Testimony on S. 36 by Heidi Henkel
I support the goal for health care workers in emergency rooms to have good workplace safety and not get injured or work under the threat of possible injury.
I doubt that arresting people who threaten or commit violence in the ER, and sending them back out onto the street with their physical and mental health conditions untreated, is a good way to accomplish that.
I am concerned that it would leave the causes of the person’s poor social functioning, which could include mental illness and/or delirium caused by the medical condition they’re seeking help for by going to the ER, untreated, and push the behavior out into the community.
Perhaps the person will be terrified by having been arrested, and will be afraid to seek medical care or mental health care in the future. I also don’t think arresting people in the ER will do much to make the ER a safer place to work, because it wouldn’t address the reasons why people become violent in the ER.
There are three reasons for violence in the ER:
1. Delirium from serious medical problems.
A wide range of medical problems can cause delirium. Infections, organ failures, extreme blood loss, etc. Delirium can include anger, confusion, and even violence.
Treat the medical condition. Try to deescalate the patient. If needed, restrain and sedate the patient in order to do that. Be quick to treat the medical condition that is causing the delirium.
How to prevent violence in cases of delirium: Check patients for delirium and for medical conditions that could lead to delirium, thoroughly and frequently. Some physiological causes of delirium can be detected more quickly by regularly taking blood pressures, oxygen saturation, temperature, and other simple things.
Preventing, detecting, and rapidly treating delirium and the physiological causes of delirium is the primary strategy.
2. A mental health crisis, when the patient has come to the ER to get help with their crisis.
If the patient doesn’t get help soon, the patient’s condition can deteriorate, so it’s important to help the patient soon. Having a cozy, friendly, low-stress architecture and décor, well-staffed living-room type situation for people in mental health crisis, would help.
Peer support specialists could be a big part of this. Focus on psychosocial strategies and start addressing the mental health crisis immediately, no warehousing.
Open Dialogue is the most effective modality for psychosis in the world, and can be carried out by peer support specialists who are trained in Open Dialogue. One reason Open Dialogue is so effective is because it is started within a few hours of when the patient or their family makes a request for help.
Peer support strategies are also very effective — more effective than hospitalization and medication — for people considering suicide. Peer support specialists should be in ERs to help people in mental health crisis. It would be great for there to be other mental health professionals there, too. The long-term outcome of a mental health crisis is much better if psychosocial interventions begin very quickly.
It should be prioritized like any other medical condition in which the long-term outcome is better if intervention begins very quickly.
A lumbar spine fracture with pressure on the spinal cord is an example of an injury where the long-term outcome is likely to be much better if intervention happens quickly (permanent paralysis vs not having permanent paralysis).
That’s triaged right after severe bleeding, cardiac arrest, and respiratory arrest. Mental health crises should be prioritized similarly because the long-term outcome is similarly impacted by how quickly they’re responded to.
The most effective interventions are psychosocial, so let’s make sure that gets started within an hour after the patient walks in the door. That would prevent most assaults due to mental health crisis. Psychosocial strategies can also help in deescalating patients who are already escalated when they first walk in the door.
The biggest investments should be in psychosocial training for all ER staff in deescalation and interacting with people who have emotional trauma and/or are in an extreme state, and into making sure that mental health crisis patients begin getting meaningful psychosocial care within an hour of walking in the door.
3. Patients who have some trauma background and then get triggered in the ER by a misunderstanding, miscommunication, or something a staff person does.
People can get triggered if they don’t understand what’s happening, if a staff person doesn’t explain what they’re going to do before doing it, if there isn’t consent, if the patient doesn’t feel heard, if the patient’s concern isn’t being addressed and the patient doesn’t know why, etc. Staff need training about how to do trauma-informed care.
Peer support workers could help as communication helpers to make sure the patient understands what is happening, and to listen to the patient about their feelings and concerns. This could defuse some tension and help make sure the patient is getting their questions answered and getting their concerns heard.
Some patients don’t know how to assert their needs without coming across as too aggressive. The communication support person can help them communicate in a way that they get taken seriously but that doesn’t come across as aggressive.
Some other things that may be helpful:
More staff in the ER, so patients can be treated more quickly and there are more staff available to interact interpersonally with patients, to make them feel heard, make sure they understand what’s happening, detect delirium early, start meaningful psychosocial interventions quickly for people who are there for psych reasons, etc.
More other places for people to go with emergencies, to alleviate the overload on ERs. More urgent care centers, primary care, and peer-run crisis respites.
Fewer mental health emergencies, by having more and better outpatient mental health care.
Video monitoring in the emergency department, so that people can be held accountable later, for violent or threatening behavior. If there’s an assault or threat that’s a clear behavior choice and not driven by the patient’s medical condition, the hospital can prosecute using the video footage.
Video footage can also protect patients in the event that they’re being accused of something they didn’t do or that’s more complex (for example, a staff person assaulted them first, or their behavior was misunderstood, or their behavior was caused by the condition they came to the ER to get treated.)
A variety of pain mitigation strategies, including other methods besides opioids.
I had a severe, rapidly bleeding puncture wound in the Brattleboro ER, and they had someone to just hold my hand during the entire surgery because I didn’t want to be anesthetized.
Hand-holding is an excellent pain mitigation strategy. Be creative. There’s something in between giving opioids, and ignoring the patient’s pain.
Things to bear in mind:
Many patients have combinations of mental health and physical health issues. One patient can have significant mental health needs and physical health needs at the same time.
People who go to ERs are in a lot of distress. Openly expressing their distress shouldn’t be criminalized. ER staff need to learn to deal with patients’ distress with compassion and without being distracted by it.
Have communication support helpers listen to some of the patients’ raw feelings. Don’t criminalize behavior that’s part of the condition they went to the ER to get help with. You don’t want to deter people from seeking help in the ER in the future. Use prosecution, not arrest, as the deterrent.
Use video footage (with other patients blurred) to prosecute people who intentionally choose to threaten or assault ER staff.
It’s important to make sure ER staff have adequate debriefing so that they have enough emotional support about the tough and sometimes scary things they go through, working in the ER.
Heidi Henkel is a psychiatric survivor from Putney. She provided written public comments to the House Judiciary Committee on the proposed bill to permit arrest and removal of patients in health care facilities, and this commentary provides excerpts from that testimony. Henkel has a B.S. in “Human Movement and Health,” has worked as a one-on-one community mental health worker with traumatized children and adults and currently does home health personal care for people with serious illnesses and disabilities, including with delirium and dementia.