Emergency psychiatry during COVID-19 [PODCAST]

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“The reaction to the COVID-19 pandemic in the comprehensive psychiatric emergency program (CPEP) began insidiously, with an initial sense of unease. Patients are brought into CPEP when they pose a danger to themselves or others. Often they are brought by police, but occasionally they come on their own or with concerned family members. CPEP is a locked unit, separated via locked double doors that require a valid ID badge to pass. It is its own world, walled off from the rest of the hospital, and is a place where overwhelmed patients tell their stories and seek help.”

Ruchi Vikas is a psychiatry resident.

She shares her story and discusses her KevinMD article, “Emergency psychiatry during COVID-19.”

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho. I’m founder and editor of KevinMD. Today on the show, we have Ruchi Vikas. She’s a psychiatry resident and graduating very soon, and she wrote this KevinMD article, “Emergency psychiatry during COVID-19.” Ruchi, welcome to the show.

Ruchi Vikas: Thank you so much.

Kevin Pho: So tell me about your story and your journey to where you are today.

Ruchi Vikas: My parents were both state psychiatrists at the last state psychiatric hospital in Brooklyn, Kingsboro Psychiatric Center, and I pretty much always knew what I wanted to do. I’m completing my psychiatry residency here at Stony Brook after spending a lifetime around the severely, persistently mentally ill. In three weeks, I’ll go to Bellevue at NYU and start working there as an emergency physician.

Kevin Pho: Wonderful, and I think that your services will be sorely needed, especially in a hot spot like Bellevue. So you wrote a KevinMD article, “Emergency psychiatry during COVID-19.” Before I get into the article, you talk about a comprehensive psychiatric emergency program. Can you tell us what that is?

Ruchi Vikas: So it’s exclusive mainly to the northeastern United States. A lot of places have different versions of this, but what we have is a locked psychiatric emergency room. So once you come in, you can’t leave in any sense until you’re evaluated by a physician, or really by the team. And people come when they’re perceived as being a danger to themselves or others. So sometimes family brings people in, sometimes patients bring people in, they can be referred, and they’re very often brought by police.

Kevin Pho: And during COVID-19, during the pandemic over the last three months, describe what you have been seeing.

Ruchi Vikas: It’s been all kinds. I mean, we always get all kinds because we’re the only CPEP in Suffolk County, so we get a lot of people. But for us, a lot of people have called saying they’re suicidal. A lot of general practitioners or other physicians that those patients see have called us and said, “I had a phone call,” or “I had a telemedicine call with this patient. I’m really worried about them. They don’t seem to be doing OK.” And police have been bringing a lot of people in for public intoxication, or just people. We’ve all seen psychotic people in the streets. I don’t know the statistics, but I think that there have been more in the past couple of months, because we have gotten more.

Kevin Pho: And when they come to your institution, what do you do for them?

Ruchi Vikas: They come in, they change into scrubs, and they kind of wait to be evaluated. CPEP was initially meant to be therapeutic in itself, so patients were supposed to interact and socialize within the big milieu area. Sometimes that happens; other times it gets crazy. But while they’re waiting to be seen, we kind of watch to see how they interact and how they’re doing. You can tell a lot about a person just by looking at them.

And then when we do the interview, we’re really trying to ascertain if they are a danger to themselves or others, so if they can go home safely and take care of themselves without hurting anyone, and especially without hurting themselves. And if they can’t, we admit them to the inpatient unit, which has been a challenge in and of itself, because so many psych units have been closed due to the pandemic.

Kevin Pho: And how has access been?

Ruchi Vikas: It’s been OK. People stay maybe a little longer than usual, but for a while the census in CPEP was lower than usual because people weren’t really going out. They were utilizing the suicide hotline a little more. Now it’s picking back up, but now also a lot of psych units, inpatient units, have opened back up too, so it’s been better. But it’s been kind of a puzzle piece, figuring out how to get everyone where they need to go.

Kevin Pho: So I’m reading a lot in mainstream media about the psychiatric manifestations of social isolation and coming out of lockdown. So over the next three months or so, what are some of these psychiatric issues that you see becoming prevalent in public?

Ruchi Vikas: A lot of drugs, a lot of drugs and alcohol. You know, drinking has come to be normalized because there’s no routine to time. Also, all of the people who are experiencing a lot more domestic violence are going to be struggling and traumatized from the amount of time they’ve potentially spent in an abusive relationship. Plus, just people’s natural anxiety has increased so much. Never in my life have I seen more than a few people coming in for the same reason in the same day. One day in CPEP, we had over four people come in for attacking someone for not washing their hands properly.

Kevin Pho: So I’m in primary care. I do internal medicine in Nashua, so I do a lot of virtual visits and telemedicine, and now I’m seeing more and more patients in the office. Now, from a behavioral health standpoint, what are some of the things that I can do to help mitigate some of the psychiatric effects of the pandemic?

Ruchi Vikas: That’s a great question. One thing that I wish primary care, any physician really, would do more of, including us, including psychiatry, is just ask how you’re doing: “How are you?” But not in a dismissive or cursory way. Not that you do that; I find myself doing that at times, just “How are you?” And let them answer, and then try to engage with them on a narrative and personal level, which sounds like it’ll take a lot of time but doesn’t usually. So, “What was the last thing that made you laugh? When was the last time that you laughed? How has your anxiety been today?”

