A&E is no place for a suicidal patient and yet this is where they come, at least one or two cases a day, to the chaos of our busy department. It is hardly conducive to dealing with someone who views life itself as a disease. Staff process patients while forced to meet four-hour targets, and always have one eye on the clock to avoid financial penalty-incurring breaches. Sometimes the irony of the situation cannot be missed: in one cubicle is a patient so sick they are fighting for their life and in the next is another wanting to give up theirs.
The descriptions on our computer screens vary. Overdose, deliberate self-harm and sometimes simply “unable to cope”. If patients have harmed themselves in any way they need to be examined to ensure nothing life-threatening lingers. We make sure their paracetamol levels are not within liver-killing range and call the psychiatry teams. But how can you really ask a patient properly about the reasons they have ended up here, when you have a tsunami of others lined up behind you?
For patients with mental health issues we call psychiatry liaison and some people who I would never envisage being safe to go home, I see being discharged for follow-up in the community. I have to accept that they have focused specialism in this area of medicine and their judgment outweighs mine. But how much of their decisions are partially influenced by resources? It flickers through my mind cynically that we may see that patient again at their next attempt.
It’s not just the depressed and suicidal we see. Those with psychosis come in scared and wide-eyed – confused by the voices in their heads and their experience made much worse by the noise around them in the department. We wear scrub uniforms which for a paranoid patient can be deeply unnerving. If they become agitated, security arrives in black uniforms making it even worse. One woman became fixated by me and was threatening violence. I spent most of the shift repeatedly calling psychiatry.
Then there are the children, for whom we have to call the child and adolescent mental health service (CAMHS) team. Some are depressed, some display new psychosis, or others as young as 11 are diagnosed with personality disorders and have taken life-threatening overdoses. Sometimes they hear voices threatening violence to their family and so act to protect them, which can involve harming others or themselves.
One A&E consultant described paediatric psychiatry as a Cinderella speciality – sidelined and under-resourced. As the numbers of such patients appear to be increasing, the network to care for them does not. A patient referred to CAMHS waits in an A&E cubicle, thus limiting space to see other patients. At night CAMHS staff often suggest admitting them under paediatrics until they arrive in the morning. The paediatric team understandably refuse for a multitude of reasons such as lack of space, or because a psychotic patient on a ward with other sick children would be difficult to manage. The bottom line is that these children will be better served being in the right facility, with experienced mental health staff, so they stay in A&E.
People will keep coming to A&E for their mental health problems because they do not know where else to go. We can help them to get access to the right people but it appears that demand far exceeds existing capacity. A&E is just a small sticking plaster for a whole host of mental health conditions that warrant the right care, backed by better resources.
One thing is certain, judging by the number of attempted suicides we see in A&E: there are a lot of people out there who need help. Depression and its consequences seem to be as common as a year-round seasonal viral infection. Why are we not calling it an outbreak?