Time: 3 a.m. Sunday morning, Anytown, U.S.A.
An 18-year-old boy is brought to the emergency department (ED) of a community hospital. He has been in a gang fight. His shirt and pants are bloody. After taking the patient's history, the triage nurse starts an IV and urgently pages the ED physician on the intercom. A quick examination by the physician reveals multiple stab wounds to the abdomen. Immediate calls are made to the general surgeon on call and to the surgical operating room to prepare for a potential emergency procedure. Appropriate lab work is performed, with steps taken to stabilize the patient's condition while awaiting the surgeon and the availability of an operating room.
Time: 4:30 a.m. later Sunday morning in the same ED.
The police bring a 16-year-old boy to the ED for assessment. He had attended a party where alcohol was served. After consuming an indeterminate amount of beer, he told his friends that he was quite upset because his girlfriend had just broken up with him. He said that his only out was to kill himself. He then ran out of the house in the direction of the commuter train tracks two blocks away. Unable to stop him and frightened for his safety, his friends called the police. The police apprehended him and brought him from the railroad tracks to the ED.
As the triage nurse obtained the history from the police, she drew blood for labs. At this point, the patient was unable to give a coherent history. Lab results indicated his blood-alcohol level was 2.5 times the state level for intoxication. The ED physician concluded that the patient was only intoxicated and not in other medical distress. He advised the triage nurse to place the patient in observation and repeat the blood alcohol level in two hours. If it approached a range below legal intoxication, the nurse was to ask the social worker on call to assess the patient for suicide potential and determine if he needed either a psychiatric evaluation or hospitalization.
These two cases involve two boys of similar age with potentially life-threatening conditions who were seen and treated in the same ED in two totally different ways by the same staff. The first boy's care was directed by the ED doctor to a surgeon. The second boy's care was directed by the same doctor to a non-M.D. Each boy had an equally life-threatening situation. For the boy with the stab wounds, a surgeon was critical for his ongoing care. For the intoxicated suicidal boy, a non-M.D. was seen as appropriate.
Are psychiatrists not seen as front-line physicians for acute, serious mental disorders? Why wasn't a psychiatrist called to assess the potentially suicidal boy? Was this hospital's response new in the treatment of a suicidal patient or was this the standard of care?
The answers to these questions will go a long way in explaining psychiatry's current status in society and medicine. Who are the actual front-line deliverers of care for the seriously or chronically mentally ill? A varied group of providers and organizations have been developed to provide services for these patients. Community mental health centers provide care to individuals with serious and chronic mental illness. These community-based agencies are staffed by a mix of community residents, social workers, psychologists, counselors and physicians who may or may not be a psychiatrist.