Did the hospital mess up by discharging someone experiencing psychosis?
May 31, 2022 11:43 PM Subscribe
Hospital discharged a woman with schizophrenia that seemed to be experiencing psychosis (positive and negative symptoms), was expressing suicidal thoughts, and was acting in a way that was a danger to herself and others (through erratic, not violent, behavior), and when returning with her to the ER, they more or less said "we're going to leave her in the waiting room until she's leaves, and that's not our problem." The reason they gave was that she was a regular, and she already saw the psychiatrist and he discharged her. They screwed up, right?
(I realize my question there is loaded and leading, but I can't imagine that not being the case.)
I am trying to figure out if what the hospital staff did is incorrect, and if there is anything I can do about it, even if it is complaining to someone.
I will call the woman we helped V. I saw her sitting on the sidewalk with a man (G) talking to her and a woman (A) crouched next to her, she seemed distressed. It was warm today, and I somehow thought maybe it was heatstroke, and since I had just gotten a case of water at the store, I decided to stop and try to help.
That wasn't the case, V was distressed in other ways. She apparently walked out in the street in front of G and A as they were driving and they came close to hitting her, which is why they stopped. Before I arrived but after G and A were there, V tried to walk into traffic a couple times, she wasn't saying much, and A didn't know what was wrong with V. V was vacant, her eyes kinda looking up but not rolled back into her head. She had a significant tremor. She would get up, and then slowly sink down. G and A already knew she was recently discharged from the hospital (less than a block away), seemingly from the people at the bus stop across the street.
V wasn't really responding to much, but would let us lead her and stop her from going into traffic. She would slump down like she was falling slowly, and that happened the first time shortly after I arrived, while the A was holding her arm, called to her boyfriend because she couldn't hold her up, but he was on the phone with the police. So I grabbed on, helped lower V to her knees.
V seemed to be going in and out of these episodes where she would move, shake, and then stop and stare. I took a look at the papers V was holding, which were her discharge paper and it said the diagnosis was schizophrenia, thus how we figured out what was happening. I honestly was terrified she was slumping down and dying of a heart attack, thankfully, that was not the case and these episodes of movement and shaking to slowing down, V closing her eyes, and even the tremor stopping happened many times.
We waited for the police for about a half hour. In that time, we were able to get her to speak occasionally, not about much other than religious (jesus, god, the bible). She also talked about dying and wanting to go to heaven. I believe she was having auditory and visual hallucinations along those lines based on that and later conversations. She eventually had some water and we got her to lie down for a little bit, the other woman grabbing a blanket for her head, and this calmed her for a bit. When she opened her eyes, she seemed a bit brighter in mood, asking us about jesus, and pointing to the sky, even air hugging something.
After a half hour, the police hadn't arrived, and V had gotten up a couple times and tried to walk into the street, so we made the decision to drive her to the ER ourselves. It was a one way street, so we had to drive further than the as the crow flies distance to get there, about 3 blocks. V did say that she was supposed to go to a "mental hospital" before I got there, and at some point before getting in the car, she said she wanted to go to [name of a different hospital] but we decided to take her to what was close especially as she had just been there.
She was easy to walk to the car and got in with little suggestion. But about a block into it, she took off her seatbelt and proceeded to open the car and tried to get out while it was moving. Thank god I was back there with her (more on that shortly), I was able to grab her hands, pull her towards me and direct her to stay there and get the door closed again. She was then calm until we got to the ER.
Once there, she wanted to leave, but we asked her to sit in the "hospital chair" (the wheel chair) and brought her to the security and front desk, but were told that she had been there and was discharged so they weren't going to do anything. They said she was a "regular", but couldn't say more. We told the admitting nurse that we saw her discharge papers and that it had a diagnosis of schizophrenia. The nurse (rightly) said she couldn't say much but the psychiatrist already saw her and said there wasn't anything else they could do.
The other woman, disgusted, argued how could they let someone that was not well leave and walk into traffic, especially when she's experiencing a mental health crisis and expressing a desire to end her life. The nurse tells us that they "called an uber for her, but she left before it got there" (remember how I said that she tried to exit the car while moving? Imagine an unsuspecting uber driver and no one in the back seat.) And the police were called? I am unclear if it was prior to her leaving the first time, or if it was in response to her leaving before the uber came.
At this point, I was talking to V, she actually seemed clearer for a bit, explained how she didn't know what was real and what wasn't anymore, and she was afraid, and did not want to live. But she then faded out into one of those kind of stupors. She had stood up at that point, so I and A guided her back into the chair. At one point, I heard the nurse say that we can leave V, but they won't do anything and would leave again anyway. I ask them if I sit with her and make sure she doesn't leave the waiting room before she's seen, will they see her? No, because she's already been seen. I don't remember the next few things that were said, but the end result was that they were going to have the police come and make sure she was ok/take her to somewhere she could get help/take her home.
We decided to stay with her until the police came. V expressed fear of going home. She also seemed to be going in and out of being lucid, and had more emotional tone some of the time (before the hospital, it was flat and single word answers, mostly). Now she told us about church, and god, and singing in church. A asked V if she had a bible in her purse and if she could read V's favorite passage. (And V did, dunno how A knew that but she said at one point she worked in a nursing home.) In one of her more lucid moments, she said something about how she wanted to just be in a hospital to get help because she wasn't sure she could make it on her own.
The conversation mostly went like this until the police arrived, though she also would have moments of stupor or trying to get out of the chair, and she made some other references to dying, to god telling her she was going to die, to wanting to die.
