Dr. Jeff Louie
Appearances
Health Chatter
Pediatric ER Concerns
And again, our assessors are very good at what they do. Once they deem a child that needs to be an inpatient unit, they will work with our inpatient mental health unit on the West Bank, as well as talk to the other mental health facilities in the state.
Health Chatter
Pediatric ER Concerns
That is a great question. There are emergency medicine physicians who are duly trained. They are emergency medicine and psychiatric trained, but those are far and few between and they tend to be the adult doctors. There are very few pediatric emergency medicine physicians who are duly trained in psychiatry. I only know one. And it's not you, right? And it's not me, and he's in Rhode Island.
Health Chatter
Pediatric ER Concerns
So I don't think that Peds, emergency medicine docs are ever going to be to a level of comfort to start treatment of mental health in our emergency department. And matter of fact, we probably don't even want to do that because mental health is a whole new subject that, you know, we get trained in medical school. Like I said, in fellowship, very little training fellowship.
Health Chatter
Pediatric ER Concerns
And so we literally would start from scratch and that's, that would not be safe for the patients.
Health Chatter
Pediatric ER Concerns
Great question. So What we've decided to do in my unit is obviously need to balance the safety of my medical patients, our patients with chronic trauma, as well as the safety of the mental health borders, as well as the residential borders. And my emergency department is small. It only has 12 beds.
Health Chatter
Pediatric ER Concerns
And so we can't, if I have seven mental health children or patients in the emergency department, I can't afford to put them in rooms. which I would want to do, but I can't because we're still seeing 80 to 100 medical kids a day. And if I lose seven beds, that only leaves me with five beds to move these 100 patients.
Health Chatter
Pediatric ER Concerns
And so we've chose to board them in the hallways, which is not ideal, but it's the best that what we can do for my small footprint. Other hospitals may room their mental health kids in their rooms, but then they lack the number of rooms to see the medical kids.
Health Chatter
Pediatric ER Concerns
And with our complexity of medical conditions, you know, heart transplants, liver transplants, bone marrow transplants, we can't afford to have those patients wait in the waiting room. Yeah. you know, on top of it. It's not safe. It's not safe. Yeah. The balancing measure that we do every single day.
Health Chatter
Pediatric ER Concerns
And it's, it's, it leads to burnout because you're dealing with all so many different variables at any one particular time. And then we have to keep them, keep in the back of our minds is that these residential borders or these mental health borders at any one time became, can become violent. So now I have violence in my hallway and,
Health Chatter
Pediatric ER Concerns
And I still need to try to protect kids in the emergency department. So why are they only showing up?
Health Chatter
Pediatric ER Concerns
I think a lot of the problem, I'm not 100% sure on this particular topic, but during COVID, a lot of the residential mental health units or houses or facilities closed down. So... And there are resources outside of the emergency department, but maybe families don't know about them. There's a crisis hotline that you can call from Hennepin County to have someone come to your house.
Health Chatter
Pediatric ER Concerns
But I kind of understand, too, if your child is so violent at home that you fear for your own life, you call 911 and then the police and the ambulance crew pick up the kid and bring him to our hospital. Right, right, right.
Health Chatter
Pediatric ER Concerns
The many issues that we've come across is obviously is financial. We would love to have the kids who are boarding, the mental health kids as well as the residential boarders, to initiate some kind of therapy in the emergency department since they're there for days for the mental health kids.
Health Chatter
Pediatric ER Concerns
And what we haven't talked about are the residential boarders who can be in the emergency department for months at a time. So if you're there for months at a time, not getting any kind of therapy, any kind of coping skills,
Health Chatter
Pediatric ER Concerns
You know, we try to get them at least a psych consult to maybe adjust medications or whatnot, but then they really don't get face time with the therapist to discuss their issues, their anger issues, their suicide ideation and teach them the code.
Health Chatter
Pediatric ER Concerns
And there has not been a process yet because of lack of mental health professionals who actually could come down, who have time to come down to the emergency department. Because our mental health folks right now are in the inpatient units trying to take care of those folks to get them out of the inpatient units.
Health Chatter
Pediatric ER Concerns
So we do have, mHealth do have senior administrators who are working with DHS, Department of Human Services, I guess. These talks have been going on for several years. And there are several theories of why it isn't working as well as it should. One, obviously, is there aren't enough specialized group homes to take care of these kids because it closed down. They haven't opened them up again.
Health Chatter
Pediatric ER Concerns
And two, one theory is, and I'm just going to say this, is that DHS says, well, at least they're in the emergency department and they're safe. Yeah. And that, you know, and to me, yes, they are safe, but we are in the emergency department are incurring costs. Yeah. So there was a paper, and I'll have to send this to you guys, I apologize for not even thinking about it.
Health Chatter
Pediatric ER Concerns
There was a publication in New England Journal of Medicine, it was a commentary manuscript, and they basically did cost analysis for specifically pediatric mental health boarders. And they found out that it costs about $227 an hour to board these kids in our emergency department. So if you have a kid from my residential kids, $227 an hour times three months, right?
