Pubdate: Tue, 19 Jun 2012
Source: Province, The (CN BC)
Copyright: 2012 Postmedia Network Inc.
Contact: http://www2.canada.com/theprovince/letters.html
Website: http://www.theprovince.com/
Details: http://www.mapinc.org/media/476
Author: Ethan Baron

'NOWHERE ELSE IN CANADA'

St. Paul's is unique in the country in having to serve a concentrated 
population of mentally ill, often addicted patients - 1,489 of them 
last year - often brought in by police

He's male, 20 to 25 years old, and psychotic. He may be talking to 
the walls, or screaming and pounding walls, or sitting quietly 
focused on the delusions swirling through his brain. Quite likely, 
he's addicted to crack, and possibly heroin and alcohol. If he's been 
smoking crystal meth, he may be raving, and dangerous. He may have 
HIV, and hepatitis C.

He's the typical psychiatric patient in the St. Paul's Hospital 
emergency department. And there are many, many of him.

"They can be paranoid. They can be hearing voices, seeing 
hallucinations. They're often very irritable and agitated. They can 
be threatening or violent," says Anna Nazif, director of emergency 
psychiatry at St. Paul's. "Our system is non ideal for psychiatric 
patients. We're basically always doing the best we can in less than 
ideal situations with less than ideal resources.

"We have a population that everyone agrees exists nowhere else in Canada."

Admissions of mentally ill patients at St. Paul's emergency have 
risen steadily, to 1,489 in 2011 from 813 in 2005.

Because the hospital serves the Downtown Eastside, people having 
psychotic episodes from mental illness, drugs or frequently both are 
often picked up by police then trans-ported to the hospital's 
emergency department.

There, a doctor may certify a patient as mentally ill, allowing two 
days' detention in hospital. Another 30 days can be added upon 
another physician assessment.

"You're taking a fundamental right away," Nazif says. "We don't take 
that lightly."

However, psychotic patients may pose a threat to them-selves, the 
public and emergency department staff.

"You don't ever want to get within reaching distance because you'll 
get assaulted," says psychiatric nurse Shirley Wingo, who has been 
attacked half-a-dozen times in her 11 years at St. Paul's. "The worst 
was when a lady tried to snap my neck. She grabbed the sides of my 
head and tried to snap it.

"You can't let your guard down in this type of work. If you show 
fear, they're going to try to use that against you. It's not unusual 
that patients, anti-socials, will threaten to kill you."

Emergency psychiatric staff work in a high-stakes environment where 
the wrong clinical decision can lead to tragedy. "You can't get cocky 
about it because you're dealing with people's lives," psychiatric 
nurse Mary Shervin says. "Nobody wants anyone to leave here and kill 
themself or some-one else."

Patients come from all walks of life, suffering from illnesses such 
as depression. Often, a desire for suicide, or attempts at it, are 
triggered by alcohol or drug abuse, Nazif says.

"No one's immune. I see West Van teenagers who come from great 
families, with lots of support, [who are] homeless and living in a 
park and using heroin."

Nazif, during a Province visit, was inside a "seclusion room" beside 
a paranoid schizophrenic crystal-meth addict. "I was probably taking 
a risk," Nazif says. "He didn't seem agitated, he didn't look drugged 
out. He was settled. I was thinking when I was there that he could 
just grab me."

Although treating mentally ill and addicted patients is difficult and 
dangerous, the St. Paul's doctors and nurses do the job because they 
want to, Nazif says. "At this hospital you have wonderful people who 
have chosen to work with this population, and who like the people," 
she says. "Mental illness and addictions are chronic illnesses, but 
they're treat-able. The stigma of mental illness starts with the 
underfunding of treating it."

Staff compassion only goes so far when the treatment facilities are 
insufficient, Nazif says. The main psychiatric-patient room in 
emergency is a windowless box where the clock is stopped at 1: 36. 
Four doors open off this room into isolation rooms, green-painted 
cells with a mattress on the floor and a steel prison toilet.

"If this isn't stigma," asks Nazif, gesturing toward a cell, "what is?"

Sometimes, an elderly patient suffering from dementia will have to be 
put in a room next to one containing a raging addict. "You have them 
beside a 25-year-old guy with drug psychosis who's screaming and 
screaming and banging on the walls," Nazif says. "That's a scary situation."

A suicidal patient could spend two or three days in one of the cells, 
with none of the fresh air, natural light and interaction with other 
patients that help mentally ill people recover from psychotic 
episodes in other North American hospitals, Nazif says. "Fresh air 
and natural light - these things go a long way toward settling people 
without medication or restraint," she says.

Vancouver's concentration of low-income housing in the Downtown 
Eastside turns many mentally ill people into drug addicts, Nazif 
says. "The low-cost housing that mentally ill patients who are on 
disability can afford happens to be near all the drugs."

St. Paul's vast numbers of "dual-diagnosis" patients who are 
men-tally ill and addicted require treatment on multiple fronts. 
"You're not dealing with just mental illness," Shervin says. "They're 
homeless, they're hungry, they're using [drugs], they're not taking 
their meds."

The stigma around mental illness and consequent underfunding hampers 
advancements in the emergency psychiatric department, Nazif says.

"Addictions are a mental illness - they have a genetic basis. They 
occur in people that have other psychiatric problems. We still give 
patients exceptional care, but there are things we'd like to do for 
them that we can't. When these people are treated well, they can 
overcome these illnesses. We have the capacity to be world experts in 
this area if we had the resources."

Heartbeat is an eight-month series for which The Province has been 
granted special access to St. Paul's Hospital. The series runs for a 
week each month until November.
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MAP posted-by: Jay Bergstrom