We ask a lot of the questions that we have to ask, like, “Are you feeling suicidal? Do you want to hurt yourself?” But sometimes those can be yes-or-no answers, or they can be more below the surface. If people feel seen as human beings right now, as someone with a story, instead of just lost in this blanket of lockdown and isolation, it might help. We never realize the smallest things that we do for people that make them feel better. So if you ask someone, “When was the last time you laughed?” they’ll remember it, or they’ll remember that it’s been a while. Just recognition of someone as a human, even briefly, means so much to people. I know because it means a lot to me too.

Kevin Pho: Well, thank you. That’s great advice. So I’m also reading about mental health issues, or behavioral health issues, within the health care profession as well during the pandemic, especially frontline workers. So I was wondering if you could comment on that, and again, what are some things that we can do to help them?

Ruchi Vikas: I have seen a couple of health care professionals on the other side of CPEP. There have been a few people, not that I knew personally, but who have been in the career before, who have come to CPEP, who have broken under the strain, because there’s this tremendous responsibility, that we’re not doing everything that we can, that we could be doing more, and that we don’t have the resources to do our job the way that we usually do. From the stories I’ve been reading about what people are going through in the city, I imagine that this sense of guilt, sense of failure, and sense of personal responsibility is heightened.

So just asking the same thing as for patients, because we’re not different. Just asking people how they’re doing, connecting as a human, asking, “How frustrated do you feel? How are you coping?” You know, being there for someone doesn’t necessarily have to mean answering the phone at 3:00 in the morning. It kind of means just looking someone in the eye and seeing them for who they are. You can do that with anyone briefly. You can’t do it for an extended period, but if you do it more often than not, then I think you’re doing your best.

Kevin Pho: And I think that’s one of the things that I try to emphasize on KevinMD and by sharing stories behind the scenes, that we in health care are all human too, and I think that sometimes gets lost in media narratives. So saying that we health care professionals are human too and that we have a human side, that’s great advice.

So how do you see the pandemic playing out in the next few months or so? I know that a lot of states are slowly opening up. We have a little bit of a piecemeal way of opening up; there’s no national strategy. But what’s your take in terms of the summer and beyond?

Ruchi Vikas: I wish I knew. I wish I had a better idea. I mean, I have so many friends across the country, and I’m watching them go out and camp and hike and hang out with all of their friends, and I’m here in New York, and we still can’t do anything. So I mean, our CPEP census is picking up, and the second time that we go through this, I think we’re all going to know what to expect. And I think, I worry that the places that didn’t get hit as badly first will get hit badly the second time, because they didn’t get hit as badly first.

And as for mental health, how many times can you go through the same thing? You know, it’s going to tell us a lot about who people are. Are you super resilient, and the second time you go through it, you’re acclimated to it and it makes you stronger? Or the second time you go through it, you think, “I just can’t do this again”? Neither is wrong; both are understandable. Are we going to see more of one than the other? I don’t know. We’ve been seeing a pretty even mix of both. I mean, there was this grocery store employee a couple months ago, and she said to me, “I just want this to be over,” and that was two months ago. It’s nowhere close to over.

Kevin Pho: And I do agree with you there. So I’m seeing a lot of studies saying that if this was a baseball game, we’re only in the third inning, and that may not be what people want to hear, but we are in this for the long haul. So tell me something that you’re passionate about right now, or something that you’re curious about right now.

Ruchi Vikas: I’m really passionate about stories. So I have a really unique window into people’s lives as a psychiatrist, because people trust me with their secrets, and not just people in the emergency room. People all over the place trust me with their secrets, and so I know people from a very deep level. One of the challenges, I think, of residency and of just being a physician overall is becoming hardened or numb to the stories that people have, because of, you know, RVUs and time and documentation and prior auths. But I found that if you see people for who they are and you just ask them a couple questions that they maybe weren’t expecting to be asked, they give away really unique parts of their personality that you would never have known and that they take for granted.

So I have this schizophrenic patient who’s much older than someone that you would usually see in that population. It would be easy, because she’s so cranky, to kind of dismiss her and just do the visit as routine. But I found, just by asking, that she cooks meals for all of the homeless people around her block once a week. And I never would have known that if I hadn’t asked, and she wouldn’t have known to tell me, because she doesn’t think it’s a big deal.

So I’m finding those stories much more interesting than any risk factor or anything that I could do algorithmically. And I’m finding the most efficient and best way to get at those stories, especially in a targeted amount of time, because in an emergency room you don’t have much time. But that opportunity for very human connection is what I’m most passionate about now.

Kevin Pho: Well, thank you for sharing that insight. And my final question: What’s your take-home message for the KevinMD audience?

Ruchi Vikas: I would like everyone to just kind of be human and be connected with one another, because even in the KevinMD article I wrote, what we see in the world and in CPEP is just a lot of division and a lot of people arguing because they don’t agree. And we’re not ever going to agree on everything, but if we can find one moment or one space to connect on in between, it might be better for everyone.

I’m working on a book proposal right now that talks about the ways that we can find connection with people that we don’t agree with. The art of gentle disagreement and confrontation, I think, has been lost, and part of psychiatry’s job is to instill that back into everyone, the ability to respect and communicate equally with everyone, because what we need right now is unity and humanity.

Kevin Pho: Well, given today’s political climate. And I’m going to be looking forward to your book.

Ruchi Vikas: Thank you.

Kevin Pho: Well, thank you so much for joining us on the show. Dr. Ruchi Vikas is a psychiatry resident and soon-to-be attending, and she wrote this article on KevinMD, “Emergency psychiatry during COVID-19.” Thank you so much for joining us.

Ruchi Vikas: Thank you so much for having me.

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