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This story is from the Anamnesis episode called Eureka and starts at 16:00 on the podcast. It's from , assistant clinical professor of psychiatry at the University of California Riverside and vice president for acute psychiatry at Vituity.
Following is a transcript of his remarks:
Scott Zeller, MD: I was relatively new as the medical director of a large psychiatric ER in California, and we had a lot of very high-acuity individuals with psychiatric emergencies being brought in by police or by police and the ambulances right off the urban streets. They were very high acuity, and they were often brought in physically restrained to gurneys. These were people who might have been out in the community screaming, running in traffic, being violent, combative, problems at home, destructive of property -- very, very high-acuity individuals.
There had been a traditional way that the staff would approach somebody like this coming in who was maybe screaming, yelling, pulling at restraints. That was the idea that this is somebody who's incoherent, and what really needs to be done is for them to be moved into a bed with physical restraints to hold them down. Then they should be forcibly medicated with several needles with heavy sedation, and then they'd be safe, and then we could worry about what happens next with them after they've slept for a few hours. Maybe they'll wake up and not be quite so bad.
I wasn't convinced that was the best way to work with individuals, and I really tried to work with the staff to start changing that idea. When possible, rather than just assuming everybody needed to be involuntarily medicated, maybe we could talk to people and help them to calm down, and use techniques like verbal de-escalation, and try to engage with them and create what we call a therapeutic alliance. Encourage them, if we thought medications were indicated, that we would give them the medications willingly and that we would give them to them as a pill with a glass of juice as opposed to holding them down and giving them an injection. I think that that kind of led to the basis of both EmPATH and EPI. That was kind of that kind of philosophy, what we would often call like the six goals of emergency psychiatry.
Amy Ho, MD (host of Anamnesis): What Zeller is talking about, the EmPath model, is an emergency psychiatric assessment, treatment, and healing unit. It's designed as a hospital-based outpatient program for patients in behavioral health crisis where disposition decisions can be made after patients are observed and assessed in a calm space. EPI, or emergency psychiatric intervention, centers on risk stratification and early medication management for behavioral health crisis in the ED. While Zeller has been working on these concepts for some time, he had one "eureka" moment in the ED that really changed things.
The Day That Changed Everything
Zeller: One day really kind of changed everything that showed that this was possible, even in a case that everybody assumed it was just out of bounds, we had a young man come in who was screaming non-stop. He was there with an ambulance and police. They brought him into the triage of the hospital emergency department, and he was just screaming, "Ya, ya, ya." They came to me and said, "Dr. Zeller, could you prescribe some sedation medication for this guy? He's really acutely psychotic. He's screaming non-stop. He really needs medicine. We need to give him some forcible injections right now."
I was saying, "Well, did you ask him if maybe he might be willing to take some meds by mouth? Is he somebody who's willing to engage?" They said, "I don't think you understand. He's screaming non-stop." I said, "Well, let me go and see." So I went into the room that he was restrained to the bed in and saw the patient, and there he was, sure enough, "Ya, ya, ya."
I said, "Sir, when you're having a tough time like now, is there a medication you might want to take that would help you?" He went, "Ya, ya, ya." Then he stopped and he told me the name of the medicine that would help him. Then he went right back to screaming again, "Ya, ya, ya."
I said, "OK. Would you be willing to take that medicine if I brought it to you?" And he kept screaming, "Ya, ya, ya." And he nodded his head, and so I went out and told the staff. I wrote an order and said, "Would you bring him this medication and a cup of juice?" They looked at me dumbfoundedly, but they went ahead and did it.
They brought him the medicine, and sure enough, he took the medication and swallowed the pill with a cup of juice, and about an hour later he was doing much better, and so I went to see him, and he was now calm. He wasn't screaming any longer.
I went to talk to him and said, "Wow. I'm so glad to see that you're doing better. Can you tell me what was going on?" He said, "Yes, thank you, Doctor, and thank you for the medication. It really helped me, and I appreciated that you didn't attack me and forcibly medicate me. I knew I needed medicine. It was hard for me to tell you." I said, "Well, you were having a tough time. It sounded like you were screaming. It seemed like you were in pain or agony."
He said, "Yeah, I was screaming because I was hearing voices in my head that were telling me to kill my parents, and the only way I could drown it out and keep myself from hearing that voice was by screaming. Now, because of the medicine that voice has gone away, so thank you. I'm doing much better."
He was so grateful and was such a nice person that we shook hands, and we were able to get him the help that he needed. I realized that there's so much that we do in emergency psychiatry that needs to be understood.
We need to really think of these folks as having the same kind of suffering as anybody else who's coming in who might have been in a car accident or had a heart attack or anything else. These are emergency conditions and need to be treated with the same kind of understanding, empathy, and rapid interventions that we do with anything else that comes into an ER, and when we do that we're going to see people get better and get the care that they need.
Don't Wait Until the Last Minute
Zeller: Maybe, if we do it really well, people won't wait 'til the last minute to seek help because they're going to feel that doctors and staff and medical professionals are not adversaries, but they're their allies. We're not going to grab them, tie them down, and give them a shot. We're going to give them a chance to get better, and then maybe next time they're not going to worry about asking for help, and they'll do it early enough and not even have to come to the hospital.
So everything that we've done with the EmPATH model concept, which is ubiquitous now in several countries, and with the EPI interventions, which is now spreading in emergency departments across the nation is really based on "Let's create that therapeutic alliance. Let's do what's best for everybody, and let's understand that people in a psychiatric emergency are undergoing the mental health equivalent of severe pain." Anybody who's in severe pain, we want to help, we want to help these folks too.
We're finding that we're able to engage and do much better, and the outcomes are so much better, and the best of all, it's these individuals who traditionally have suffered that we're going to help get better much more quickly, and that's made everything so worthwhile and really made a life's work come to fruition.
Other stories from the Eureka episode include "The Death of One Little Girl Helped Millions" and "Diagnosing the Mind of a Special Patient"
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