Friday, June 22, 2007

L.A. E.R. Tragedy . . . Emergency Mental Health Care

Connect the dots between these two stories...

Dr. Cory Franklin has a Commentary in the Chicago Tribune about this tragic story of a lady who died in an L.A. E.R. waiting room with bystanders calling 911 to help her because she couldn't get help in the ER.
Shortly after another bystander made a second futile 911 call imploring paramedics to take Rodriguez to another hospital, she died of a perforated bowel. A security videotape, still unreleased to the public, is said to show her writhing on the hospital floor unattended for 45 minutes. At one point, the tape reportedly shows a janitor going about his business mopping the floor around her.
. . .
This should be the audio of the 911 call... [removed due to misbehavior... try this link to listen: Youtube]

Mary Beth Pfeiffer in yesterday's Huffington Post discusses our broken mental health system.
In the 1990s, Virginia built 18 new prisons and closed 1,400 mental hospital beds. Across America, state spending on prisons spending tripled in the last 25 years while spending on mental health care rose by about a fifth.

And if you thought the era of shuttered hospital beds was over, consider that America lost another 57,000 psychiatric beds from 1990 to 2000. As a result, from 1992 to 2003, American hospital emergency rooms saw a 56 percent increase in people experiencing psychiatric crisis. It's time to stop the bloodletting.

Where is our compassion, our humanity, our duty?


ClinkShrink said...

OK, I'm going to leap on this one. We really really need to stop implying that there is some correlation between psychiatric hospitals and prisons. This implies that all psychiatric inpatients are potential criminals but for the fact of their hospitalization. Psychiatric patients are not all criminals. The Huffington Post is wrong to imply this.

Correctional spending SHOULD increase faster than mental health spending and it's got nothing to do with politics or social policy. The incidence (new cases per year) of mental disorders is constant and is lower than the rate of incarceration. Spending for correctional health care should increase faster than spending for free society mental health care because we (the correctional system) have more patients and are getting more every day. I don't like the idea of anyone suggesting we should stop spending for correctional healthcare because it's somehow wrong or less important than free society care.

Getting off the soapbox now. Thank you for the opportunity to rant. I suppose I should be putting this comment on the Huffington Post. OK, I'll do that.

Fat Doctor said...

Sick, sick, sick abou the LA ER. Having done a few overnight shifts in a busy urban ER, I'm betting the staff was inundated with histrionic folks who weren't as sick as they thought they were, and the janitor probably thought she was the same type of person. Tragic assumption.

I read this blog almost daily at home, but still can't comment on blogger sites from home, so I'm sneaking a comment break at work!

Alison Cummins said...


In Canada, we have an incarceration rate one sixth of that of the US (116 per 100,000 population vs 701). In addition, we have more psychiatric beds per capita (by a factor of about 2.5?). Even so, it was easier to get the cops to take care of my brother than to get psychiatric hospital services for him. They arrested him and held him in their mental health unit until someone stepped forward to ensure that he would be looked after - this involved a judge, my parents, and a lawyer and social worker both provided by the Canadian Mental Health Association. Getting a hospital to take him on was a huge obstacle that took repeated orders by a judge. Once that was accomplished, my brother was persuaded to voluntarily admit himself largely by pointing out that the alternative was jail.

So I disagree that there is no role of the justice system in the care of the mentally ill.

Someone who is disruptive or unable to maintain housing will come to the attention of the police. This has nothing to do with being psychopathic serial killers or some such. The fact is, someone who shouts angrily in public at invisible beings is frightening to most people. Ssomeone who shits in public places, or who takes things that aren't his and when confronted barks and argues incoherently about space aliens, is disruptive.

It can be difficult to accomodate psychotic people 'outside.' If the mental health system won't take them on, some of them are going to be taken care of by the justice system. Not because they are criminals, but because they have nowhere else to go.

I have another take on your figures. If the rate of mental illness is stable and similar both among the incarcerated and those in free society, but the rate of incarceration is rising, then there are more mentally ill people incarcerated than ever before. But I don't see any evidence that the mentally ill have suddenly become more inherently criminal than ever before.

Of course, if the prison system is growing then its health system should grow right along with it. Absolutely. What concerns me is precisely that the prison system is growing. Unless there are criminality-inducing chemicals in the water supply, the increased incarceration rate is only distantly related to an increased rate of inherent criminality and more to a decreased ability of the marginal to cope with a "free society" that is less and less willing to support, accomodate or treat them as the case may be.

Once someone can no longer cope with the world as it is, something needs to be done with them. Increasingly, that something is imprisonment. What the whiny liberals like me can't get our heads around is why all this money is being spent to imprison people when we could instead improve schools, offer free and accessible mental and physical health care to those who might otherwise have difficulty accessing it, whatever. It seems to us that it would be cheaper and more humane to avoid the need to incarcerate someone than to put all the onus of avoiding incarceration on those who are already struggling.

I don't think the mentally ill are inherently criminal. But I do think the relative accessiblity of the prison system relative to the health system even for someone who is floridly psychotic is bizarre. It's bad enough in Canada; judging from your stats, it seems even worse where you are.

Ladyk73 said...

My only comment to this statement....I live in the County in New York State that the City of Niagara Falls is located. The local hospital here does have a inpatient mental health ward. It is certainly not the best facility in the area (being close to Buffalo). that many severely psychotic individuals are held and the HOLDING center, or "jail." Many of these individuals are arrested for trespassing. However, many of the individuals who have been sent to this holding center, WERE ARRESTED WHILE IN AN INPATIENT LOCKED PSY INPATIENT WARD. I have a close connection to the "brass" of this holding center, and this situation has fustrated him!!!!!

