Episode 13: Psych Redux

A sequel to episode 10, with some more stories of psych visits and another example of why for-profit healthcare is evil. Be warned, there is discussion of a suicide attempt.

Remember, please call 988 the suicide and crisis lifeline if you need help.

NY Times article: https://www.nytimes.com/2024/09/01/business/acadia-psychiatric-patients-trapped.html

Department of Justice press release: https://www.justice.gov/archives/opa/pr/acadia-healthcare-company-inc-pay-1985m-settle-allegations-relating-medically-unnecessary

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Transcript

Let’s start with a story. 

A long time ago, a new ER resident encountered a patient who would not speak. The patient, a young woman, sat calmly on her stretcher, in no apparent distress. Her vital signs were normal. Her face and neck appeared fine. There was no swelling, no trauma. She wasn’t drooling. Her breathing seemed comfortable. 

When the resident attempted to interview the patient, she wouldn’t answer. She would only point at her mouth and shake her head. The resident had her open her mouth and then looked inside, seemed normal. The resident listened to her lungs and throat, nothing abnormal there. The resident tried again, in different ways, to get the patient to speak, but she would not. She would only shake her head. 

Then the resident realized something. If the patient is breathing normally, if her throat is not obstructed, then she should be able to make a sound, to phonate, to make any noise at all. So the resident asked her to make a sound, any sound. The patient opened her mouth but no sound came out. That’s when the resident realized what was going on. But how to confirm it? How to prove that the patient COULD phonate, but was choosing not to. Then the resident had an idea.

The resident walked out of the room, waited a moment, and then sprinted back in and kicked the stretcher as hard as they could. The sudden impact shook the bed and didn’t harm the patient, but startled them into letting out an involuntary yelp. Suspicion confirmed. The mutism was intentional, or, at least, not organic. The resident left again and called psychiatry to see the patient. Later it was discovered the patient had schizophrenia and had done this before. She was admitted to the psych floor for appropriate care. 

It is a grave sin Inside the ER to ascribe a symptom to a psychiatric cause without first confirming there is no physical ailment. Sometimes, that method of confirmation can be…unusual, such as injecting a patient feigning a seizure with saline while proclaiming it’s ativan, swabbing a patient’s nose who’s pretending to be unresponsive, or, in this case, startling a patient to prove they can indeed speak. These methods might seem mean, but as long as they’re not harmful, it is preferable over subjecting the patient to unnecessary testing and neglecting the true cause of their symptoms.

Ok, let’s get on with it.

Hello, my name is Padraic Gerety, I’m an ER doc, and this is Inside the ER.

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Today you’re joining us for episode 13, Psych Redux. This is going a continuation of episode 10 about psychiatric emergencies. There’s some extra stuff I wanted to include before, but my editor told me then I was running out of time, so let’s talk about it today. Ok ok yes yes, by editor I mean me. Founder? Me. Writer? Me. Host? Me. Producer? Me. Engineer? Me. Me. It’s all me. The point being, make sure you listen to episode 10 before this one, or it ain’t gonna much sense. 

First off, I wanna say if patients present with mild or chronic psych symptoms, the ER provider often will handle the situation completely on their own and not consult a psychiatrist. What do I mean? The simplest case is a patient presenting for a medication refill. It's very common. The patient is on a longstanding psychiatric medication, they ran out, they can’t get in with their doctor, so they come to the ER. As long as they’re only having mild depressive thoughts let’s say, ya know no suicidal ideation, then I’ll feel confident to represcribe their meds and discharge them. I’ll always ask these patients if they’re comfortable with this, or do they still want to talk to a psychiatrist. Sometimes they do, because turns out there’s more going on than they initially let on.

Another example of a treat and street is someone coming in for anxiety. T hey don’t take any meds, or maybe they used to but not any longer, and they felt anxious today.  If I think the visit is in good faith, as in the patient isn’t just drug seeking, AND I don’t suspect a medical condition, then I’ll prescribe them a course of medication until they can follow up with someone. As I said before, one of the cardinal sins of being an ER provider is misdiagnosing a patient as having anxiety when really something serious is going on.

Classic example, someone comes in saying they’re anxious, but I look and see they’re tachycardiac. Have any other symptoms? Oh you have palpitations oh and chest pain? Sure, you’re anxious, but maybe that’s because you have a blood clot or arrhythmia. Pinning a patient’s symptoms on a psychiatric cause without due consideration is a great way to miss something serious. Patients often ask me, could this be anxiety? It could be, but my job is to rule out, or at least consider, the dangerous stuff. I’ll never hang my hat on anxiety if the patients needs a workup first.

Some people come in and are convinced something is deathly wrong with them, hell, it seems like they want us to find something horrible. This kind of patient usually is a high utilizer of the ER. We used to say frequent flyer, or friendly face, but now we’re told to say high utilizer, anyway. They come to the ER a lot, rarely have anything diagnosed, and are very defensive if a provider suggests there could be a psychiatric component to their complaints.

But most people, most, want to just be ok. They wanna be told that nothing’s wrong, everything is fine and they can go home. That’s basic human emotion, right? So, whenever a patient with abnormal vitals tells me they think it’s just stress, I always take it with a grain of salt. They’re not lying, they’re just hoping they’re fine. I’ve found many PEs, pulmonary embolisms, blood clots in the lung, this way. I’ve always found many appendicitis..es? when a patient tells me that it was just a bad burrito. Don’t minimize your symptoms, people!

