It s Bedlam, 21st-century style
Dr David Mountain. Picture: Mogens Johansen/The West Australian

Emergency physician and past president of the AMA Dr David Mountain describes a typical day in a hospital Emergency Department.

The following description is of a fairly busy but not extraordinary day in a "modern" Emergency Department. However, I think it is fair to say the doctors and nurses in the original Bedlam 150 years ago would feel right at home.

It's 8am and I arrive, along with the day crew, to take handover from the night shift. As is often the case (in fact more often than not), they look seriously frazzled - and some of the reasons are obvious.

Two seriously unwell psychotic patients are in a cacophonous competition of cursing, shrieking and sobbing. One has set the other off - a common occurrence along the corridor of shame (our systems, not theirs or our staff's) where the sickest psychiatry patients are corralled. Both needed one-on-one supervision all night after requiring intravenous sedation, and one is strapped by all four limbs to the trolley.

Handover is disrupted as staff go to assist, and the noise is confronting, difficult to hear above, and ignore. Let's hope we don't miss something important about our other sick patients.

Overnight, the registrars have dealt with many major cases including six code blacks (physical restraint/sedations) for seriously psychotic patients. One of the junior doctors is close to tears as she hands over her first major drug-induced psychosis - that's the patient strapped to the bed. The patient has screamed profanities now for 10 hours straight, lashing out frequently at staff who she thinks are demons trying to kill her. The patient is the same age and from the same suburb as the doctor.

As duty consultant, I assess the state of "play" with our head nurse as we approach another busy day. On the right-hand side of the ED, all seven cubicles (a quarter of all our space) house severely mentally unwell patients - seriously compromising our ability to see other new patients. Four patients are on forms, waiting for a locked ward for involuntary assessment. No locked beds have come up for almost 24 hours, not an unusual problem. We are pretty sure another will go off soon to join the queue as they start to pace, swear and get more unsettled.

The agitation nearby is infectious. An acutely suicidal anorexic 16-year-old who badly slashed her arms has been in the main ED for 95 hours - an hour short of her fourth day. The teenagers are always the hardest to place given the almost non-existent beds for that age group. She will definitely be here for her fourth day.

Multiple doctors, nurses and psychiatrists will spend hours ringing mental health staff and senior administrators, right up to the chief psychiatrist, trying to find her and the others beds. Meanwhile, a vulnerable, distraught and seriously unwell girl spends another day in what must feel like one of the circles of hell.

After 10 hours spent in a busy, noisy crowded, confronting ED, our staff are frazzled. It's hardly shocking that disturbed patients go ballistic after days of sleep deprivation and sensory overload.

After completing handover and checking the observation ward, it is clear the situation is grim. Of 44 treatment spaces, over a quarter are psychiatric patients - eight in the main ED and five in our observation ward (four are attempted suicides). All but one require admission, with most stuck waiting for rare beds for over 12 hours, and two for more than two days. We start the day with only eight cubicles free for the oncoming deluge. Let's hope the patients sleep in today.

The rest of the day goes by in a blur of phone calls, escalating psychiatry problems, sedations and physical restraints for three of the patients. Meanwhile almost 100 other patients stream though the doors. Two staff are spat on by one of the patients, but thankfully no injuries have occurred. The security teams are well trained and practised in physical restraints.

As the shift ends 10 hours later, we have finally had some movement and beds have been found for most of the psychiatry patients. Finally, our suicidal 16-year-old moves out after more than 100 hours in the ED. Two other patients get locked beds as well.

Just as we finish our 50- patient handover, a code black is called at the front door. I could stay and see, but I am done. The patient will still be here waiting when I start again at 8am tomorrow.

As I leave a huge, tattooed, muscled and clearly drug-affected man comes past handcuffed, screaming, spitting and requiring five security guards. I tell the registrar looking after him not to take any chances; he could easily kill someone.

I arrive the next day for handover. It has been busy overnight. The big boy did get an arm free and busted a security guard's nose. The wailing is at the same volume, the voices are different. The corridor of shame is filled, with little movement, and again beds are scarce. Welcome to Groundhog Day in Bedlam!

If you or someone you know is thinking of suicide phone Lifeline on 13 11 14

The West Australian

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