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AUSTRALIAN MEDICAL ASSOCIATION (WA)
WA’s mental health system is in crisis and troubled patients are swamping emergency departments, senior doctors have warned.
In the latest issue of Medicus (out this week), Immediate past President of the AMA (WA) and Emergency Physician, Associate Professor Dave Mountain gives us a harrowing account of what has become the norm in EDs:
It is 8am. As always the day starts with handover from the night team, grim faced and knackered from another night in the trenches. As we look at the screen, we can see why.
The ED has been taken over by mental health patients. In 10 of the 28 main ED cubicles are psych patients awaiting assessment or transfer to locked beds in Graylands, Bentley, Armadale and Swan as well as those unable to get into the home ward on site.
Three of them haven’t been assessed yet because they arrived so unwell and aggressive they needed immediate restraint and sedation. A quick check makes sure no staff member was injured during the restraints (an occasional occurrence, thankfully due the team’s experience and co-ordination in these situations).
However the night team’s handover demonstrates that it was a very stressful night with seven Code Blacks (physical/chemical restraints) on three separate patients. Every time one patient went off, it stirred up and set off their immediate neighbours who either needed talking down or who then also required additional sedation. Halfway through handover, another patient arcs up, swearing blue murder and heard throughout the department, disturbing what fractured rest the other 12 elderly medical patients awaiting beds might be trying to squeeze in.
Two of the team peel off to assist, try and talk them down, see if they need psych review and if further sedation or physical restraint is required. Unfortunately it is one of the voluntary patients who after a night in the special circle of hell that is the ED psych corridor has gone ballistic.
Almost certainly she has gone from a voluntary to an involuntary admission and will further add to the systemic strain. After this, the psychiatry team starts its ED round where the formed patients are all reviewed. Amazingly enough some, although not many, settle enough to come off forms in the ED corridor, probably as drug-induced psychoses wear off and antipsychotic and sedative medications kick in allowing some sleep and recovery.
After they finish the round, they have great news – two are off forms although unfortunately, the recent berserker (a university student suffering from acute stress and possibly drug (Ritulin)- induced psychosis) is now on forms.
The bad news is that there is still no movement, as the voluntary ward has no beds and there is no movement in locked beds across the city. They now start to try and catch up with the six assessments that already await them from new arrivals, patients arousing from sedation and overdoses medically cleared overnight and awaiting psychiatry review as well as the innumerable phone calls checking if a bed has come up and transport can be arranged, not to mention paperwork needing to be sent.
During the morning as the rest of the ED fills to overflowing around the long-stay psychiatry patients and when we think things couldn’t get worse… the 16-year-old severely depressed, anorexic, actively-suicidal patient arrives. Adolescent psychiatry is a particular nightmare; there are just eight older adolescent beds available in the whole city. We know if adolescent psych patients need to come in, the delays are measured in days and up to a week in the ED. This patient is virtually catatonic, making immediate management relatively easy and within two hours will be in the observation ward.
However we expect her to become a regular name/face on the rounds over the next week.
We know these are not good environments for our adolescent patients as they are highly stimulating, surrounded by older patients, many with poor behaviour control, drug problems and very manipulative. Not the best place for a vulnerable 16 year old.
By 4pm, things are fermenting. We now have 14 psychiatry/ toxicology patients in the ED with possible moves only on three. The total department now has 70 patients inside – 20 stuck in the waiting room, awaiting a cubicle to come free, half of the observation ward is full with tox/psych and 25 per cent of main ED and the rest of the hospital isn’t moving that well either.
Two of the formed patients now have beds but the police is refusing to transport them as “we don’t have to come for up to 72 hours” and “we have more important things to do”. I suspect they are correct, out in the “real” world of cops and robbers.
At 5.30pm an auxiliary police team at the end of its shift does come to take a patient as they have some spare time. Unfortunately as they arrive the receiving unit rings to say the bed has just been taken by an acute formed patient from their own ED. Three phone calls to police supers later and 45 minutes of senior time, we get permission to move the other potential formed patient with the auxiliary team and luckily an ambulance team can get free to do the job as well.
As I head off at 6.40pm, police, ED crew and security go past the other way with a huge tattooed Islander – cuffed, cussing and kicking. One of the security boys I know well from many previous tussles, holds up in a security canister, the seven-inch knife they found taped on the inside of his massive arm, while he was being restrained. I could go and see how it progresses, but I’ve had enough of psychosis and antisocial behaviour for one day and need to head home for some normality. I know I’ll see him tomorrow anyway. I just hope no one is too heroic overnight letting him lighten up too early because if someone does get punched, it could be lights out!
It’s 8am and once again, I’m in paradise. As expected, I get to see the Islander patient, who is actually calm and settled this AM (the amphetamines washed out quickly). Unfortunately one of the security boys got his nose smashed by a swinging arm from him last night when he thought he was being attacked by aliens. Even well-prepared teams get caught sometimes.
The psych patient count is again 10 of the 28 cubicles in the main ED this AM, with no obvious movers. So another day of acute psychiatric access block dominates the horizon with no real end in sight. It could get you down if you were that way disposed!
For more in-depth coverage on the state of mental health care in WA, please refer to the latest edition of Medicus.