Moving on, right after I recorded that last psych episode I encountered a patient who came in for suicidal ideation. He had been seen the day before by my colleague, was evaluated by our tele-psychiatrist who recommended we admit, and therefore transfer, to a psychiatric hospital. So what did the patient do after that? You know, he boarded! Of course of course, the scourge of boarding will never end. So I go to talk to him when I’m working the next day, and he tells me he feels better and wants to leave right away.

Not so fast, I tell him, you came in for SI and the psychiatrist recommended admission, I can’t let you just walk out. And then he says, “I walked in on my own, so I’m allowed to leave whenever I want.” No no no! I tried to explain why that wasn’t true but he just started yelling at me so I don’t think it sunk in. Thankfully, you can’t yell at me, so I can explain it to you. I guess you can write me an angry email at insidetheer@gmail.com, or an angry text via the episode description, so feel free.

No matter how you get to the ER, whether you walk in or are brought in, if we think you’re a danger to yourself or others, then you lose that ability to walk right out. Coming voluntarily to the ER doesn’t mean you can leave voluntarily too if you qualify for involuntary treatment. Some patients who initially are recommended for psychiatric admission board in the ER for so long that they improve and are later discharged. For this gentleman, I had to have a tele-psychiatrist re-evaluate him first to make that call and let him go. 

This next little story is a little disturbing so be forewarned. The day after Christmas I worked the morning shift, and EMS brings in a 70 year old lady who had attempted suicide. When you hear this initial one liner from EMS, you assume this patient took a bunch of pills, that’s the most common method in women, especially older women. So I was very surprised, and frankly, freaked out, to find that she had stabbed herself, multiple times

Turns out that she had a longstanding history of depression, but had never made an attempt before. But! Her husband of decades died only weeks earlier, and on Christmas night, after her visiting family had left, her suicidal urges took over and she picked up a knife. She slashed and stabbed herself multiple times including cutting her wrists so deeply she injured the tendons and stabbing her abdomen so forcefully that she lacerated her liver. Even though it had happened hours before I saw her so there was no more active bleeding, it was still horrific. She was so calm, too calm. The whole thing rattled me in a way that rarely happens anymore.

She, like the man I just mentioned, wanted to refuse something, strangely an IV? I almost laughed when she said it, “I don’t want any IVs.” No, no, I’m not an ass, it’s just so absurd. She stabbed herself multiple times but now is uncomfortable with an IV? And also the idea she would be allowed to refuse care. I explained to her, politely but firmly, that we needed an IV to take care of her and she complied. Now don’t worry, she did fine. Her wounds were ultimately not life threatening and the surgical service repaired them under anesthesia in the OR. Later, of course, she was admitted to a psychiatric hospital.

Oh, but how did we get her? How did EMS hear about it? Simple, in the morning, she called her family and told them what she did. And I think that’s the most important point here. Excluding those understandably seeking euthanasia, people that survive a suicide attempt, almost everyone regrets it. They all want help. Even this lady consented to all of the care she needed. It’s a choice you can’t take back and these patients realize that and want to try to live again. As a reminder to all, if you are having thoughts of hurting yourself, please please call 988, the suicide and crisis hotline.

Before we close out, I want to mention some news that caught my eye, in line with our last episode about UnitedHealthCare, that further demonstrates the evil of for-profit health care. Ya know, let’s go ahead and sound a warning for anyone that has to interact with Acadia Healthcare. They run over 200 facilities, including over 50 psychiatric hospitals and the largest chain of methadone clinics in the US. 

The initial article that brought them to my attention was by the New York Times called, “How a Leading Chain of Psychiatric Hospitals Traps Patients," it’s a great, rage-inducing read. I put a link in the show notes, but there is a paywall, so forgive me. In summary, it details allegations that Acadia’s psych hospitals have a pattern of lying about patients’ symptoms so they can detain them against their will much longer than necessary all to maximize their billing. One such patient was a school social worker held for six days against her will even though she had no suicidal or homicidal urges. Now, of course, she and others like are scared to seek psychiatric care in the future in fear of repeating this nightmare.

The thing is with this company, Acadia, the more you dig, the more crap you find. Numerous allegations including inappropriately prescribing methadone, sexual abuse, intentional fraudulent billing, and falsifying medical records. Ya know, just look at the “Legal and ethical issues” section of Acadia Healthcare’s wikipedia page. It’s truly astounding. There thankfully seems to be some punishment for these ghouls, as in Sept 2024 they agreed to pay the US government nearly 20 million bucks in settlement due to the inappropriate hospitalizations we mentioned. I’ll put a link to the Department of Justice press release in the show notes . But, as I said last episode, the fines these companies have to pay is minuscule compared to their profits and no one at the top is truly punished.

Having a fake, hopefully amusing, ad break doesn’t seem to fit the vibe of today’s episode, so let’s forget that and let me just give you this advice. Do not let anything I’ve said dissuade you from seeking psychiatric care if you need it. It takes bravery to get help and you are brave. In all my years I’ve personally never encountered a situation where I thought a patient was being held appropriately. BUT, if you do find yourself in this situation, tell a loved one where you are going, so they know to check up on you. An informed family member is a great defense against an abusive institution.

That’s it for today, I hope you enjoyed the episode, or at the very least, learned something. Please follow the show if you haven’t already and we’ll be back next month. In the meantime, check out the socials, shoot us a text, sling us an email, leave a rating, bang out a review, whatever you wanna do. 

Thanks for listening and all the best.