When the police came, they sent a regular officer and crisis officer? I think that is what they called her. She asked some questions, and when V wasn't very helpful, I explained the discharge papers and schizophrenia, the walking into traffic, that she appeared to be seeing and hearing voices, but also would have these long pauses where she wasn't able to communicate well in kind of a stupor or would act erratically. And at one point, she asked the officer to shoot her, kill her.
(I honestly can't remember when, but she started to have times where she would cover her ears. A thought it was from noise in the environment, but I am pretty sure it was when she was hearing voices, and they were telling her to do something that was incongruent with what we were telling her to do because it almost always came when we would ask her to come and sit down or to not get up if she was trying to.)
After the crisis officer asked a bunch of questions, some she seemed to answer with some sense, others she said things that were wrong (like what day it was), or didn't make any sense. The regular officer wanted to go in and talk to the hospital staff and see if they could get the staff to do more, and the crisis officer wanted to stay with her, but reg officer said she didn't want her to be alone with V (V wasn't violent, but it seemed like it was perhaps policy?) So the crisis officer asked us if we would be willing to stay with V and keep her there while they did. Which at that point we did.
I can't remember when or how, but both we and the crisis officer figured out that she had to take a daily medication for her schizophrenia, and she took it today. And in retrospect, she was pantomiming something at one point when we asked her what she wanted, and I believe now she meant "pill". (We thought she meant more water or food). In fact, I think perhaps she went there because her medication was not working and she wanted another/a different pill. (sigh, which i had realized then)
After roughly 20 minutes (the time was uneventful/more of the same), the officers came out and said they would take over now, and we could go. (I am bothered in retrospect that they didn't say what they were going to do; i.e. take her into hospital, take her to a different hospital, take her home, or just let her leave after we left.)
So, writing this out, I know schizophrenia is an incredibly difficult disorder to treat, and I know ER departments struggle with mental health issues. Is this normal? It seems like releasing someone who is experiencing psychosis is not a good idea. Same with releasing someone that is expressing the desire to kill themselves, and is a danger to themselves and theres, i.e. walking into traffic. Is that just how overwhelmed ERs do when someone has a severe mental health issue?
I should mention that V was a black woman in her 50s. Seems relevant to the treatment she was getting (or lack there of).
And assuming that it is as messed up as I think it is, what do I do? Like is a strongly worded letter enough? It doesn't seem so.
(I realize my question there is loaded and leading, but I can't imagine that not being the case.)
I am trying to figure out if what the hospital staff did is incorrect, and if there is anything I can do about it, even if it is complaining to someone.
I will call the woman we helped V. I saw her sitting on the sidewalk with a man (G) talking to her and a woman (A) crouched next to her, she seemed distressed. It was warm today, and I somehow thought maybe it was heatstroke, and since I had just gotten a case of water at the store, I decided to stop and try to help.
That wasn't the case, V was distressed in other ways. She apparently walked out in the street in front of G and A as they were driving and they came close to hitting her, which is why they stopped. Before I arrived but after G and A were there, V tried to walk into traffic a couple times, she wasn't saying much, and A didn't know what was wrong with V. V was vacant, her eyes kinda looking up but not rolled back into her head. She had a significant tremor. She would get up, and then slowly sink down. G and A already knew she was recently discharged from the hospital (less than a block away), seemingly from the people at the bus stop across the street.
V wasn't really responding to much, but would let us lead her and stop her from going into traffic. She would slump down like she was falling slowly, and that happened the first time shortly after I arrived, while the A was holding her arm, called to her boyfriend because she couldn't hold her up, but he was on the phone with the police. So I grabbed on, helped lower V to her knees.
V seemed to be going in and out of these episodes where she would move, shake, and then stop and stare. I took a look at the papers V was holding, which were her discharge paper and it said the diagnosis was schizophrenia, thus how we figured out what was happening. I honestly was terrified she was slumping down and dying of a heart attack, thankfully, that was not the case and these episodes of movement and shaking to slowing down, V closing her eyes, and even the tremor stopping happened many times.
We waited for the police for about a half hour. In that time, we were able to get her to speak occasionally, not about much other than religious (jesus, god, the bible). She also talked about dying and wanting to go to heaven. I believe she was having auditory and visual hallucinations along those lines based on that and later conversations. She eventually had some water and we got her to lie down for a little bit, the other woman grabbing a blanket for her head, and this calmed her for a bit. When she opened her eyes, she seemed a bit brighter in mood, asking us about jesus, and pointing to the sky, even air hugging something.
After a half hour, the police hadn't arrived, and V had gotten up a couple times and tried to walk into the street, so we made the decision to drive her to the ER ourselves. It was a one way street, so we had to drive further than the as the crow flies distance to get there, about 3 blocks. V did say that she was supposed to go to a "mental hospital" before I got there, and at some point before getting in the car, she said she wanted to go to [name of a different hospital] but we decided to take her to what was close especially as she had just been there.
She was easy to walk to the car and got in with little suggestion. But about a block into it, she took off her seatbelt and proceeded to open the car and tried to get out while it was moving. Thank god I was back there with her (more on that shortly), I was able to grab her hands, pull her towards me and direct her to stay there and get the door closed again. She was then calm until we got to the ER.
Once there, she wanted to leave, but we asked her to sit in the "hospital chair" (the wheel chair) and brought her to the security and front desk, but were told that she had been there and was discharged so they weren't going to do anything. They said she was a "regular", but couldn't say more. We told the admitting nurse that we saw her discharge papers and that it had a diagnosis of schizophrenia. The nurse (rightly) said she couldn't say much but the psychiatrist already saw her and said there wasn't anything else they could do.
