Dan Currin, an emergency department crisis intervention specialist, discusses ERs’ role when psychiatric patients have nowhere else to go
For people on the streets suffering from mental health issues, a crisis often means a trip either to jail or to the emergency room. ERs, like the back of a squad car, are one of the few remaining safety nets for people suffering a mental health crisis, especially those without a residence. The increasing, well-documented local and national mental health crisis can hit both the police force and ERs hard.
While both options can offer temporary solutions, neither the criminal justice system nor the ER is designed to address the long-term safety, recovery and well-being of individuals at risk and the community at large.
People arriving at an ER in a mental health crisis might stay a few hours, or several weeks. In some cases, ERs can become de-facto boarding facilities for psychiatric patients with nowhere else to go, straining a busy ER’s limited resources. In the past decade, substance abuse has become more severe, homelessness more prevalent, and services harder to come by, leading to a perfect storm in a broken mental health care system.
Street Roots recently talked with Dan Currin, an emergency department crisis intervention specialist at a Portland area hospital. (The hospital requested that it not be named in this article.) Currin’s job is to assess, diagnose and collaboratively develop a care plan for those who arrive at the ER with mental health issues.
For the past five years, he’s been working the graveyard shift between 2 p.m. and 2 a.m., a time of night when a greater percentage of people arrive experiencing mental health crises.
Helen Hill: Can you describe a typical night in the emergency room?
Dan Currin: There are times when it is really crowded. It’s really busy right now. When I left last night, there were 14 mental health patients in the ER. It can get so that half of the ER is mental health patients, and that can be hard on the doctors because there are medical patients coming in, too, who need their attention. Mental health patients take time to work with. If you want to do a good job, you have to investigate what’s really going on; you can’t just give them a pill.
Sometimes the people are violent, agitated. It can get a bit raucous. But the ER is the lowest common denominator. It’s always open. I am glad it’s there. There’s a law that says we can’t turn anyone away, and I’m glad of that. There are many people who come in who don’t have resources. I don’t know what it would look like without an ER.
We are in a very fragmented society. Our families and communities are fragmented. Without an ER, it would fall to police, then community, family, whatever there is, and there isn’t much.
Hill: What are the main causes of a mental health crisis for people checking into an ER?
Currin: It’s difficult to define a root cause. I think there’s an intersection of three basic causes, an overlapping of mental health issues, substance abuse and poverty. When people use drugs, are they using because of the stress of poverty and depression? Which came first? What caused what? It’s impossible to say.
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I would say depression is a major factor that can lead to a mental health crisis. Depression escalated by alcohol, drugs and the trauma of homelessness, abuse etc.
Hill: How do people experiencing a crisis get to the ER?
Currin: Sometimes the police bring them in. Sometimes they come in on their own, or their family or friends might bring them in.
Hill: Do you ever feel at a loss with no idea how to help someone?
Currin: I’ve been working in the ER over five years, and I still feel at a loss. The cases can be just so complex. Someone comes in with a brain injury, they live in a tent and they have a foot that’s rotten and their pet just died, the problems keep going on and on. Or they are undocumented and they were beat up after receiving racial slurs. There are just very difficult situations people are dealing with. I fairly regularly feel at a loss. Not at a loss to do the job – I know how to do the job – but what can we really do for this person?
That said, there is always some sort of plan we can leave them with. For instance, they can always call the Multnomah County crisis line. It’s staffed 24/7 with trained mental health practitioners on the phone. It’s not everything, but we give that out as part of every plan, whether or not the person is in a place where they can actually utilize that.
For some, the plan is to follow up with a team of people we recommend. Often they don’t follow up, and I’m not criticizing them for that. Often people have legitimate reasons why they are unable to. Sometimes they can’t physically get where they need to be. Lack of stable housing makes it difficult for people to follow through with an outpatient treatment plan.
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Hill: What sort of gaps do you see in our mental health services that may be causing the ERs to fill up with people experiencing a crisis?
Currin: The biggest gap I see is that many of the frontline mental health agencies, such as Cascadia, Lifeworks NW, these types of places, are underfunded. Everything is focused around billable hours and the logistics of insurance-run mental health. How that plays out is someone who has a problem easily may have to wait a month to get a counseling appointment. Counselors are so busy because their caseloads are too big, and there’s not enough money to hire more, and there is a high turnover rate because the stress of the job is high and the pay is low. So it ends up that people in crisis are put on hold for weeks. Then, when they do get an appointment, they are only able to see a counselor once a month for an hour.
