Sorry for being tardy with the latest post to the blog. I hope you had a pleasant Thanksgiving holiday. Between two emergency shifts plus working on this week's episode of WCBA, I had just enough time to take my kids to see the new animated film "Cloudy with a Chance of Meatballs" and go on a bike ride with the family.
You certainly reacted strongly to the most recent WCBA that aired October 10 and 12 on patients with mental health problems. I thought I'd share some of your comments. Where I include comments by patients in the mental health system, I've identified them by their initials only:
SA of Guelph, Ontario, sent this heartfelt email:
"I was pleased to see that you devoted an episode to mental health issues in ERs-this is an issue near and dear to my heart, as I have used the Emergency Room when I have had a mental health crisis. What I was disappointed about was your comment when you were speaking with the nurse at the psychiatric emergency room about the isolation room; you asked how long it took patients "to get the point". Sorry, Dr. Goldman but you MISSED the point! Isolation is not used there, and should never be used to make a point. It is a treatment. Your question identifies the core issue of physicians dealing with those of us who live with and suffer from psychiatric disabilities. You would never ask a surgeon how long he needed to operate upon a heart patient before he or she got the point! Isolation is a means of decreasing stimulus input for the patient in order to allow them to begin to self regulate their mood, perception and behaviour. It is a treatment, and the duration of treatment is to effect, not to make a point.
When I am in crisis, my perceptions of the world are skewed. I see danger where there is none. I cannot modulate my activity level. And the more stimulating the environment, the harder it is for me to accurately interpret the environment I find myself within. In these situations, I may go to great extremes to get help, and I have to trust that the medical professionals that I interact with will be sympathetic to my efforts. The woman you spoke about who went to a funeral home, looking for her casket was doing her very best to find help. Speaking as someone who screamed out for help for over a year before being able to access it, I would like to point out that this is NOT manipulative behaviour any more than the person standing in your waiting room bleeding on the floor is trying to manipulate your triage nurse into dealing with her problem. Often, by the time someone has gotten to the point of buying their own funeral, they have made dozens if not hundreds of calls for help. When the medical profession doesn't hear me say "I am too frightened to travel on the bus" and my fear develops to the point of a crisis, then extremism feels like my only option.
As I said in the beginning of my letter, thank you for devoting an episode to mental illness in the ER. I only wish you had been better prepared yourself to ask more appropriate questions and help the audience understand that mental illness is just that; an illness, not a choice. The extreme behaviour that I might exhibit while in a critical condition is no more normal for me than is writhing on the floor in agony normal for the person who is suffering from acute appendicitis-and it is time that the medical profession get themselves better educated and better prepared for dealing with me when I am ill. I trust. And I trust that you will remember my letter the next time that you see a patient like me in your Emergency Room."
SA, I'm glad you wrote in. I agree with your comment that isolation should never be used as a punishment. Maria Raptis, the nurse featured in the tour of the Archie Courtnall Centre actually made that precise point in the story that aired. However, my question came on the heals of the psychiatrist volunteering that patients put in isolation "get the point." I was as surprised as you by the psychiatrist's turn of phrase, and so I asked him the natural follow up question how long it takes for patients to get the point. In asking that question, I was allowing you to see that some psychiatrists might in fact see the seclusion room as a form of punishment -- however wrong you and I think it is to hold that view.
Nancy Miki of Vancouver sent us this:
" I listen to your program frequently and, as a physician, find it is refreshingly realistic. As least as far as my experiences as a Canadian trained physician go. As a practising psychiatrist, I listened with particular interest to your show on mental illness. I have some concerns about your heavy focus on Borderline Personality Disorder (there are other psychiatric illness that present to Emergency Rooms). I appreciated your frankness regarding your own counter transference to "difficult" patients but I want you to ask yourself the following question, "Does using the word 'berserk' to describe a patient in distress function to increase or decrease the stigma against those with mental illness?" While it may have some technical accuracy, it is completely lacking in compassion. You are in a position of influence, please choose your words carefully as they may set an example for many others."
Fair points that I'd like to take one by one.
You're absolutely correct that we focused on Borderline Personality Disorder at the expense of discussing other psychiatric disorders. We did so deliberately because my experience in front line medicine is that the diagnosis is misunderstood and the term overused by health professionals. The mission of the show is to show the system, as it is, warts and all. Moreover, the phrase "borderline" has entered the common vernacular in a way that completely misrepresents its meaning.
As to using the term "berserk", I chose it so as not to mince words. However, the main point of using the word was not to stigmatize patients, but to say that when patients act with impulsive violence, people like me have trouble dealing with it. In other words, the sharp stick was pointed at health professionals, not patients. My passion in this show was to try and understand why we find it so difficult to treat people with mental health disorders.
Dr. Ralph Jones, a physician in Chilliwack, BC, had this to say:
"Hi Dr Goldman, I heard your radio programme today, very good. I am a GP with an interest in mental health. I recently retired as clinical chef of mental health & addictions here in Chilliwack BC ,however I still work in mental health. In other lives, I've worked in the UK & in ER's in cities & the isolated North. I just had to share this anecdote.
Like many ER physicians in the UK I hated seeing psychiatric patients. One night as a final year student in ER, I saw the usual half dozen overdoses treated with the usual measures of a rubber hose down the throat, tied to a gurney, unsympathetic porters assisting. The next day I rotated to psychiatry. I was going to hate this waste of my time. My first patient was one of the young women we "hosed " the night before. Fortunately she didn't remember me. Her story? Every time her father came home on leave from the army he raped he. This had been happening since she was 8 years old, and she was now 16 years of age, and he was home again. We managed to help her. I ended up enjoying psychiatry & to my great surprise was rather good at it. This life long interest led my career into interesting academic & leadership roles in general practice & mental health. I'm still ashamed of the way we acted in ER on that night & many previously I'm sure you know that we learn a lot from our patients & some we never forget."
Thanks for sharing your stories.