The other woman, disgusted, argued how could they let someone that was not well leave and walk into traffic, especially when she's experiencing a mental health crisis and expressing a desire to end her life. The nurse tells us that they "called an uber for her, but she left before it got there" (remember how I said that she tried to exit the car while moving? Imagine an unsuspecting uber driver and no one in the back seat.) And the police were called? I am unclear if it was prior to her leaving the first time, or if it was in response to her leaving before the uber came.
At this point, I was talking to V, she actually seemed clearer for a bit, explained how she didn't know what was real and what wasn't anymore, and she was afraid, and did not want to live. But she then faded out into one of those kind of stupors. She had stood up at that point, so I and A guided her back into the chair. At one point, I heard the nurse say that we can leave V, but they won't do anything and would leave again anyway. I ask them if I sit with her and make sure she doesn't leave the waiting room before she's seen, will they see her? No, because she's already been seen. I don't remember the next few things that were said, but the end result was that they were going to have the police come and make sure she was ok/take her to somewhere she could get help/take her home.
We decided to stay with her until the police came. V expressed fear of going home. She also seemed to be going in and out of being lucid, and had more emotional tone some of the time (before the hospital, it was flat and single word answers, mostly). Now she told us about church, and god, and singing in church. A asked V if she had a bible in her purse and if she could read V's favorite passage. (And V did, dunno how A knew that but she said at one point she worked in a nursing home.) In one of her more lucid moments, she said something about how she wanted to just be in a hospital to get help because she wasn't sure she could make it on her own.
The conversation mostly went like this until the police arrived, though she also would have moments of stupor or trying to get out of the chair, and she made some other references to dying, to god telling her she was going to die, to wanting to die.
When the police came, they sent a regular officer and crisis officer? I think that is what they called her. She asked some questions, and when V wasn't very helpful, I explained the discharge papers and schizophrenia, the walking into traffic, that she appeared to be seeing and hearing voices, but also would have these long pauses where she wasn't able to communicate well in kind of a stupor or would act erratically. And at one point, she asked the officer to shoot her, kill her.
(I honestly can't remember when, but she started to have times where she would cover her ears. A thought it was from noise in the environment, but I am pretty sure it was when she was hearing voices, and they were telling her to do something that was incongruent with what we were telling her to do because it almost always came when we would ask her to come and sit down or to not get up if she was trying to.)
After the crisis officer asked a bunch of questions, some she seemed to answer with some sense, others she said things that were wrong (like what day it was), or didn't make any sense. The regular officer wanted to go in and talk to the hospital staff and see if they could get the staff to do more, and the crisis officer wanted to stay with her, but reg officer said she didn't want her to be alone with V (V wasn't violent, but it seemed like it was perhaps policy?) So the crisis officer asked us if we would be willing to stay with V and keep her there while they did. Which at that point we did.
I can't remember when or how, but both we and the crisis officer figured out that she had to take a daily medication for her schizophrenia, and she took it today. And in retrospect, she was pantomiming something at one point when we asked her what she wanted, and I believe now she meant "pill". (We thought she meant more water or food). In fact, I think perhaps she went there because her medication was not working and she wanted another/a different pill. (sigh, which i had realized then)
After roughly 20 minutes (the time was uneventful/more of the same), the officers came out and said they would take over now, and we could go. (I am bothered in retrospect that they didn't say what they were going to do; i.e. take her into hospital, take her to a different hospital, take her home, or just let her leave after we left.)
So, writing this out, I know schizophrenia is an incredibly difficult disorder to treat, and I know ER departments struggle with mental health issues. Is this normal? It seems like releasing someone who is experiencing psychosis is not a good idea. Same with releasing someone that is expressing the desire to kill themselves, and is a danger to themselves and theres, i.e. walking into traffic. Is that just how overwhelmed ERs do when someone has a severe mental health issue?
I should mention that V was a black woman in her 50s. Seems relevant to the treatment she was getting (or lack there of).
And assuming that it is as messed up as I think it is, what do I do? Like is a strongly worded letter enough? It doesn't seem so.
Best answer: To answer your initial question, yes they screwed up. If she was not evaluated in the ER when brought in for a psychiatric evaluation with you the stranger when you had witnessed suicidal gestures/attempts that is what is called an EMTALA violation. When somebody is brought to the ER there are specific things they have to do and with suicidal gestures/attempts, there are specific things the ER has to do- like put them on a 1:1, etc. People in mental health crisis don't get to chill in the waiting room. Even if they were just there.
That includes people who are high utilizers of emergency room services, people just discharged from psychiatric facilities. You can report by googling EMTALA (your state) and finding the correct link. The important thing to note is that they did not perform a medical screening exam even with corroborating information that this person had just tried to walk into traffic, jump out of a moving vehicle - whatever you told them. This can be up to a 50,000 dollar fine after an investigation by accrediting bodies.
You can also report it to your local department of public health (which may or may not be the same person that receives the other one) if they are the people who regulate hospitals in your area they will have their own form. I would be pretty clear and succinct - something like the brought patient to ER after witnessing her try to walk into traffic, they refused to see her even though I had witnessed a suicidal gesture/attempt and reported it to the triage nurse/registration staff. And leave it there. Patient harm: did not get the care or evaluation she needed.
For these reports it will be helpful to know 1)the police report number if you have it 2)as much of the demographic information of the person you encountered 3) dates and times 4)your name and other witnesses' names if available to you.
