Posted by: medicblog999 | March 15, 2009

Psych ER


Happy Medic has recently asked how to fix the things that are broken in EMS  systems around the world. This got me to thinking and resulted in this post which is all about one aspect of pre-hospital health care that I think the system in the UK and probably most other countries fail dramatically in.

If you phone 999 (or 911) for a chest pain, you will get, at a minimum, an emergency ambulance with a paramedic. He or she will fully assess your cardiac emergency, take all of your vital signs,  do a 12 lead ecg, then interpret it to diagnose an acute myocardial infarction. You will receive aspirin, buccal GTN, 100% Oxygen and Morphine (if not contra-indicated) If evidence of an MI is  seen, the ecg will be transmitted to one of the receiving cardiac units where you will be transported directly to, on lights and sirens, to have your angioplasty within the shortest possible time frame.

 If you phone 999 for a stroke you will, at a minimum, have an ambulance response within 8 mins from a paramedic who will assess your condition and the presence of a positive FAST (face, arm and speech test). He or she will provide 100% oxygen, a chair to the vehicle, will contact a local stroke unit and transport you there with lights and sirens so that you can get a fast scan (CT scan) and clot busting thrombolysis treatment if appropriate.

If you phone 999 because you feel suicidal, acutely depressed, very anxious, have taken an overdose,  have harmed yourself or have some other emergent mental health problem, you will receive and ambulance response, usually with a paramedic. He or she will look at your physical wounds(if you have harmed yourself) and will transport you to a local A&E department to wait for hours before possibly seeing an on call psychiatrist who will not admit you to a psychiatric unit as you will most likely by intoxicated with alcohol and will therefore be out of bounds for getting onto an acute psychiatric ward. You will eventually be sent back home with instructions to follow up with your GP. You will feel let down by the NHS, you will feel as though no one is there to help you and you may feel that the next time you “cry for help” you will have to try that little bit harder, which may result in your early and very unnecessary death.

The ambulance service cannot be the life line for acute and chronic psychiatric illness. We do not have the necessary expert training nor the time to talk to a patient for the length of time required to have any significant  impact on a person in crisis. All we can do is to try and be understanding,  not judge the patient, and treat them like any other patient who has a physical problem.

Mental illness is so incredibly common. Sometimes I think paramedics can forget that the crushed and despondent patient sitting in front of them in the back of the ambulance could so easily be one of us at any time. God knows, we see and deal with enough stuff to cause us to have some sleepless nights and to leave some unpleasant thoughts with us. How long before it all builds up and manifests itself in a mental illness. I can easily tell which of my colleagues have had experience with mental illness on a personal level, either themselves or with a close loved one. I can see the different way they approach these patients, the obvious empathy they have and the kindness and compassion in their words and actions.

I am one of those paramedics. I have had my own problems in my life (some of which I intend to share at a later date) and some I have witnessed in my family. I have also had the opportunity to undergo some mental health training whilst studying for my registered nurse qualification. I only hope that if ever I become poorly and need help from the NHS, that I get someone who can empathise and sympathise with what I may be going through at the time. 

However, as I said, the ambulance service isn’t the real problem. The real problem is the lack of help for patients with acute manifestations of mental illness.

How wonderful would it be to have specialist centres where as pre-hospital clinicians, we could refer and transport these patients to their own type of “definitive care”?. Imagine what it would be like to have a purpose built unit, staffed with RMN’s (registered mental health nurses), counsellors and psychiatrists. There would of course need to be the facility to triage their patients so that the genuine ones get all of the help they need and the not so genuine ones get told that it is not just the easy option to keep going there. There would be a unit or a ward where they would actually take intoxicated patients, because, lets face it when everything goes pear shaped, most people turn to the drink which shouldn’t really result in “definitive treatment” not being given. There would also be follow up  clinics for patients who do not require immediate “life saving” emergency psychiatric care (like a follow up in a fracture clinic for a broken limb) and there would be clear links to further community care to continue the patients treatment.

Do you think this is all a dream?? Probably, although I hope that one day there may be some equality in the way that mental health is approached when compared to the money and resources thrown at the big physical problems out there.



  1. Thanks for writing about this , it’s an issue Im close to. I especially relate to your observation about colleagues who are familiar with mentally ill patients and how best to handle them. It has always been one of my strengths as an EMT.

  2. Wish I’d known you’d done mental health training. I’d have sought your advice. Hats off to RMNs – they do a fantastic job.

  3. I am well aware of the issues you raise. It’s not much better in A&E Departments. My hospital has a psychiatric unit 100 yards away from the door of the A&E, but it might as well be 100 miles for all the help we get from them. If we call the team at 5am to see an acutely psychotic patient, we are told that the night team are going off at 9, so can we ring the day team when they come on. I despair…

  4. I think that’s a fantastic idea, although sadly it seems more like a dream than something that would happen. The subject is one I am also very familiar with, and I agree it is definitely noticable when a health care professional with their own similar past experiences approaches a self harming/suicidal patient when compared to someone who has never experienced it.

  5. […] Mark from Medicblog999 shares his vision of improved psychiatric services from a U.K. perspective. Much of what he proposes would be a great improvement in the U.S., also. Check out Psych ER. […]

  6. Thanks for this. I took an Applied Suicide Intervention Skills Training course a year ago, and it’s definitely coloured my viewpoint of what an emergency could possibly be – the deepest wounds aren’t necessarily physical. Do you think this course could have any impact on how we approach emergencies in mental illness?

    • Hi Jha,
      Im not sure if the course would help things along, as I am not aware of the course or the course content. However, I do firmly believe that any courses that improve understanding of mental health issues and the impact that they have on the patient and their families can only do good for how emergency services staff deal with and treat patients with acute mental illness.
      Thanks for the comment

  7. Thanks for directing me to this post. I can only wish there had been a similar system in place for me in my time of need. Luckily, I was seen by a psych before my physical health was all sorted out, and he sorted out all my medication – if I had not messed myself up so royally, I would have just been sent home with a “Don’t do it again” warning.

  8. […] caring for them, so they just keep going around and around without receiving any definitive care (Psych ER […]

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s


%d bloggers like this: