Dear emergency department clinicians:

We at the top of the administrative and regulatory chain understand that you deal with enormously complicated mental health and substance abuse patients all the time. Your resources are limited, and the demands placed upon you are growing.

As such, we (the anointed and well-meaning) wish to offer you some guidelines based on our committee’s extensive lunch-time meetings and brainstorming sessions. All of which, you will certainly understand, are meant for your good and designed to help you to do your job at all hours of the day and night in such a manner that we need not be called and awakened from restful sleep.

Regarding the suicidal:

Please remember not to let these patients leave the emergency department without being fully evaluated. It is imperative that they be kept safe in rooms free of danger, and with “sitters” who will gaze at them endlessly for the hours to days necessary to keep them healthy. Bear in mind that their well-being depends upon being stripped, placed into a paper gown, and escorted to an empty room with 24-7 fluorescent lights. As a happy coincidence, it is entirely possible that they will 1) confess to crimes such as murder or espionage or 2) develop full-blown sleep-deprived psychosis making commitment easier.

Important note: these patients are not in “seclusion” because that would be unkind and violate their civil rights. They are not being restrained.

Nevertheless, as stated, do not let them leave the department. You may do anything up to and including telling them to stay, pleading with them, offering them delicious and distracting sammiches and standing in the way with your arms akimbo. You may NOT touch them in any way to restrain them. Nor may your aged and infirm security guards.

It is entirely acceptable to use telepathic powers or invisible force fields (this includes Reiki therapy) as long as these do not actually violate the suicidal patient’s autonomy by inappropriately touching patients with your physical form.

In summary, they must be kept but not touched, held but not restrained and evaluated fully whether or not they desire it as long as they are not compelled to stay but simultaneously kept against their own desires.

It is our sincere hope that this clears things up.

Regarding the dangerously psychotic or those afflicted with stimulant driven delirium:

We of the committee recognize that these patients can seem frightening and dangerous. But, like all dangerous creatures, this is merely an illusion; a civilized perception of “normal” which you are imposing on them. In fact, they are far more frightened of you than you are of them. Much like, say, wolves, cobras or mountain lions.

Thus it is important to recognize that they are afraid and avoid anything which might worsen this, including (as above) holding them against their will and violating their autonomy, applying physical restraints on limbs or trunk or forcibly injecting them with medications.

These measures should only be done in the most dire circumstances to avoid the perception by the patient and by those in authority that you are trying to impose false standards of “normal” behavior on those who are simply having a bad go of it.

Indeed, these patients can be dangerous to staff, but this in no way offers an excuse to harm, hold, medicate, or terrify those who are in your charge.

It is, as above, acceptable to compel them into paper gowns, and place them in empty and well-lit rooms with sitters to stare at them, one on one. These patients may be particularly agitated by such interventions but keep in mind that this is, again, not their fault. If they engage in outbursts or assaultive behavior, please exercise all possible restraint and use every intervention possible to bring them back to peace of mind.

If they should attempt to leave, do not let them. But do not under any circumstance try to physically hold them. The telepathic techniques suggested, along with food, drink, coloring books, and sincere pleading may also be used.

It has come to our attention that from time to time, such patients attempt to seriously harm or kill staff members. Please remember that this behavior is generally not intentional and does not constitute any personal feelings on the part of patients and is not generally a reflection of customer satisfaction since such patients may well confuse staff members with demons, family members or politicians.

It is incumbent on staff to endure this with all the patience and professionalism we have come to expect from physicians, nurses, PAs, NPs, medics, police officers and others who are accustomed to dangerous conditions with few resources.

Please do not attempt to harm those who are assailing others. Remember, that even with a solid chokehold the staff has a full minute (or more) before serious brain damage occurs to co-workers. During this time try not to focus on the cyanosis of your co-workes, but rather call police and attempt to employ negotiating techniques, calm music and re-direction.

We of the committee feel that interventions such as striking, irritant sprays, tasers, or firearms are always unacceptable. Once the patient perceives that he or she is in a safe, loving environment odds are good that why will cease their assaultive behavior.

These are trying times. No small number of us have carpal tunnel syndrome from wringing our hands in concern and writing policy statements. And frankly, the lunch meetings have not been good for our weight loss! But sacrifices must be made.

We are here for you no matter what happens. So keep up the great work! The mentally ill and dangerously intoxicated count on you to keep them safe. And we count on you to do it with as many restrictions and rules as we can devise.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan. 

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