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Emergency room visits for mental disorders have surged in San Diego County over the last decade, challenging both hospitals and patients who can be traumatized by their experiences in chaotic ERs.
Vincent Dimeo recalls feeling relieved as he left his friend Ann Ruhlman at Sharp Grossmont Hospital for a psychiatric evaluation in December 2017.
On their way to the hospital, Dimeo said his friend was behaving erratically and he twice had to slap her hand away she tried to scratch her right eye. Now she was safe and checked into the emergency room. Dimeo could head to work.
“They said she’d be in good hands,” Dimeo said.
About nine hours later, Ruhlman gouged out her right eye in Grossmont’s ER.
Ruhlman and Dimeo are now haunted by the experience.
“I feel like I’m being punished for something,” said Ruhlman, who recalls hearing voices that encouraged her to pull out her eye.
Emergency rooms are often the only option for patients grappling with a mental health crisis or the families and police officers assisting them. Ruhlman is one of the many San Diegans who have waited long hours – even days – in local ERs.
ER visits for patients treated for mental disorders surged 60 percent in San Diego County hospitals in the last decade, according to a Voice of San Diego analysis of hospital data reported to the state.
Many of those patients remained stuck in ERs while they waited for longer-term care and services already filled with other patients in need.
Three large local hospital systems reported to VOSD that their patients wait an average of about 20 hours to move onto more specialized inpatient beds while a separate hospital association analysis released last year suggested patients can often wait up to 36 hours for those beds.
Those waits and the frenzied environment of an ER only escalate patients’ suffering while taxing the emergency departments of hospitals dealing with an array of urgent care needs. Patients who spoke to VOSD described increased anxiety, agitation and depression as they laid in gurneys – some waiting as long as two days for an inpatient bed – and going for hours without water or food.
Ruhlman’s case is especially tragic.
Dimeo felt sick when he learned days later what had happened.
“I shouldn’t have left,” he said.
Ruhlman has since filed a lawsuit alleging medical malpractice and that she was inappropriately left unrestrained and without supervision. She now has a false eye and said she struggles with depth perception.
Ruhlman questions why Grossmont ER staff didn’t intervene and recalls repeatedly calling out to ER workers about the compulsion.
“I figured that they wanted me to pull out my eye,” Ruhlman said.
In a statement, Sharp Healthcare wrote that patient safety is a high priority and described Ruhlman’s case as “most unfortunate.”
“Sharp Grossmont Hospital provides high quality care and complies with all regulatory requirements specific to the use of physical and chemical restraints,” Sharp wrote in the statement. “Due to patient privacy concerns, we are unable to provide any specific details regarding care provided to patients, however it is the hospital’s policy to provide care to its patients based on clinical presentation. The acuity level of a patient determines the level of care and observation needed.”
Other patients and advocates who spoke to VOSD also described harrowing experiences in local ERs.
“I’ve had people go through the emergency room process and say, ‘I’m never doing that again. That was more traumatic than the thing that brought me to this point to begin with,’” said Michelle Routhieaux, who leads San Diego’s Depression and Bipolar Support Alliance and has accompanied patients on dozens of ER trips over the last 15 years.
Medical experts, county health officials, patients, advocates and law enforcement leaders agree that ERs can further traumatize patients who are already suffering.
Yet ERs have long been the front line of a broken mental-health system with insufficient resources for both patients in crisis and those seeking to avoid one. And in more recent years, bolstered by an explosion in Medi-Cal enrollment tied to the Affordable Care Act, patients in crisis have rushed in.
County behavioral health director Luke Bergmann and other county officials say they hope to reshape the region’s mental health system from one focused on ER visits and hospitalizations to more accessible and less costly treatment in the community. They hope to bolster preventive care and to open psychiatric urgent cares to give patients in crisis options other than ERs.
But for now, San Diego’s mental-health patients are flooding ERs.
When San Diegans experience mental health emergencies, feel suicidal or their friends or family fear for their safety, they usually face one of two choices: Call 911 or go to an ER.
Neither is ideal.
Both emergency calls and ER visits tied to mental health crises have skyrocketed.
Last year, San Diego County hospitals reported more than 42,200 ER visits where a mental disorder was considered the patient’s primary health need.
That’s up from about 26,400 such visits in 2008, according to data from the Office of Statewide Health Planning and Development.
Chaotic ERs are ill-suited for the avalanche of new patients.
“It’s not a therapeutic environment,” said Dr. Gary Vilke, an emergency medicine physician and professor at UC San Diego. “It’s a place to keep people until they get to a therapeutic environment.”
For patients, the experience can be agonizing.
Patients and law enforcement officers tasked with taking them to the hospital after concluding they are a danger to themselves or others can sit for hours in busy, loud waiting rooms.
The delay in care can heighten patients’ challenges, said Dr. Scott Zeller, former chief of psychiatric emergency services at the Alameda Health System who now chairs the Emergency Medical Foundation’s Coalition on Psychiatric Emergencies.
“Our patients are really not doing well, and many times, they are having the worst days of their lives,” Zeller said.
David Helsten of Escondido said he has visited ERs at least a dozen times in the years he has been treated for bipolar and post-traumatic stress disorders.
He recalls being stuck in a gurney that aggravated his bad back and going hours without water despite his fragile condition.
“The emergency room situation to me is horrific,” Helsten said.
For patients in need of an inpatient stay, the waiting only continues.
Helsten said he has almost always waited at least a day to move from the ER to an inpatient psychiatric bed.
Last spring, Helsten said, he waited 48 hours in a gurney at Sharp Memorial Hospital before moving to an inpatient bed at Sharp Mesa Vista Hospital. He recalled staring at the ceiling in a state of despair.
“It was torture,” Helsten said.
Kathi Coyne, who lives in the Serra Mesa area, said her suicidal thoughts following a breast cancer diagnosis five years ago ratcheted up during a day-and-a-half stay in UC San Diego’s ER. Like Helsten, she was waiting for an inpatient bed.
“At the time, I was just ruminating with really bad, negative thoughts, and my mind was caught in that,” Coyne said.
Scripps Health, Sharp and UC San Diego Health, three prominent local hospital systems, report that patients waiting for inpatient beds remain in their ERs for an average of about 20 hours.
A September 2018 analysis by the Hospital Association of San Diego & Imperial Counties based on interviews and focus groups conducted during the prior year concluded that waits for those beds are routinely longer.
“On a typical day in San Diego County, more than 50 patients are being cared for in acute care emergency departments while they wait for up to 36 hours for a psychiatric inpatient bed to become available,” the industry group wrote.
Those waits are costly for both hospitals and patients.
A 2012 Wake Forest University study estimated that boarding psychiatric patients as they await inpatient resources costs an average of $2,264 per patient, in part by preventing the beds they are laying in from turning over an average of more than two times during their ER stays.
Psychiatric patients waiting for inpatient beds typically remain in emergency rooms three times longer than other patients, the study found.
And doctors say those waits can escalate mental health patients’ conditions.
“People can often get worse,” said Dr. Aimee Moulin, an ER doctor and professor of emergency medicine at UC Davis. “Anyone who is strapped to a gurney in an emergency department for a long period of time is going to do poorly.”
Moulin and others also said San Diego’s emergency room waits and the rising number of emergency room visits for patients with mental health conditions are a symptom of systemic issues in both the national and regional mental health systems.
Psychiatrists are rarely available on call, and there are often long waits for appointments. Other services and programs are often full, costly and not immediately available.
ER visits are often the only option for patients in crisis.
“It is such a broken system, and it is so broken it has all fallen on the emergency department because our doors are open,” Moulin said.