My first call

Contrary to popular belief, psychiatry is not what Jack Nicholson experiences in One Flew Over The Cuckoo's Nest. Popular culture has spread the belief that psychiatric wards are menacing, terrifying places where people are strapped down to beds and electrocuted against their will. Overall, psychiatric wards have become much more pleasant and patient-centered than they once were, but the stigma usually still prevails.

The Charity hospital system is a healthcare system in New Orleans that cares for anyone, free of charge, that lives at less than 200% of the poverty line. It was housed at the famous Charity hospital, but due to the damage of Katrina, Charity hospital was closed. Since then, psychiatric beds in the city have been cut in half and the ERs are filled with psychiatric patients waiting for a bed.

One such ER is at the University Hospital. It was supposed to be a temporary structure post-Katrina but found itself being used permanently as a psych-ER. Monday was my first day on call, and I spent the majority of the day in the 20-bed "temporary" unit, intimately known among the staff as "the trailers."

I got there around 7 am and was happy to find that, although the trailers were outdated and leaked a little in the rain, they were not something out of a horror movie. The staff was nice and the nurses extremely competent. The ER is certainly not a place for psychiatric treatment, though, and is no place to house psychotic patients for 3-4 days while waiting for an inpatient bed. I rounded from patient to patient, trying to get to know the patients and their treatment protocol. Then I, with the help of the LSU resident, tried to ascertain whether they needed to be admitted.

There are a few major problems with this approach to psychiatry. For one, I was working a holiday weekend. The primary team doesn't usually work weekends, so I was likely the third doctor working that weekend. Because of the lack of continuity, no one (I included) started medications that were any more frequent than an "as needed for agitation" basis (it's standard protocol and appropriate practice to delay major treatments until patients were admitted). Some of these patients were in the hospital for three days without any real, continuous medication plan. Secondly, a psych-ER is not a psych ward. Psychiatric wards have multidisciplinary teams of social workers, psychologists, nursing staff and physicians that work in a supportive environment to stabilize mental illness. A Psych-ER is a place for patients to go so they don't hurt themselves or others. It's a place where the police officers are doing a lot of protective work and the physicians are sedating patients who cannot keep calm. It's not a place that anyone should have to be treated for long periods of time. Still, it's better than nothing (and with psychiatric funding these days, it's not going anywhere anytime soon).

As I was saying, I made my rounds and tried to figure out who needed to stay and who could go. Twice on Monday, I made the very novice and intern-ish mistake of giving patients a hope that they may be able to leave that day. After talking with the other, more experienced resident, I changed my mind and had to go through the joyous experience of telling them that they can't leave. At this point, the patients are under emergency commitment and can be held against their will for 72 hours. They usually have figured out that the only person who can send them home is the physician.

They weren't happy with me. In fact, one patient was livid with me. To the point where I tried to stay on the opposite side of the ward because I had this strange feeling that he might jump over the nurses station and attack me. My evasiveness worked, though, and the night went on without incident.

The night flew by and I was able to leave, exhausted, at about midnight. 17 hours after I arrived (I know, that's nothing for an intern), I came back home and collapsed on the couch. I woke up to my alarm a few hours later, a little less tired and a lot more experienced and made my way back to the wards.