Emergency rooms are intended for short-term care. Say a child comes in with a broken bone. She'll have it set, get a cast and some pain meds, and be sent on her way with an appointment for follow-up care.
At the University of Vermont Medical Center’s emergency room, most children average less than four hours in the ER before they are sent home or admitted for specialized care.
But for children suffering from mental health emergencies, the ER is more like a windowless purgatory. It’s a secure place to wait for a bed to open up someplace else — often 150 miles away, in Brattleboro.
Last year, about 73 children in severe psychiatric distress spent an average of three and a half days waiting for care in the University of Vermont Medical Center’s ER. Some spent much longer. They received minimal medical attention while they were there.
There are 11 full-time child psychiatrists working on the hospital's campus — they treat outpatients, conduct research, and teach medical students. They rarely interact with the children waiting for care in the ER.
Pediatricians in the community say UVM Medical Center can and should do more to meet the needs of the children who spend days inside the ER.
Meanwhile, about a dozen involuntarily detained patients — including children — have filed motions over the last year, arguing it’s unconstitutional to make them wait in the ER without treatment.
Steven Hale of Essex Pediatrics said one of his patients recently spent eight days waiting in the ER for an inpatient psychiatric bed.
While a general psychiatrist did see the girl each day, she did not receive a treatment plan, according to Hale. “I asked mom,” said Hale, “she said they’d just come by and look at her, and that was pretty much it. There was no assessment. No plan.”
After waiting eight days for treatment, Hale said, a psychiatrist at the Medical Center changed the child’s status and released her home with no plan for additional care.
“This is the longest I’ve had,” Hale said, “and we kind of came out worse than we started.”
The responses VPR received from hospital officials did not correspond neatly with the stories we heard from doctors and parents. While officials acknowledged patients’ care did not meet parents’ expectations, they did not believe children were going days without seeing a doctor trained in psychiatry — or that patients were leaving without a plan for care.
“The psychiatrists do provide evaluations twice a day, where they engage with the patients and the families,” said Chief Medical Officer Isabelle Desjardins. Bob Pierattini, chief of the Medical Center’s Psychiatry Department, said a team of nursing staff, mental health technicians and psychiatrists work together to “make a treatment plan for every person that we see.”
When presented with anecdotes to the contrary, Pierattini said “If that is the case I would want to know the specifics and I would review it. I mean our expectation is that everybody’s seen everyday.”
Elizabeth Hunt, a South Burlington pediatrician, said that is not the case. “Personally, the last few patients I’ve had haven’t seen psych in the hospital,” said Hunt, referring to both child and adult psychiatrists, “they haven’t seen them at all."
Hunt recently convened a task force to evaluate access to child psychiatrists.
While the hospital acknowledged evaluations by child psychiatrists in the ER are very infrequent, local pediatricians said their patients' access to general psychiatrists were also inconsistent.
Over six months at the end of 2017 and beginning of 2018, a thirteen-year-old named Emily made six visits to the University of Vermont Medical Center ER, often for three or four days at a time. Over the 17 days she was there, she was seen by a general psychiatrist briefly, five times, according to Emily's mother and family doctor who reviewed her chart.
VPR is using the first names of children and family members to protect patients’ identities.
Aside from those brief evaluations, Emily’s mom Jennifer said the only interactions Emily had with hospital staff were with a nurse who fetched her food and DVDs.
Jennifer isn’t the only parent who said the hospital has failed. Another mother named Maggie has a similar story. Maggie would seem to be in a position to know — she works at the hospital, as a family doctor.
“You know if a kid were to come in with appendicitis or if a kid were to come in with, you know, any other sort of medical concern — they would be seen by an expert in that field,” she said.
During a snowy week in January, Maggie’s 12-year-old daughter spent 30 hours waiting for a bed to open up at the Brattleboro Retreat.
The second day that her daughter was in the ER, Maggie said, she saw a psychiatry intern “for a few minutes.” That was all the medical attention her daughter received. Maggie said the remaining 29-some hours her daughter was there, she merely waited.
Parents and guardians have long complained about the lack of treatment provided to children during long waits in the ER, according to Department of Mental Health records obtained by VPR.
The mother of a suicidal teenage boy called the department in 2016, after he had waited for a bed for four days. “She stated that he is getting worse with no treatment,” an employee noted.
Another parent called that year about a teenager “sitting idly and having nothing to do” while waiting days for a bed. “Mom sounded very exhausted,” wrote a state official, “I’m worried about her ability to continue to provide supports.”
Officials say the ER isn’t designed to provide the kind of therapeutic activities typical of an inpatient psychiatric setting.
But in records, hospital executives said adding child psychiatry staff would improve care and reduce wait times. Hospital officials told VPR they are trying to do just that.
“It’s important to know that we are right now seeing a surge in emergency department visits with kids,” Pierattini said. “You know, five years ago it was so rare that if a kid came into the emergency department, somebody would call me and say ‘what am I supposed to do?’” Now, Pierattini said, “there can be two or three at any time. And this is very recent.”
The hospital couldn’t provide data to back up this claim. But numbers from the Department of Mental Health track how frequently a subset of sick kids — those in state custody — must wait for treatment in the Medical Center ED. And those numbers are down 30 percent from five years ago, with a slight rise, more recently.
Because of the alleged spike, officials said, they had just found funding to hire a new child psychiatrist to help staff the ER.
They’ve made such promises before.
In a letter submitted to Vermont’s hospital regulator during the budget negotiations in 2017, UVM Medical Center said it would add two child psychiatry fellows by 2018.
The fellows have not materialized.
Pierattini said a national shortage of child psychiatrists made recruitment difficult. Now, he said, the hospital plans to fill the positions in July of this year.
In the meantime, pediatricians including Hunt said the hospital should take advantage of the resources it already has. “Because every minute you spend in a windowless room not knowing what your future holds, when you’re already scared, or angry, or completely out of control, is toxic. It drives the problem.”
In her office, Hannah Rabin of Richmond Family Medicine recalled the rotation the Medical Center once required all family physicians do in exchange for admitting privileges. “It was tremendously inconvenient,” she said, chuckling. “I would get a call at two in the morning,” she said, “and I would go and meet the patients in the emergency room.”
Still, Rabin said, a rotation might be a stopgap solution. “I would think that that would be a very reasonable plan. You know, everybody takes their turn. They have their week of call and during that time they're providing care, you know good continuity care over the course of a week. And, you know, really initiating treatment for these children who are in enormous distress.”
Hospital officials said that proposal wouldn’t work because it would take existing psychiatrists off of their outpatient care, research and teaching duties. That’s why, they said, it makes more sense to focus on hiring.
“Our hearts go out every time a family comes to that emergency room with a mental health crisis, a medical crisis, a surgical crisis,” said chair of pediatrics, Lewis First. ‘This is a systems problem. We are part of the solution. We cannot be the heroes. We have to be the partners.”