Editor’s note: This commentary is by Ben Smith, MD, a doctor in the Department of Emergency Medicine at Central Vermont Medical Center in Berlin.
[R]ight now, all across the state of Vermont, critically ill psychiatric patients are waiting for care in emergency departments. Some have been there for hours, but many will have been there for days, and even weeks. Their stays can, and do, exceed three weeks. Some of these patients are children. All of them are vulnerable. Some hospitals, like Central Vermont Medical Center, where I work, have built psychiatric holding areas in their emergency departments to provide a safer, quieter space for long-term stays. Some others have not. Even in cases like ours, the number of patients often exceeds the capacity of our holding area, which means that psychiatrically unstable patients can be kept for weeks at a time in a noisy environment, pulsing with activity at all hours, where the lights are always on, where anything can happen, and where the staff are necessarily distracted from the ongoing care of long-term patients by the near continual influx of newly ill and injured patients requiring immediate attention.
These patients, stuck in limbo, receive medication, meals, and shelter, but their sleep cycles are disrupted, and they rarely, if ever, see the sky. They don’t get exercise. They don’t get in-depth counseling. They do receive the caring, if fragmented, attention of emergency department staff, psychiatrists, and mental health clinicians, who do their best in a situation that is beyond demanding. But they receive nothing like the care and attention they require, which any reasonable person would expect in a crisis, and which they would receive in an inpatient psychiatric unit.
As an emergency physician, working in this state for 10 years, I have written this piece so that I can say loudly and clearly that this is no longer simply a policy failure: It’s a violation of human rights. It involves our most vulnerable citizens, and is perpetrated by a neglectful and distracted state which has systematically ignored and underfunded its inpatient mental health capacity, all the while in thrall to a utopian vision of outpatient care that works well for the majority of patients but ignores the practical realities of caring for the severely mentally ill.
A few things are important to know. Emergency departments function under a federal law, known as the Emergency Medical Treatment and Labor Act, that requires us to see and evaluate every patient who walks through our doors. This is entirely as it should be, and serves as well as anything to describe the values that led many of us — doctors, nurses, technicians, and clerks — to pursue a career in the emergency department. There are few institutions left in our fractured society that are there for everybody, regardless of background, illness or ability to pay. We are very proud to fill this role, but this legal and ethical backstop also enables the state to use emergency departments as a black box, where the challenges of critical psychiatric patients can be hidden, while assuming – wrongly – that there is some sort of magical, infinite capacity, and that it has done its job.
As I see it, the blame rests squarely on the shoulders of past state leadership, who have systematically disregarded their responsibility to one of our most vulnerable populations.
Emergency department patient flows are entirely unpredictable, and demand flexibility. A department can go from sparse to overflowing in moments. To accommodate this, emergency nurses do not have the mandated nurse-to-patient ratios that nurses in other parts of the hospital have. They can’t, or the place wouldn’t function. But this get-the-job-done-whatever-it-takes model is predicated on the idea that patients move out of the ED as often as they move in. Otherwise, the situation quickly becomes overwhelming, and unsafe. This is simple math, and anything that offsets this balance means that our nurses – among the most professional, compassionate and hardworking people I have ever seen – are unable to provide the level of care that should be reasonably expected for a patient who is, for all intents and purposes, hospitalized. The nurses feel this every single day – the gap between what they are able to provide and what they are expected to provide, and the toll of this moral trauma is clear: At last check, the emergency department at UVMMC had 13 open nursing positions. Our nursing staff at CVMC has also gone through a significant upheaval.
Emergency departments face other enormous, and growing, burdens – an aging population, more medically complex than ever; the medical, psychiatric and social fallout of economic inequality, cultural instability and the opioid epidemic; and a population of medically fragile people, kept alive by modern technology but dependent for their safety on frequent and repeated hospitalizations.
All of this background is simply to help paint a picture of why the long-term boarding of psychiatric patients in emergency departments has ramifying effects, and is well past the crisis point. When I left work last night (during the first week of February,) there were two children in our department, each less than 11 years old, who had been there for 200 and 170 hours, respectively. That’s seven or eight days. There were two adults who had been there for close to 100 hours. At roughly the same time, the UVMMC emergency department had 14 psychiatric patients with nowhere to go – more than a quarter of its entire emergency room capacity.
This has been going on for years now, and it’s a crisis of human rights. We are warehousing our most vulnerable citizens, adults and children, in unstable, non-therapeutic environments, where they cannot receive the care they deserve. This is not the fault of the emergency providers, who do their best in an under-resourced and chaotic environment; it’s not the fault of the mental health caseworkers, who work tirelessly, for low pay and at some personal risk, at all hours of the day and night; it’s not the fault of the psychiatrists, who repeatedly assist us in trying to piece together adequate care. As I see it, the blame rests squarely on the shoulders of past state leadership, who have systematically disregarded their responsibility to one of our most vulnerable populations.
I am a proud, lifelong Vermonter. I love this state, and I think that we live up to our values more than most. But this issue is a stain on our honor. When our leadership finally decides that it cares about this problem, I want this piece to serve as a form of testimony: that those of us who live and breathe this work, who do our utmost to care for these patients every single day, believe our current system to be ethically intolerable, and an embarrassment. Of course we will continue to care for these patients, as best we can – that’s our job, and we are proud to be there for everyone who comes through our doors. But let me be clear – this situation is unconscionable. Our leaders should direct themselves immediately towards a viable solution, which is relatively simple: more inpatient psychiatric beds, for adults and children, adequately staffed.
A joint legislative hearing on Vermont’s Mental Health Crisis & Frontline Workers will be held on Tuesday, 5:30 to 7 p.m., in Room 11 at the Vermont Statehouse in Montpelier.
