And so it goes… | AMA (WA)


Exhausted doctor

And so it goes…

Saturday October 12, 2019

Dr Anne O'Sullivan

It’s 3pm on a Thursday afternoon.

I’ve just left ED to teach my students when my phone rings. It’s a community mental health nurse.

“I’m really sorry doctor, but we can’t contain him anymore. We thought we had a bed earlier today but it fell through. Mum’s never seen his Bipolar this bad before. He’s really erratic and not sleeping, but he’s started to talk about suicide. That’s new. “Also, we think he’s used meth a few days ago, because he was really stable lately. “I heard you have four patients on Forms already. Sorry to add to it.”

“No worries, send him in.” What else could I say? We have no choice.

This is becoming increasingly common where community mental health services are stretched and have no choice but to bring their patients to ED. The methamphetamine use doesn’t help our patients either, causing them to relapse just as they are getting well. Plus, it often makes them so violent.

One of my patients waiting for a secure bed has this same story. He’s been in ED for more than 55 hours.

Immediately after I hang up, the ED duty consultant rings me: “Just heard. We can’t possibly manage another one. We’re starting to ramp. We need space. We’re going to have to call a Code Yellow if this keeps up. It’s getting dangerous in here.”

I have to agree. I reassure them that I’ll do what I can.

Today has been hard work.

Four patients on Forms who have been boarded in ED between 15-55 hours. This doesn’t include the patients either waiting for a voluntary bed or waiting for assessment. We’ve had 10 patient referrals this morning and another five since lunchtime – all suicidal and distressed.

Patients often come to EDs when they’re in a mental health crisis because they don’t know where else to go and their families are desperate. Often it’s their first contact with mental health services. Having specialist mental health services in ED is critical to providing immediate and appropriate therapeutic treatment and support.
Yet when they’re acutely agitated, it can be the worst place for them, especially given the wait for a hospital bed is so long.

Yesterday, we finally transferred a 16-year-old acutely psychotic patient after waiting over 96 hours in the ED, where he spent the majority of that time sedated to control his agitation.

I call Bed Flow again, but no change. Only one bed in the State, and they’re waiting for the green light. They reassure me they’ll try to push things along from their end.

While I’m on the phone, my SMS beeps. It’s my registrar.

“Can you call me ASAP?” She sounds breathless when she answers the phone. “What’s happened?” “Well, you know that patient, the one who’s been here since Monday night? He woke up from that IV sedation we gave him from the last Code Black. He needed to use the bathroom but because he’s in restraints, security had to help. “As soon as the restraints were removed, he made a runner for the door, screaming he wanted a cigarette. Security had to stop him and then he head-butted a security guard. One of the nurses got in the way and got hit too. “The patient’s not hurt, but it was really awful. His mum is here and saw it all. Can you please come and sort it out? It’s a mess.”

I arrive in ED several minutes later. I can hear my patient yelling for people to get away from him. He sounds terrified. He’s on the bed in four-point physical restraints, secured at his elbows and ankles. He’s struggling and screaming out for people to leave him alone.

Twelve people surround the cubicle – a mix of ED staff, hospital executive and security along with my registrar and the psychiatric liaison nurse (PLN), both of who look exhausted. The patient’s mum is also there, tears streaming down her face.

They all turn to look at me when I arrive and the pressure is palpable. In the next cubicle, nurses are also trying to contain another patient of mine with post-partum psychosis who has become distressed by the yelling.

The ED consultant just looks at me and shakes her head. “I know, I know,” I say to her. I know she wants to have the patient transferred immediately
but she also understands the pressure the system is under. ED staff have to deal with work conditions that are relentless and difficult, but they manage to do a magnificent job. Now one of their own is injured – again. Everyday there is violence and aggression in the ED. No wonder 10 per cent of ED nurses want to quit.

I realise we’re going to have to hold a debrief after. Everyone looks so shaken up. I go into the cubicle with my team, with security standing outside. My patient looks angry and confused. “You’re all part of it too,” he yells.

Police brought him to ED after he attacked his parents thinking they were part of a conspiracy to kill him. Now he’s convinced this is true. He has paranoid schizophrenia but was stable until he used meth a week ago and then stopped his medication. He starts to tell me that his mum has been replaced by someone else, then screams at her when she tries to come in to talk with him. He becomes even more terrified as the ED staff enter the cubicle. We have no choice but to give him further IV sedation.

He struggles before he finally goes to sleep. I try to block out his angry abusive words mixed with distressing calls for help, but it’s hard. I don’t want to give him any more sedation and I hate having to use physical restraints. We should not have to resort to this.

He needs to be in a psychiatric ward with staff trained in working with acutely unwell patients. He needs medication, rest, food and an area to walk around. He needs the holistic psychiatric treatment I know he’ll get once he’s on a ward.

In here, it feels like we’re torturing him. This ED environment is making him worse. It’s so noisy and bright every moment of the day. This is not the place for an acutely agitated psychiatric patient.

My phone rings. It’s my PLN. Bed Flow finally has that bed. Now we just need to arrange transport so hopefully our patient will be in a secure ward tonight.

“Oh and by the way, the community team and police have just arrived with that other Formed patient.”

And so it goes… ■

Dr Anne O’Sullivan is an Emergency Psychiatrist and Clinical Lead for the Emergency Psychiatry Team at Sir Charles Gairdner Hospital.

Mental Health Week 2022 is October 8-15.