours, 7 hours…”
The psychiatric patients have been waiting for days and weeks in the emergency department. There are no beds to send them to. UVM is full. Brattleboro is full. A little-known fact about emergency medicine is we’re the only entity in the health care system that, by law, can never say no to a patient asking to be seen.
That’s a vital, necessary and moral aspect of what we do, but it’s also the heart of the mental health care problem. Just send “them” all to the ED, and let the ED figure it out.
“They’re dual diagnosis; we can’t send them anywhere,” my colleague states.
I hear screaming down the hall. Crazy talk. Expletives, threats. A psychiatric patient is agitated.
A nurse got beaten with a plastic lunch tray one night. I stitched up her face. I felt bad. She’s in her early 20s. I used the smallest size suture (6-0) to try to minimize the scar.
Broken bones abound. Dozens of our staff have been violently attacked by mental health patients. That’s not an exaggeration. Dozens.
The cops rarely come. For the assaults against staff, I mean. They do in other states. Some of our docs practice in New York, or even New Hampshire. It’s not their fault. The cops, I mean. There’s only a couple of ’em for a city of 45,000 people overnight. If they’re here escorting a violent patient away, who’s watching Battery Park? And why come if no one’s going to file charges?
We’ve lost almost all of our physician’s assistants, close to half of our nurses. I’ve been here six years. It’s rare for me to know the nurses I’m working with now. They’re all “travelers” from out of state on 90-day contracts.
That’s the way we staff the ED now, gobs of money to maybe get beat up.
Policy got us here. Choices got us here. Choices, some done with the best intentions, got us to “yeah, I know him," and 400 hours in the ED.
We can choose differently, if we want to.