Scenes from the Emergency Department…

In an emergency setting, providers are frequently faced with the dreaded psychiatric emergency: The middle-aged woman who is brought in by police after telling her sister that she just wants to end it all; the veteran who wakes up at 0200 hrs in a cold sweat after vividly reliving the horrors of war in his sleep; the 19 year old who found out his girlfriend has been cheating on him and suddenly feels like he’s been hit in the chest with a sledge hammer; or the semiconscious young woman who’s decided to give life a chance again halfway through swallowing all her medications. I call these situations “dreaded” as many will find themselves ill-equipped to deal with the emotional needs of these patients. All the little pocket charts of medications and interventions and smartphone apps that money can buy become useless against the monster that is one’s own mind.

When you step into the room and see this shattered person sitting on the stretcher, knees tucked in and arms wrapped around them tightly, you often find yourself in foreign territory — a clinical no man’s land between the safety of trenches filled with cold symptoms and simple fractures. Everyone has an opinion on how to deal with it, ranging from nurturing to tough love, and even callousness.

In my hospital, most of the emotional support — or browbeating, as the case may be — is left to nurses, technicians, and sitters who are able to interact with the patient more frequently than the physician, who may swamped with 10 other patients demanding attention. On one end of the spectrum lies the older nurse with a large family who will be caring and supportive, thinking “What if this was my brother or sister?” On the opposite end lies the bitter soul who can’t understand why they’re unable to just man up and face their problems.

Stuck somewhere in the middle are those with a true understanding of the patient’s emotional turmoil; the person who wakes up every morning and swallows a pill to feel normal. For them, knowing how to handle the situation is not a relief, but a burden. They worry about who will overhear them identifying with the patient, telling them about how they’re just like them; how they used to wonder if waking up anymore was worth it; how they kept trying different medications to feel whole again; how they’re living proof that you shouldn’t give up when one pill fails.

The bottom line is that ED’s are not meant to handle these patients any longer than it takes to medically clear them. Leaving the patient to suffer the prejudice of those who don’t understand, or the silence of those frightened by the stigma of identifying with them, is just an undue encumbrance on all involved. The best policy is speed: Speed in identifying a need for inpatient treatment; speed in removing anything they can use to inflict harm on themselves from the room; speed in medically clearing them; and speed in transferring them to definitive care.

No,” she said slowly. “No, the blues are because you’re getting fat or maybe it’s been raining too long. You’re sad, that’s all. But the mean reds are horrible. You’re afraid and you sweat like hell, but you don’t know what you’re afraid of. Except something bad is going to happen, only you don’t know what it is. You’ve had that feeling?”

“Quite often. Some people call it angst.”

“All right. Angst. But what do you do about it?”

From Breakfast at Tiffany’s by Truman Capote

Sam Goldstein is an ED Technician and Nationally Registered Emergency Medical Technician currently working in a large urban emergency department. He has spent the last several years working in both field and clinical settings for various agencies and hospitals, as well as with the US military.