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Key points
- Families should know what to expect in an emergency room evaluation.
- The key elements of a mental status examination provide a guide to the diagnosis.
- Sometimes the patient and family are left with no solution.
My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes, and also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health, how to work with treatment providers, and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.
The essence of an emergency room evaluation should be to arrive at a diagnosis, especially if one is not already known, and to get expert help with treatment and resources. Emergency rooms sometimes don’t have psychiatrists located in the ER but usually have consultation available for psychiatric evaluations. Patients may be brought in by the police for disruptive behavior, although more often mentally ill individuals are brought to jail and then are sent for evaluation at the request of the criminal justice system.
When I saw Bill in jail, he sat behind bars looking forlorn and scared. The jail staff told me that if I took him to the emergency room, they would release him immediately and wouldn’t ask me to post bail. I called a friend to meet me outside the emergency room to make sure that Bill was calm enough for me to manage him by myself. The sergeant released him, saying, “Bill, I hope you feel better.”
We rode together to the ER. I asked him what had happened, but he didn’t respond. I asked him if he had done drugs; he shook his head. I explained that in the emergency room they would ask him questions about his life and that he needed to answer as carefully as possible. He nodded and we went through the glass doors.
Inside, we passed through the metal detectors, past the security guard, and were ushered to a receptionist. She took down the usual information, then asked if Bill was feeling okay. He nodded. We sat next to each other quietly while we waited to be seen. I told him they would ask him what had happened and would do a quick physical exam and get some blood work. He stared straight ahead, nodding at intervals, but it was impossible to tell what he was thinking.
Outwardly I was calm, my behavior ingrained after years of treating psychotic people. But inwardly I was deeply shaken, uncertain what my son’s illness was, and frightened by the prospect of having to hospitalize him against his will.
A half-hour later, Bill was called into his examination. Although I knew exactly the usual sequence of events—calling for the resident, the psychiatric consultation, physical exam, and venipuncture to obtain blood specimens—my expertise was of little comfort. It didn’t make the time go any quicker as I sat stranded in the waiting room, anxiously waiting for any indication of what was going on in his interview.
Finally, I asked one of the clerks what had happened to Bill. She checked, and no one seemed to know his status. She went back to look and soon reappeared, saying they were ready to release him. I was surprised since I had expected they would likely plan to hospitalize him to figure out what the underlying illness was, as it wasn’t obvious.
I went back to where Bill lay on a stretcher looking up at the ceiling. I found the resident who had evaluated him, introduced myself as an attending psychiatrist at the hospital, and asked what his evaluation was. The resident said, “Well, basically he says everything is fine and I don’t see any signs of illness.”
“People don’t usually go around smashing up cars for no reason,” I pointed out.
“If he’s been in trouble with the law, then it’s consistent with an antisocial pattern,” the resident said.
Expected questions in an emergency room evaluation: Patients will usually have a mental status examination in which they are asked very basic questions to determine if their thinking is clear—name, today’s date, and location. Also they will be asked questions to determine if their reasoning and judgement is sound. (What would you do if you found a stamped letter on the sidewalk?) Does the patient understand the current situation? The speech flow and thought content are evaluated to determine if thinking is slow or appears speeded up. Thought content will be assessed for any evidence of hallucinations or delusions, suicidal or homicidal ideation. Patients will be directly asked their mood and also assessed for their affect: Is there variation in facial expression and tone of voice? Do they appear flat or overly animated? Do they make good eye contact?
“So you didn’t ask him anything else?” I was incredulous that the resident hadn’t asked the usual questions pertaining to psychiatric illnesses: drug use, psychotic symptoms such as hallucinations or delusions, or changes in mood and energy.
I was also appalled that he hadn’t even asked to speak with me to find out what had been going on, first as a mother and Bill’s best collateral source, and second as an attending physician at the same hospital, a psychiatrist with many more years of experience than he had.
My fury left me momentarily speechless. When I could talk, I said, “Did you get a tox screen?” He said yes, and I said, “Well, that will be all then.” I couldn’t believe that he hadn’t questioned Bill more thoroughly, and that he could be arrogant and ignorant enough to assume that there was one answer: that this kid’s problem was that he was in trouble with the law, and therefore a “sociopath” rather than someone who could be seriously ill and needed further evaluation.
This was my initiation into needing to question the conclusions reached by fellow physicians about Bill’s diagnosis and treatment. It pains me to say this, but there is a degree of arrogance shared by some physicians that blinds them to their own mistakes.
With the ER evaluation concluded, we were left to our own devices to figure out what to do next. I decided the best option would be for him to stay at his father’s house and he agreed. Recalling this now, I feel a surge of sympathy for all the families that are left in this predicament, when the ER decides that their family member doesn’t meet criteria for hospital admission and they have to scramble to come up with a plan. This was one of countless interactions with the mental health system during Bill’s struggle with mental illness. In describing these encounters I hope to convey the commonalities of these experiences, the similarities and differences across various psychiatric illnesses, and the feelings of despair and isolation that these encounters may engender. And also the strength that sharing the pain with other families can bring as we grapple with our choices for treatment.