Overall this won't fix the broken health care system and all of its messes and problems. But at least it will give them a warning that this is an absolutely unacceptable standard of care. There aren't necessarily good answers in cases like this, but there are certainly bad ones- and this was definitely over the line and reportable.
I have filed many reports through my department of public health, for a variety of reasons due to my professional role. Sometimes they come through, there are fines and stuff, sometimes not. Your state's general practices on regulation may impact the outcome. But it is something that people can and do take seriously and hospitals listen to.
posted by AlexiaSky at 3:44 AM on June 1, 2022 [33 favorites]
That includes people who are high utilizers of emergency room services, people just discharged from psychiatric facilities. You can report by googling EMTALA (your state) and finding the correct link. The important thing to note is that they did not perform a medical screening exam even with corroborating information that this person had just tried to walk into traffic, jump out of a moving vehicle - whatever you told them. This can be up to a 50,000 dollar fine after an investigation by accrediting bodies.
You can also report it to your local department of public health (which may or may not be the same person that receives the other one) if they are the people who regulate hospitals in your area they will have their own form. I would be pretty clear and succinct - something like the brought patient to ER after witnessing her try to walk into traffic, they refused to see her even though I had witnessed a suicidal gesture/attempt and reported it to the triage nurse/registration staff. And leave it there. Patient harm: did not get the care or evaluation she needed.
For these reports it will be helpful to know 1)the police report number if you have it 2)as much of the demographic information of the person you encountered 3) dates and times 4)your name and other witnesses' names if available to you.
Overall this won't fix the broken health care system and all of its messes and problems. But at least it will give them a warning that this is an absolutely unacceptable standard of care. There aren't necessarily good answers in cases like this, but there are certainly bad ones- and this was definitely over the line and reportable.
I have filed many reports through my department of public health, for a variety of reasons due to my professional role. Sometimes they come through, there are fines and stuff, sometimes not. Your state's general practices on regulation may impact the outcome. But it is something that people can and do take seriously and hospitals listen to.
posted by AlexiaSky at 3:44 AM on June 1, 2022 [33 favorites]
Re speculation on substance abuse i want to suggest to believe the OP. OP was able to look at her discharge papers and writes:
I took a look at the papers V was holding, which were her discharge paper and it said the diagnosis was schizophrenia,
posted by 15L06 at 4:04 AM on June 1, 2022 [6 favorites]
I took a look at the papers V was holding, which were her discharge paper and it said the diagnosis was schizophrenia,
posted by 15L06 at 4:04 AM on June 1, 2022 [6 favorites]
I just wanted to say that helping someone in an ambiguous crisis when you know that you individually cannot resolve their problem is really difficult and does not often have a satisfactory outcome and thus can be something that troubles you for long after - so, I mean, I hope you feel all right about processing this with friends, etc. You did your best in a very unclear situation where you did not have the kind of institutional support that you should have had and where you had no training.
It feels really shitty to see someone who is suffering like that, be largely unable to help and then have to release them into the hands of hospital/cops/etc, not knowing what will happen, since there is literally nothing else you can do, is what I'm saying.
I think what the hospital did was shitty and racist, even though probably anyone in an ambiguous mental health situation would also have been treated fairly badly too. (But I bet at least some people at that hospital are the kind of people who would have liked to help but after years of being unable to help, they have had to callous over. Which is why this stuff is a moral injury to society, being unable to help people who need help pitches people into despair or indifference.)
If you are in a medium to large city, there is probably some kind of homeless support/mental health support street-level group, maybe several. "Harm reduction" groups do stuff specific to drug use, but the people in those groups often have pretty broad experience with people in crisis, such services as are available, etc. If you feel like you want to talk to/work with people on this issue, those may be the people to go to.
posted by Frowner at 5:15 AM on June 1, 2022 [16 favorites]
It feels really shitty to see someone who is suffering like that, be largely unable to help and then have to release them into the hands of hospital/cops/etc, not knowing what will happen, since there is literally nothing else you can do, is what I'm saying.
I think what the hospital did was shitty and racist, even though probably anyone in an ambiguous mental health situation would also have been treated fairly badly too. (But I bet at least some people at that hospital are the kind of people who would have liked to help but after years of being unable to help, they have had to callous over. Which is why this stuff is a moral injury to society, being unable to help people who need help pitches people into despair or indifference.)
If you are in a medium to large city, there is probably some kind of homeless support/mental health support street-level group, maybe several. "Harm reduction" groups do stuff specific to drug use, but the people in those groups often have pretty broad experience with people in crisis, such services as are available, etc. If you feel like you want to talk to/work with people on this issue, those may be the people to go to.
posted by Frowner at 5:15 AM on June 1, 2022 [16 favorites]
Worth noting that OP did not call the police and in fact did exactly the right thing when someone else called - stayed with the woman to make sure that she was safe.
I assume that on-the-ground homeless support or harm reduction people would know some strategies around this stuff, but in my own experience you don't always control whether the police are called. For instance, if you call 911 they often send cops even if you make it clear that you only need an ambulance (and even if you sound extremely white and middle class on the phone). If people have training and narcan, they can try to treat an overdose themselves without calling 911, but obviously if someone has a heart attack, etc, you aren't just going to treat that yourself.
Sometimes other people call the cops - you can ask that people not, but you can't stop them.
