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The Forgotten Emergency: The Mental Healthcare Crisis

By Lancer Scott
MD, FACEP

Imagine you are having a heart attack. You arrive at the emergency department where you are greeted by a triage nurse who escorts you to an open bed.  Your EKG is completed within minutes and the emergency physician standing in the room makes the diagnosis.  Before you know, you are whisked off to a special operating room where your heart vessels are opened and your life is saved.  No problem.

Now imagine the same scenario but there are no open beds and the emergency waiting room is full.  The nurse completing your EKG is interrupted by a patient who threatens to harm himself.  The emergency physician is delayed reading the EKG because she is sedating a psychotic patient.  You are diagnosed and your life is saved, but not so easily this time.

Emergency medicine is the only medical specialty to care for every patient regardless of complaint or insurance status.  This includes tens of thousands of patients a year with mental health emergencies who have nowhere else to turn and who have arguably suffered the most.

In the past, most psychiatric patients were handled by mental health providers and psychiatric clinics or hospitals.  But increased costs, legal exposure and declining resources have forced many psychiatric providers to stop offering emergency care.

The result has been catastrophic for both patients and emergency departments.  More than three-quarters of emergency departments in my home-state of South Carolina and nationwide have psychiatric patients waiting days to be admitted to the hospital.  Last year well over a 1,000 mental health patients at the Medical University of South Carolina (MUSC) sat in the ER for at least 24 hours before they were admitted and one patient at Trident Health waited 47 days before being admitted to a bed designated for behavioral health care. In small rural ER’s across our state, it is not uncommon for mental health patients to spend a week in an emergency room without ever seeing a psychiatrist.

The consequences for mental health patients are staggering.  Imagine your suicidal family member waiting a week in the emergency room for psychiatric treatment following a suicide attempt.  The delay in specialty care caused her to miss work and lose her job. Following discharge, her depression worsens and the cycle starts all over again.

Our immediate priority should be to recognize that we are doing a terrible job at preventing mental health emergencies in South Carolina and around this country. 

Second, we need to organize psychiatric emergency resources in the same way we organize trauma resources, through greater regionalization of care.   If your car flips on a rural highway, you are taken to a Level 1 trauma hospital where you can be quickly assessed by experts.  By permitting emergency departments and ambulances to transfer mental health patients directly to hospitals offering onsite psychiatric consultation, we can reduce boarding times as much as 80 percent decrease the need for inpatient admission and decrease costs.

Since existing Medicaid will likely not be enough to cover our mental health care debts, we should consider establishing a psychiatric emergency fund, similar to the SC Trauma Fund to support hospitals that provide onsite psychiatric consultation and other services for mental health patients.

Finally, we can stabilize the situation by providing increased community resources through mental health crisis stabilization units and centers, providing early intervention for individuals with mental health, substance abuse and other problems.

By intervening before problems escalate, we can significantly reduce the need for hospital admission in the first place.  We can also save lives of patients during their most desperate hour.

About the Author: Lancer Scott, MD, FACEP is the president of the South Carolina College of Emergency Physicians (SCCEP) and Associate Professor at Medical University of South Carolina.  He is also the Chief of Emergency Medicine at VA Charleston in South Carolina.