Hill: So the ER gets the fallout from the people who are waiting for counseling appointments?
Currin: Yes.
Hill: And each of these ER visits, for uninsured patients, is charged to the Oregon Health Plan.
Currin: Yes, it’s a very expensive model for care.
Hill: What are some other drawbacks for using the ER as a primary point of access for people experiencing a mental health crisis?
Currin: It’s an environment where there are a lot of people sick with pneumonia, flu. Also, many people can feel shame coming in to a clinical environment they aren’t used to, depending on what culture they are from. It can be embarrassing or challenging, further triggering the crisis.
Hill: Do you change your standard of care or allow people to stay longer at the ER if they tell you they are homeless?
Currin: We had four homeless guys come in last night. One was staying in a car, one in a shelter, one in a tent and one wherever he could find. That’s pretty common.
We try to do what we can, but there are so many factors. If they need to stay in the ER for safety, if they are suicidal, homicidal, psychotic or on a substance where their mental status is altered, they may stay overnight or a couple days. If they are suicidal, we can transfer them to an inpatient psych unit, obviously as soon as possible. But if there are 14 patients waiting for a bed, it will get backed up.
The ER is like a haven to many. They get to talk to someone; they might get a sandwich, even if they are only there for an hour. Sometimes one of the biggest things we have to offer is a quiet room for someone to be in for a couple hours, a place where they have a chance to collect their thoughts. Hopefully they can get some sleep, relax, eat some food, and be able to step away from the stress of their lives and have a mental health practitioner to talk to.
We have people who come in over and over again, sometimes 100 times a year. If someone comes in 100 times, are they in a crisis all those times? What does that mean? It’s challenging because there are people whose lives are chronically a crisis. It’s a desperate situation living on the street. For the person who comes in 100 times, the reality is, good outcomes are hard to come by and they aren’t always in the realm of what we can do.
It’s a hard part of the job, if someone is coming in over and over and not following up with recommendations, maybe not wanting to be there for treatment but for somewhere to sleep, sometimes I have to ask them to leave. I try to remember this is a situation where people are just trying to get their needs met and survive.
There are times when it is so cold out, people can literally die if we release them. In extreme cases, we can call them a cab to take them to a cold-weather shelter, but we have limited resources for this, so there has to be judicious use of this fund. Even now with the nice weather, it’s hard to discharge a guy at 2 a.m. who is in a wheelchair with nowhere to go. It can be very dangerous for him out on the streets.
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Hill: In your opinion, is the ER overburdened with mental health cases that could be dealt with somewhere else?
Currin: I think it’s a real thing that needs addressing. Someone in a crisis needs to go somewhere. But when it’s the ER, the charge nurses feel overburdened. When people are agitated and yelling in the ER and it’s midnight and people are sick and trying to sleep, it’s disruptive.
There are so many other things we could do. Just housing, period. Lack of housing is one major component of people’s desperation.
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Hill: Do you have any suggestions on how to improve the mental health care system?
Currin: When I was in grad school, we went on a field trip to Vancouver, British Columbia, in Canada to look at their mental health system. They had more steps from the ER to release. We only have a few options. We can keep someone in the hospital or send them to an intensive outpatient program or to a mental health agency like Cascadia or Lifeworks.
What I liked about Vancouver was there was a lot more gradation with the levels of care. Patients could leave the ER and go to a step down, sub-acute, more prolonged stay with not as much need for medical or acute crisis care. Once they become stabilized, from there, they could go to a loosely structured, unlocked residential facility. From there, they could move to an intensive outpatient program where they come in every day for six hours, and go home every night or to a shelter. There are models that are more effective, but they take more buy-in, more money.
Hill: Universal health care.
Currin: Yep. It’s a lot better than what we have here. We spend more on health care than every other country, but we don’t really have the ability to take care of people.
Hill: You are dealing with the darker side of the human experience. How do you take care of yourself?
Currin: Whatever you got to do to make it work. The ER is an extreme enough place – you have to do all the things to stay healthy. An exercise regimen, meditation, music, creativity, family, I have a sweet wife and good kids, friends, gardening. I do all the self-help stuff. I have some really good colleagues. We laugh a lot to balance out the pain of the people living these really hard lives.
I love my job. People come to the ER because something intense is happening in their life, so there’s an openness there. A lot of people are open to changing, open to hearing another perspective, open to sharing something deeper than just a superficial conversation. I thrive on that. What makes life worth living for me is connecting to people on a deeper level, and there’s a lot of possibility for that in an ER.
It’s an honor to be there, an honor to interact with people.
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