Sometimes the person in crisis or their friends ask you to call the cops. I have called the cops once at someone's request in a situation where I was literally afraid that the person and I were both going to be killed and therefore felt that the cops probably wouldn't make anything actually worse and I have refused twice, one time when the situation was very low stakes and I felt that I could not actually help and one time when I felt that I could successfully de-escalate.
On those occasions when cops have come, I have tried whenever possible to stay with the person until I had a good sense of where things were going. It's not so much that the cops always do the wrong thing, it's that you are rolling some dangerous dice when you call them, so like with the "I am plausibly afraid that we are both going to die" situation, the cops actually didn't do anything bad even though it was a potentially violent situation. I think calling them was the least-bad option given the extremely unusual details of the situation - since that night, I have often asked myself what else I could have done and I still feel that way.
My point being that not calling the cops is a good first principle but you may still find yourself dealing with them.
posted by Frowner at 6:43 AM on June 1, 2022 [1 favorite]
I assume that on-the-ground homeless support or harm reduction people would know some strategies around this stuff, but in my own experience you don't always control whether the police are called. For instance, if you call 911 they often send cops even if you make it clear that you only need an ambulance (and even if you sound extremely white and middle class on the phone). If people have training and narcan, they can try to treat an overdose themselves without calling 911, but obviously if someone has a heart attack, etc, you aren't just going to treat that yourself.
Sometimes other people call the cops - you can ask that people not, but you can't stop them.
Sometimes the person in crisis or their friends ask you to call the cops. I have called the cops once at someone's request in a situation where I was literally afraid that the person and I were both going to be killed and therefore felt that the cops probably wouldn't make anything actually worse and I have refused twice, one time when the situation was very low stakes and I felt that I could not actually help and one time when I felt that I could successfully de-escalate.
On those occasions when cops have come, I have tried whenever possible to stay with the person until I had a good sense of where things were going. It's not so much that the cops always do the wrong thing, it's that you are rolling some dangerous dice when you call them, so like with the "I am plausibly afraid that we are both going to die" situation, the cops actually didn't do anything bad even though it was a potentially violent situation. I think calling them was the least-bad option given the extremely unusual details of the situation - since that night, I have often asked myself what else I could have done and I still feel that way.
My point being that not calling the cops is a good first principle but you may still find yourself dealing with them.
posted by Frowner at 6:43 AM on June 1, 2022 [1 favorite]
Without the context of the person's recent, prior visit to the same hospital, I don't think anyone can say whether the hospital "screwed up." She may have been given a bona fide evaluation by a psychiatrist, as the hospital said. The psychiatrist may have had access to prior medical records that provide much more information than we have here and decided that there was not a basis to admit her. The system as a whole clearly does not do enough for people in this type of condition, but did this specific hospital do the wrong thing in this specific moment? I don't think anyone can really judge that here. I mean, clearly the hospital isn't set up to provide long-term housing or care, even if that is what this person (and people like her) need. +1 to getting involved in homeless support and advocacy groups if this is something you feel strongly about.
posted by Mid at 7:14 AM on June 1, 2022 [4 favorites]
posted by Mid at 7:14 AM on June 1, 2022 [4 favorites]
Response by poster: I don’t know if she was transient, she gave a home address at some point (but also thought the year was 1947, which I think was her birthday). I don’t believe any drugs were involved besides medically prescribed- she was a very god-fearing woman and her delusions centered around that. She seemed to have (at least in the past) been an active member of a church. She told the crisis officer she was taking a medication daily, I assume for the schizophrenia. I didn’t realize until later that at one point A and I asked her what she wanted, and she was indicating putting something in her mouth. We thought she wanted water or food, but I think she was indicating she wanted medication; it was the same gesture someone would make taking a pill. She also seemed to indicate she was seeking inpatient care because she was afraid of/for herself, and when A told her she worked at a nursing home, V said she wanted to go there. I think she was really doing the best she could to seek help with a brain that was making it difficult to do that, which is all the more frustrating that she wasn’t receiving help.
The only kinda good thing is if she is indeed a regular, I live close to there and regularly walk or drive by that intersection and if she truly is a regular, I can keep an eye out - she was suspiciously close to the bus stop that serves the hospital. I don’t know what I can do if I see her again, but I would at least like to see her and would do the help again if I saw her having the same difficulty. Maybe walk her more directly to the emergency room.
I’m going to take AlexiaSky’s advice, try and get a police report and distill the events down to dates and times and l report to EMTALA. Even if it doesn’t help her directly, maybe it will be enough to nudge in that direction someday.
I will say that I was impressed with what I could see of the response from the PD, especially the crisis officer. She seemed to be genuinely concerned and wasn’t approaching it as if V was dangerous. Whether that amounted to a good outcome, I don’t know. I do wish I had thought to warn them that V was prone to taking sudden action but wasn’t dangerous, just needed to be redirected and talked calmly to.
posted by [insert clever name here] at 8:49 AM on June 1, 2022 [4 favorites]
The only kinda good thing is if she is indeed a regular, I live close to there and regularly walk or drive by that intersection and if she truly is a regular, I can keep an eye out - she was suspiciously close to the bus stop that serves the hospital. I don’t know what I can do if I see her again, but I would at least like to see her and would do the help again if I saw her having the same difficulty. Maybe walk her more directly to the emergency room.
I’m going to take AlexiaSky’s advice, try and get a police report and distill the events down to dates and times and l report to EMTALA. Even if it doesn’t help her directly, maybe it will be enough to nudge in that direction someday.