That being said. The individuals that appear at their hearing, or trial, or court (whatever the proper name is...) their charges are dismissed.

The bright side of this, is that this avenue has resulted in mnay of these individuals being sent to the State facility (where I volunteer)...which is by far the best setting for these individuals.

Just my thoughts

ClinkShrink said...

Alison: I agree that coerced treatment is sometimes necessary for forensic patients. Unfortunately, the coercion sometimes also has to be directed to the agencies that are supposed to be caring for them. I was just concerned that the general public might think that all psychiatric patients were like this.

Re: "If the rate of mental illness is stable and similar both among the incarcerated and those in free society, but the rate of incarceration is rising, then there are more mentally ill people incarcerated than ever before." Exactly. The number of prisoners is increasing and the number (but not proportion) of mentally ill prisoners is also increasing.

I agree with the importance of improving social services. Unfortunately, until we solve the problem of how to cure (not just treat) drug addiction I think we will still have rising incarceration rates.

Ladyk73: I'm confused. Or maybe I really do understand the situation and it doesn't make sense. Are the alleged offenses taking place in the hospital, or are they just coming to the hospital to carry out an arrest warrant?

Roy said...

Alison has it right, I think. It is too easy to access the prison system and too hard to access the mental health system.

Also, Clink, your assertion doesn't add up. You state that the rate of growth for folks with mental illness is constant and low, but that the growth rate for prison is higher. If that is the case, then the percentage of prisoners with mental illness should be continuously dropping, which does not appear to be the case. If your two premises are correct AND the percentage of prisoners with mental illness is, in fact, increasing, THEN the only explanation is that the people with mental illness are preferentially being committed to prisons. N'est ce pas?

ClinkShrink said...

Mais non, ma cherie petite Roy.

The percentage of mentally ill prisoners is staying constant but the absolute numbers are rising because the population as a whole is growing. We aren't preferentially draining free society of psychiatric patients, it's just that they are being incarcerated, along with others, usually as a result of substance abuse. In my outpatient clinic somewhere between two-thirds to 80% of my patients have an active addiction. In free society, according to Baltimore Mental Health Systems, only about 15% of outpatients have addictions. I was surprised when I heard that, but that was their data. I don't see them being incarcerated so much due to mental illness and lack of services so much as due to chemical dependency.

Roy said...

(Clink, I will not take exception to your gender faux pas.)

If 80% of your clinic have a mental illness (I include addiction in that term) and 15% of the free population does, then prisons ARE collecting more than their share based on chance.

I think you are jumping on the wrong "implication". It's not the thought that "all psychiatric inpatients are potential criminals", but that untreated psychiatric illness can result in behaviors which our national stigma, prejudice, and ignorance misidentify as something else. This something else sometimes results in entry into the judicial system. And I have met many patients in the ED who tell me they get better health care in prison than out, and that they intentionally go back when they need care that they cannot get on the outside. That is f'd up!

Look at Mrs Rodriguez. Bill-O on FoxNews stated she was a "methamphetamine addict" who had been to the ED three times in three days asking for pain medications. It is conceivable to think that the ED staff presumed that she was "acting out" to get pain medicine; that she was "faking"; that she was "just" going through narcotic withdrawal; that she deserved what she was going through; that drug users should be considered to be faking and FOS until proven otherwise. I'm not saying they thought that, but what other explanation could there be?

There are many in the health care -- and judicial -- system who carry around these biases and presumptions, resulting in diminished access to care, diminished access to justice, and the consequences of these barriers.

And this whole voting discussion just shows how misunderstanding and mean some people can be. Now I'm getting all riled up... I need to step away from the keyboard.

Ladyk73 said...

Clinkshrink: To clarify....
Individuals are arrested, because of their actions in the inpatient ward.

Ironically...these patients are many times "assulting" staff while during or before a five point restraint.

An individual who is currently a patient at the state facility in which I volunteer, was arrested because she was pounding on the ceiling walls...and a piece of the wall fell on a staff member. Another person was arrested for throwing items at staff members.

I know these to be true, because I have known with these individuals before the incidents. And when you know the someone who is a captain at the holding center....
And have discussed the situation at length, in the spirit of changing the situation. You know you are very close to the truth.

Ladyk73 said...

Huh? What did I just say?
I think you get the point...grammatical challanges due to be on the smallest of which I am working 30 hours in 2.25 days

ClinkShrink said...

Roy: Forgive me. Thank goodness computer code knows no gender; it's equally unforgiving to male and female alike.

I agree, it is f'd up that free society can't do what correctional facilities do as it pertains to health care.

I excluded substance abuse from the mental illness category because clearly that's a confounding variable for the likelihood of arrest and prosecution. My proposition was that it's such a large confounding variable that you can't really parse out the effects of mental illness.

Lady: Oy. I guess I did understand your situation, I just didn't believe it. I obsessed about the prosecution-of-patients dilemma last October in my post Fully Charged Battery.

Roy said...

I just opened this page in a different browser, and the audio of that 911 call plays automatically (I hate that). If anyone else is getting that, let me know and I'll take it out and just make it a link.

Midwife with a Knife said...

This is a bit of a tangent, but is there any way to set that 911 call so that it doesn't automatically play when your page is opened?

Anonymous said...

Yes, is there someway to get rid of this??? I keep the volume off, but I turned in on in a rare attempt to actually listen to our podcast and I can't get to the podcast and the 911 call is upsetting. Roy? Roy!

Roy said...

It wasn't doing this autostart thing with Flock or Firefox, but I tried it with Safari and it wouldn't shut up. Shoulda known better. I took it out and just put in a Youtube link instead.

Sorry for the nuisance, folks.