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London and District Academy of Medicine – Patient Healthcare Forum: Improving Healthcare and Ending Hallway Medicine Presentation

My mental health journey began when I was 10 years old. I was admitted to the Adolescent Unit at the old Children’s Hospital here in London when I was 15 and 17. In my twenties I was admitted to the 8th floor at the Old Victoria hospital.
The next leg of my journey was Two- Years- Less- A- Day in the Correctional System. I was re-arrested in my early 30’s and spent 9 months psychotic in a Detention Centre. This included about 6 weeks in solitary confinement. I was found Not Criminally Responsible On Account of a Mental Disorder and remained in the Forensic Mental Health System for 6 years.
More recently I have experienced two ambulance rides, two mental health arrests by London Police Service, two one week stays in the London Health Sciences Centre ER department and a one month say on an acute unit at LHSC. At present I am an outpatient with Parkwood Institute (St. Joseph’s Health Care).
The difficulties I have faced accessing Mental Health Care are both personal and systemic.
When individuals fall through the cracks the costs are enormous. I might not look it, but this province has invested over a million dollars in me. You might think that would be pleasing but many days I am fragmented. It’s no one’s fault but we can do better. There are a multitude of highly qualified and deeply compassionate care providers who also need something more workable.
The ER at London Health Sciences is a miniaturization and mirror of the penal system. Patients don’t wear orange, but we are coloured by diagnosis and risk. The ER rooms are quite like solitary confinement. I hope that doesn’t sound hyperbolic because they are worse. There are no windows and when you enter the hallway there are Correctional Officers monitoring prisoner patients and if you need to use the toilet it is a shared jail toilet. Stainless steel no seat. To get there you must walk the gauntlet of police officers and security staff who all look alike. This is not therapeutic it is traumatizing and a criminalization of mental health crisis. The one room I was in I urinated in the corner drain most of the time I was there. We didn’t call it the ER in jail. It was called the Hole or the Digger.
My view of LHSC is that security runs the show. Safety and security are paramount, but this makes the situation no less stigmatizing. I realize it is cheaper to handle chaos with security rather than hire health care workers but is that ethical? Is it even humane?
In the 80’s and 90’s we had orderlies. They interacted with and were familiar with patients. In those days’ patients had many of the same symptoms and the availability of sharps was the same or worse but today we have paramilitary forces in hospital. It seems as far from therapeutic as you can get. My hospitalization’s in the 80’s and 90’s were by comparison positive experiences. To treat everyone as a risk to themselves or others is stigmatizing and redundant.
The ER and acute system are not only chaotic and frightening but once you’re there you’re only honest enough to find freedom. I deal with suicidal thoughts regularly and often repetitively. As an outpatient my mind was made up that if I made that decision it would be my last. There was no way I was going to be left for emergency services or the acute unit to impart what are in my estimation traumatic treatments.

 

We need a mental health care system that is more community based with improved coordination between agencies. My perception is that we have a funnel whereby individuals access mental health care through the ER and acute services. I’m a poor example as I have an aversion to assistance, but individuals and families would be better served in the community.
We need more Mobile Crisis Teams and Teams that can deliver care in the community. Having the police involved in mental health apprehensions is inefficient, traumatizing and stigmatizing. The police by nature are agents of control rather than agents of care. When an individual is brought to the ER by the police, health care workers have a perception of that individual and it can be a barrier to compassion and care.
Too much funding is being used by the police in mental health interactions and it becomes a snake swallowing its own tail as these forces call out for more funding for a job they do ineffectively. The further they progress the more they consume. We provide piecemeal mental health training to police who are paid 70 thousand dollars per year while there is a shortage of mental health and addiction workers who are paid 40 thousand dollars per year. Using the ‘Sunshine List’ to deliver patients for healthcare is a dim idea and there are more humane interventions.
If a perennial patient can access the system outside of emergency services it is the best possible outcome. The individual can depend on familiarity and continuity of care. These elements are not only lifesaving, but they are fiscally functional as well. It costs about 25 hundred dollars for a therapist to see a patient once a week for a year. The bill for my one month stay on the Acute Unit was over 75 hundred dollars. The personal and familial costs are incalculable.
When I consider how quickly a mental health difficulty can spiral out of control I think family doctors should be able to make a true urgent referral. Many of these incidents are a matter of life and death. My family doctor made an urgent referral and had I been swiftly seen I may have been able to stabilize without calling on emergency services. It makes absolutely no sense that you can call the police and be seen right away but to access a healthcare worker you must wait. Family doctors need to be more effectively included in the circle of care.
Spirituality seems like an odd antidote for hallway medicine but distress can be intertwined with faith structures and some of my symptoms can be overcome or integrated by utilizing a spiritual framework. Spirituality can be a basis for or link to community and community supports can be a preventative factor in healthcare. Stigma is isolating, and isolation can be lethal. When I see a person of any faith I can converse with fewer words while comfort and compassion are a gesture I do not have to see with my eyes. These individuals can dissolve portions of uncertainty and fear. In the Forensic System the interdenominational pastor was part of the team.
To alleviate hallway medicine, I believe we need a two-pronged approach. I see two pressure points on the mental health system. One point is individuals who need to be able to access the system prior to emergency care. Patients are presenting at ER because of waiting 6 months or more. If these individuals can see someone within days, there is hope. That someone could be a recreational therapist. When I see my recreational therapist, I know there is a psychiatric nurse, a psychiatrist and Team behind her. These Teams can be a great resource and can be part of a system of triage where they can recognize difficulties and direct individuals to the care that best meets their needs. Hopefully this would prevent individuals from getting worse and requiring more intensive healthcare. Sometimes what a person needs most is simply to be seen. Mental health difficulties are usually manageable healthcare needs.
The other pressure point is individuals who are more chronic and require longer term beds and more intensive healthcare. It seems counterintuitive to have a hospital bed occupied for longer but if a longer admission prevents others in the future the savings are real and in effect more humane. If surgeries were left half completed, we would be appalled. Long- term treatment is integral for a subset of individuals with complex mental health care needs.
The individuals who we fail to fully intervene with and for, may not weigh directly on the healthcare system but they still require resources from other agencies. When I drive by the Elgin Middlesex Detention Centre I know that over 70 percent of inmates need mental health care and addiction services. This is the most expensive backwards delivery of care that anyone could imagine.
If we can alleviate these two points I believe we can make headway in ending hallway medicine and hopefully much of the funding required can be recouped by lessening the demands on emergency medicine, policing, corrections, forensics and shelters.
We have been feeding the wrong end of the elephant.

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