Our state of South Carolina is a delight. From wonderful people to beautiful landscapes, from a vibrant Southern culture to excellent food like shrimp and grits, it’s a place I’m thrilled to live. But we do lack a few things. And one of the most striking is adequate mental health care.

The state budget, like so many state budgets, has been trimming anything and everything. And of course, mental health coverage is one of those things lopped steadily away. I don’t need to tell anyone in emergency medicine that this is often a problem.

For instance, our hospital has no psychiatrist available to come to the emergency department (they hired some, but their pay structure seems to preclude ER consultation). Our county mental health department won’t come to the ER after hours or weekends, or (it seems) on days that end in ‘y,’ or days when the Sun is shining or covered with clouds. Not their fault really; they have no money and precious little staff.

All of this I understand. All roads do converge in the ER; especially when something needs to be done for free. So, mental health patients end up in our department fairly often. We have a wonderful option in a tele-psych arrangement graciously funded by the Duke Endowment. It helps, because it gives us the possibility of consultations and the recommendation to either discharge or commit.

But the commit part is the problem. When we have a patient on detention orders, the police bring them and watch them. Once they are committed, but waiting (often interminably) on a psych bed at another facility, the police can, by law, leave. But the patient is usually not restrained.

So, the patient may choose to leave. That is, the angry, PTSD schizophrenic can up and walk away. The suicidal, bitter, drug-abusing teen can walk away.

We are supposed to detain them. And according to all the powers on Medical Olympus, we have to have ‘one on one’ observers; usually nurses or volunteers the hospital pays extra to sit and read a book by the patient’s room, so that they can say, ‘doctor, your patient is leaving!’ Of course, the observers aren’t (and shouldn’t be) expected to detain these people.

But who is? Recently three of my partners have physically returned fleeing psych patients to their rooms. But is this their job? Will their malpractice cover an injury to the patient? Will their disability cover an injury they sustain themselves? Will a nurse or physician, albeit well-meaning, be stabbed to death or choked?

Security is told to stand by. But they have no (or desire no) authority to actually detain. The police can come, but usually after the patient has fled to our nearby forest. Can we train the bears to do this work?

On the other hand, when patients do escape it’s a clip-board carrying, carpet-walking, high-healed, business-suit nightmare as everyone in the hospital descends (in the bright light of the next morning) to figure out ‘what happened, why it happened and how we can prevent it from happening,’ as they busily walk about, video-tape and take notes. (Remarkably free of screaming psychiatric patients to detain).

The last time it happened it was because the staff was busy, and caring for a critically ill person. Thus, they were reasonably distracted and did not notice the suicidal young man walking away.

So, we’re between the devil and the schizophrenic. Or the frying pan and the administrator, or between the injury and the attorney.

No one will restrain them, but we must. No one should touch them, but they should not leave. No one is allowed to hold them or tie them down, but there’s hell to pay if they escape. No one should have their rights violated by inappropriate restraints or medications, but one’s job is imperiled if the suicidal escape. That’s a Zen Koan at it’s best! ‘Restrain the fleeing madman, but do not touch him.’

My solution is pretty simple. I’m not here to wrestle. If they leave, they leave. Until someone finds a way to legally, and effectively, restrain these people within the bounds of hospital policy, they can go. I’ll ask them to stay. I’ll offer them coffee. Heck, I’ll put an X-box in the room if it helps. But I’m a physician, not a security guard. I don’t have a belt with cool things like a Taser, pepper-spray, baton or hand-cuffs. And a stethoscope is not as good a weapon as any of that.

Furthermore, I have no legal authority or power of arrest. I suppose, one day, I may be sued. But if I restrain them, or hurt them, I’ll be sued anyway.

Surrounded by administrators, suicidal patients, psychotic patients and attorneys, I’ll just get back to work. Next patient please?

And yes, I know bed 20 is walking out.

I may just walk out myself.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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