I will say that I was impressed with what I could see of the response from the PD, especially the crisis officer. She seemed to be genuinely concerned and wasn’t approaching it as if V was dangerous. Whether that amounted to a good outcome, I don’t know. I do wish I had thought to warn them that V was prone to taking sudden action but wasn’t dangerous, just needed to be redirected and talked calmly to.
posted by [insert clever name here] at 8:49 AM on June 1, 2022 [4 favorites]
Response by poster: Any suggestions for writing out the timeline when I don't know exact times? I have a solid guess of the time I parked my car to help, because I had a split second of debating whether or not to stop as I had loose plans with roommate that required daylight, and I remember the time getting back to my car because I checked for the same reason. But the timeline in between was rough estimates at best.
posted by [insert clever name here] at 9:19 AM on June 1, 2022
posted by [insert clever name here] at 9:19 AM on June 1, 2022
I am not a psychiatrist and am not going to speculate on what was going on in this specific case. I have, however, sent people in crisis to the ED and have been on the evaluating end as well. Here's what happens during that process:
In the US, as noted, EMTALA requires emergency departments to stabilize patients prior to discharge or transfer. This is often easier assessed on a medical side than a psychiatric side. If a patient is deemed to require psychiatric care (e.g. active suicidal ideation) but is refusing such care, the ED may request a psychiatric hold for involuntary commitment. This is a 24 hour hold during which a patient is assessed by psychiatry. If on two separate examinations by different practitioners, the person is deemed to lack capacity for medical decision-making, the hold goes before a judge who either upholds or overturns the order. If on either of those two examinations, the person is deemed not to be a danger to self or others, they must be released.
The whole process is traumatic, especially if not conducted in a dedicated psych ED of which there are vanishingly few.
EMTALA is a law rather than an agency, but suspected violations can be reported to your local CMMS agency. Patient advocates or social workers at the institution might also be a good person to talk to. However I suspect the latter would be limited in what they could tell you, because of HIPAA. (Technically, the ED triage people should not have even told you that they had seen this person before, but I guess since they had the discharge papers in hand, that cat was out of the bag.)
posted by basalganglia at 9:27 AM on June 1, 2022 [6 favorites]
In the US, as noted, EMTALA requires emergency departments to stabilize patients prior to discharge or transfer. This is often easier assessed on a medical side than a psychiatric side. If a patient is deemed to require psychiatric care (e.g. active suicidal ideation) but is refusing such care, the ED may request a psychiatric hold for involuntary commitment. This is a 24 hour hold during which a patient is assessed by psychiatry. If on two separate examinations by different practitioners, the person is deemed to lack capacity for medical decision-making, the hold goes before a judge who either upholds or overturns the order. If on either of those two examinations, the person is deemed not to be a danger to self or others, they must be released.
The whole process is traumatic, especially if not conducted in a dedicated psych ED of which there are vanishingly few.
EMTALA is a law rather than an agency, but suspected violations can be reported to your local CMMS agency. Patient advocates or social workers at the institution might also be a good person to talk to. However I suspect the latter would be limited in what they could tell you, because of HIPAA. (Technically, the ED triage people should not have even told you that they had seen this person before, but I guess since they had the discharge papers in hand, that cat was out of the bag.)
posted by basalganglia at 9:27 AM on June 1, 2022 [6 favorites]
in the car, she said she wanted to go to [name of a different hospital] but we decided to take her to what was close especially as she had just been there.
you are certainly not at fault in any way for having gone out of your way to try to help someone, but I think that insofar as it is ever possible, I would try to give the utmost weight to such a request. I don't know that she would have received more or better care anywhere else, and perhaps she wouldn't have. but if someone has already been to a given hospital, knows what it is like, and is asking to be taken somewhere else, I would assume they have a serious reason for that and that it matters. particularly in the case of a health issue such as this specific one. I would not want to bring anyone back to a place that had discharged her onto the street in that condition, because she had just been there. I say that while being well aware that the place she asked to go to might not be any better.
I absolutely, absolutely understand that you were worried about her and did not want to take the chance of transporting her somewhere further away when you had no way of knowing whether the delay would worsen her immediate condition. also that it was not your responsibility in the first place and you did much more than most people do, and you may have saved her from being hit by a car and killed, and you should in any case be able to trust the safety of the care offered by any hospital. this is not intended as any critique of your very generous actions and willingness to go out of your way for a stranger.
posted by queenofbithynia at 10:39 AM on June 1, 2022 [8 favorites]
you are certainly not at fault in any way for having gone out of your way to try to help someone, but I think that insofar as it is ever possible, I would try to give the utmost weight to such a request. I don't know that she would have received more or better care anywhere else, and perhaps she wouldn't have. but if someone has already been to a given hospital, knows what it is like, and is asking to be taken somewhere else, I would assume they have a serious reason for that and that it matters. particularly in the case of a health issue such as this specific one. I would not want to bring anyone back to a place that had discharged her onto the street in that condition, because she had just been there. I say that while being well aware that the place she asked to go to might not be any better.
I absolutely, absolutely understand that you were worried about her and did not want to take the chance of transporting her somewhere further away when you had no way of knowing whether the delay would worsen her immediate condition. also that it was not your responsibility in the first place and you did much more than most people do, and you may have saved her from being hit by a car and killed, and you should in any case be able to trust the safety of the care offered by any hospital. this is not intended as any critique of your very generous actions and willingness to go out of your way for a stranger.
posted by queenofbithynia at 10:39 AM on June 1, 2022 [8 favorites]
The EMTALA violation you should report to CMS (Center for Medicaid and Medicare Services) or the hospital regulatory agency or both. The psychiatric hold thing is correct in general but the details will vary by jurisdiction. It’s not always exactly 24 hours for example.
posted by kerf at 1:07 PM on June 1, 2022
posted by kerf at 1:07 PM on June 1, 2022
Best answer: By day, I’m an RN who acts as a professional go-between, helping hospitals coordinate discharge plans for the low-income seniors who receive their primary care through my employer. By night and weekend, I’m a volunteer who provides bare-bones medical screening and referral for unhoused people, some of whom I’ve now known for years.
This hospital absolutely crossed a line in their maltreatment of V, but also, welcome to my daily heartache.
First off, I want to thank you for taking the time to engage with V and try to help her to the best of your ability. It would have been so easy to keep on walking and leave her be, I’ve seen people do it countless times, and you did not take the easy route of disengagement. Keep that up.
As for the interaction itself:
-In my experience, anyone who has had extensive, traumatizing interactions with healthcare, especially mental health care, develops strong opinions as to which hospitals are the least awful. These preferences won’t necessarily map onto which hospitals are considered “best” from the perspective of, say, a person seeking the most advanced specialist in a cutting-edge surgical technique. If particular hospitals in your area are known to dismiss the concerns of POC, or deliberately under-treat withdrawal symptoms in people who use drugs, or even just have unusually long wait times, people who are the most marginalized will absolutely know that and plan ahead to the best of their ability when trying to access care.
In your situation, I don’t fault you for taking V to the nearest available hospital, given her erratic behavior. I also don’t fault you for thinking that taking her to the hospital where she had already been seen would be the most helpful. Continuity of care is important! An astoundingly large part of my job is just telling people at hospital A “look, this patient already had testing done at hospital B, this is a known stable condition, do you need me to send you the documentation?” But if you ever find yourself in this situation again, know that if a person tells you to take them to a specific hospital, there is probably a strong reason.
-There are a whole slew of reasons why someone could end up being a “regular” at a given hospital. In my experience, 9 times out of 10 they boil down to “this person has needs that don’t neatly fit into any of the tiny boxes available in our shredded social safety net, and every available resource is trying to wash their hands of this person because they’re complicated.” I can picture the dismissive tone the intake RN used when describing V as a regular, because I hear it all the damn time. This absolutely does not forgive her dismissiveness though. There are ways that a health care provider can signal that someone is well-known in the ER/hospital in general as a neutral fact, or with a sense of regret that it has to be that way, vs showing obvious disdain for the patient and all others like them. You’ll learn to see the distinction over time.
-There is a huge gray area where a person can have a severe mental illness that makes their day to day life difficult if not unbearable, but also not meet the very narrow criteria that allow them to access inpatient treatment. (Which is itself an imperfect and often traumatizing “solution,” but that’s a rant for another day). If V did not tell the hospital staff explicitly that she had suicidal ideation during her initial attempt at seeking treatment, that means she didn’t meet admission criteria in their eyes even with psychosis that appears to be life-altering. This is probably why the staff dismissed your pointing out the schizophrenia diagnosis out of hand—the diagnosis on its own is not enough for further action.
That said, your description of V explicitly stating she wanted to die and deliberately running into traffic should have warranted further assessment, even if she had just been assessed previously. This is the part which justifies an EMTALA violation report to CMS. I monitor some people who are known to regularly go back to the same ER within hours after being treated and discharged, I have access to all of their records at said ER, can confirm that there’s at least a short baseline assessment being done at every documented encounter.
-Don’t even get me started on hospitals effectively outsourcing a large chunk of their transportation to Uber. It should be a huge concern from both a liability and a physical accessibility standpoint, and yet.
-I can’t back this up with actual data, but in my experience psychiatrists are especially stretched thin right now and inclined to do the most perfunctory assessments possible/write off anyone who doesn’t need absolutely emergent care. I spent the past few days fighting tooth and nail, along with a hospital social worker, to get a psychiatry evaluation for a patient who was admitted for non-psychiatric reasons but would have benefitted enormously from assessment as part of planning for discharge. Even with extensive documentation from this patient’s outpatient care team, with the official recommendation for evaluation from said care team, with the support of the hospital social worker, we could not make that evaluation happen. Not urgent enough. When I called that social worker back this morning, I told him, dejectedly, “tell the doctors they win.”
-Frowner’s suggestion of seeking out people who do grassroots harm reduction outreach is a good one. You’ll want to bear in mind that these kinds of groups can be intense, and can self-select for big personalities with messy interpersonal lives, but they will absolutely know more about handling crisis situations like you found yourself in.
posted by I am a Sock, I am an Island at 3:58 PM on June 1, 2022 [7 favorites]
This hospital absolutely crossed a line in their maltreatment of V, but also, welcome to my daily heartache.
First off, I want to thank you for taking the time to engage with V and try to help her to the best of your ability. It would have been so easy to keep on walking and leave her be, I’ve seen people do it countless times, and you did not take the easy route of disengagement. Keep that up.
As for the interaction itself:
-In my experience, anyone who has had extensive, traumatizing interactions with healthcare, especially mental health care, develops strong opinions as to which hospitals are the least awful. These preferences won’t necessarily map onto which hospitals are considered “best” from the perspective of, say, a person seeking the most advanced specialist in a cutting-edge surgical technique. If particular hospitals in your area are known to dismiss the concerns of POC, or deliberately under-treat withdrawal symptoms in people who use drugs, or even just have unusually long wait times, people who are the most marginalized will absolutely know that and plan ahead to the best of their ability when trying to access care.
In your situation, I don’t fault you for taking V to the nearest available hospital, given her erratic behavior. I also don’t fault you for thinking that taking her to the hospital where she had already been seen would be the most helpful. Continuity of care is important! An astoundingly large part of my job is just telling people at hospital A “look, this patient already had testing done at hospital B, this is a known stable condition, do you need me to send you the documentation?” But if you ever find yourself in this situation again, know that if a person tells you to take them to a specific hospital, there is probably a strong reason.
-There are a whole slew of reasons why someone could end up being a “regular” at a given hospital. In my experience, 9 times out of 10 they boil down to “this person has needs that don’t neatly fit into any of the tiny boxes available in our shredded social safety net, and every available resource is trying to wash their hands of this person because they’re complicated.” I can picture the dismissive tone the intake RN used when describing V as a regular, because I hear it all the damn time. This absolutely does not forgive her dismissiveness though. There are ways that a health care provider can signal that someone is well-known in the ER/hospital in general as a neutral fact, or with a sense of regret that it has to be that way, vs showing obvious disdain for the patient and all others like them. You’ll learn to see the distinction over time.
-There is a huge gray area where a person can have a severe mental illness that makes their day to day life difficult if not unbearable, but also not meet the very narrow criteria that allow them to access inpatient treatment. (Which is itself an imperfect and often traumatizing “solution,” but that’s a rant for another day). If V did not tell the hospital staff explicitly that she had suicidal ideation during her initial attempt at seeking treatment, that means she didn’t meet admission criteria in their eyes even with psychosis that appears to be life-altering. This is probably why the staff dismissed your pointing out the schizophrenia diagnosis out of hand—the diagnosis on its own is not enough for further action.
That said, your description of V explicitly stating she wanted to die and deliberately running into traffic should have warranted further assessment, even if she had just been assessed previously. This is the part which justifies an EMTALA violation report to CMS. I monitor some people who are known to regularly go back to the same ER within hours after being treated and discharged, I have access to all of their records at said ER, can confirm that there’s at least a short baseline assessment being done at every documented encounter.
-Don’t even get me started on hospitals effectively outsourcing a large chunk of their transportation to Uber. It should be a huge concern from both a liability and a physical accessibility standpoint, and yet.
-I can’t back this up with actual data, but in my experience psychiatrists are especially stretched thin right now and inclined to do the most perfunctory assessments possible/write off anyone who doesn’t need absolutely emergent care. I spent the past few days fighting tooth and nail, along with a hospital social worker, to get a psychiatry evaluation for a patient who was admitted for non-psychiatric reasons but would have benefitted enormously from assessment as part of planning for discharge. Even with extensive documentation from this patient’s outpatient care team, with the official recommendation for evaluation from said care team, with the support of the hospital social worker, we could not make that evaluation happen. Not urgent enough. When I called that social worker back this morning, I told him, dejectedly, “tell the doctors they win.”
-Frowner’s suggestion of seeking out people who do grassroots harm reduction outreach is a good one. You’ll want to bear in mind that these kinds of groups can be intense, and can self-select for big personalities with messy interpersonal lives, but they will absolutely know more about handling crisis situations like you found yourself in.
posted by I am a Sock, I am an Island at 3:58 PM on June 1, 2022 [7 favorites]
she was a very god-fearing woman and her delusions centered around that.
My partner's son is schizophrenic. He's undermedicated (his choice) and delusional and psychotic but not "floridly psychotic" which, around where he lives is the "does he need hospitalization?" standard. There was a time when he was "banned" from some inpatient mental health options in his area because he would declare himself suicidal, get admitted, and then let them know that he wasn't suicidal but needed a place he could meditate all day and his dad kept making him do the dishes. Just telling this story to let you know that there's a huge range to how schizophrenia works and how the system that supposedly supports them works. Many schizophrenics have delusions that involve god, which is not to downplay your assessment of this woman but just... that did not seem surprising to me.
Agree very much with the various things that I am a Sock is saying above. The hospital could have done better. This woman may have known that the hospital she was being brought to would not be helpful (not ok of the hospital, but just a reminder that people who are delusional and psychotic can also have opinions about their treatment options). I could also suggest getting to know grassroots harm reduction. These stories are so difficult and you tried to do a good thing for someone who was having a hard time but that doesn't mean it wasn't also hard for you as well.
posted by jessamyn at 5:15 PM on June 1, 2022 [3 favorites]
My partner's son is schizophrenic. He's undermedicated (his choice) and delusional and psychotic but not "floridly psychotic" which, around where he lives is the "does he need hospitalization?" standard. There was a time when he was "banned" from some inpatient mental health options in his area because he would declare himself suicidal, get admitted, and then let them know that he wasn't suicidal but needed a place he could meditate all day and his dad kept making him do the dishes. Just telling this story to let you know that there's a huge range to how schizophrenia works and how the system that supposedly supports them works. Many schizophrenics have delusions that involve god, which is not to downplay your assessment of this woman but just... that did not seem surprising to me.
Agree very much with the various things that I am a Sock is saying above. The hospital could have done better. This woman may have known that the hospital she was being brought to would not be helpful (not ok of the hospital, but just a reminder that people who are delusional and psychotic can also have opinions about their treatment options). I could also suggest getting to know grassroots harm reduction. These stories are so difficult and you tried to do a good thing for someone who was having a hard time but that doesn't mean it wasn't also hard for you as well.
posted by jessamyn at 5:15 PM on June 1, 2022 [3 favorites]
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