Health Chatter
Pediatric ER Concerns
We're just losing so much money that we'll never recoup, you know?
Health Chatter
Pediatric ER Concerns
Right, right. It's the lack of care from... in my opinion, our lack of wanting to care more from the government. Because if they were to give us grants, we can afford to have therapists in our ED to help manage these kids. And maybe these kids get to go home. Or now they're more suitable to go to a residential placement. Clarence.
Health Chatter
Pediatric ER Concerns
Is that something that would be useful with this crisis? I think that's a great point. But once they're in the emergency department, again, the folks that would do the coping and the therapy are in the inpatient units taking care of those kids. And so I am unaware that there are therapists who are available to do telehealth for the kids in the emergency department.
Health Chatter
Pediatric ER Concerns
And that certainly has not started in our unit. Maybe it has started in other units, but I find that doubtful because someone would have to pay the therapist to do these consults and continually manage these kids. It's one thing to get a therapist once a week, but it might be a different therapist. And that just adds to confusion.
Health Chatter
Pediatric ER Concerns
I mean, is it just, And the insurance companies certainly are not helping. So the way I understand it, if you drop off a child for mental health, let's just say mental health issues, radiation, and they are deemed unsafe to go home, but it may take five days for them to be transferred to an inpatient unit.
Health Chatter
Pediatric ER Concerns
As I understand it, and I'm pretty sure it's true, is that the bill for that particular patient is just that one encounter. It's not five days. Even though I'm taking care of them for five days, it's just a one encounter. So like two hours worth of... Whatever it is, yeah.
Health Chatter
Pediatric ER Concerns
Yeah, okay. And this year was weird. This last winter was weird because it had to do with kids going back to school. Usually there's a sequence of events that we can kind of predict. As winter starts coming down, you know, kids are in school. Usually around December, January, maybe October, November, we'll start seeing the flu virus. And then sometime after that, we'll start seeing the RSV virus.
Health Chatter
Pediatric ER Concerns
And it kind of follows influenza. But this year, it was really difficult because we're seeing a combination for almost five months, winter months, of COVID kids, influenza kids, and RSV kids all at once. Whoa. So that's why many emergency departments, including ours, had long waiting times because we just seen so many kids.
Health Chatter
Pediatric ER Concerns
And this is back in a day where kids had to be COVID negative or positive to go back to school. And so we're doing a lot of testing for COVID that parents can say, hey, my kid was sick. We went to the emergency department and they are COVID negative. So they need to go back to school. And that was a huge problem is that there weren't enough
Health Chatter
Pediatric ER Concerns
access points for parents to get free COVID testing and get a result right away so that kids go back to school or they go back to daycare. So last winter we saw, we're seeing over a hundred kids almost 150, I can't remember, but definitely 120 kids a day for months. And, you know, on top of boarding kids for the mental health and residential.
Health Chatter
Pediatric ER Concerns
And so we had to think outside the box on ways that we can safely manage these kids, treat them appropriately, resuscitate appropriately, and then either admit them or send them home. You have 120 kids on average a day. In a 12-day unit.
Health Chatter
Pediatric ER Concerns
And how many physicians? We upstaffed our group. So we have almost two physicians for about 18 hours a day, sometimes even three. Okay. To four. Just so that we continue to need to move patients and make sure they're safe before they go home or need to get admitted.
Health Chatter
Pediatric ER Concerns
Yeah. We typically have, back in the day when this really hit us hard, we were always short nurses, but in general, in the evening time, I'd say we'd have four to five nurses. Okay. With three to four docs. Yeah. But we have to kind of keep in the back of our mind of the boarders and the EDs. They are also in our patient population that we have to take care of.
Health Chatter
Pediatric ER Concerns
So we were pretty thin on ratios, right? You always talk about nurse ratios to patient ratios. At times, and I'm sure it was across the Twin Cities where I'd have one ED nurse taking care of six to seven kids. And I'd have, and the doc ratio was, you know, especially on the overnights was one doc with maybe 15, 20 patients. So it was, we were stretched really, really thin.
Health Chatter
Pediatric ER Concerns
We were certainly seeing sicker kids because they didn't want to show up I think parents are waiting to see if their kids will get better or not. You're delaying coming in. There's also a combination of parents just want the parents to trigger too fast. It's like the old expression of bioterrorism. You may not have been exposed to the gas, but you want to be evaluated.
Health Chatter
Pediatric ER Concerns
So when you see kids in ED, how long have you had your fever? An hour.
Health Chatter
Pediatric ER Concerns
So yeah, definitely as spring, as the weather clears up and it's dry outside, we'll start seeing an uptick in lacerations because kids are tripping and falling more outside. And then you'll see an uptick in factors, risk factors, femur factors. And then there's a combination of the kids riding ATVs.
Health Chatter
Pediatric ER Concerns
whoo-hoo fashion burn um so definitely trauma is an uptick during summer yeah trauma broken ankles twisted ankles uh stubbed toes fish hook accidents we see fish hooks yeah we see those yeah you know um sports related injuries during the summer heat related injuries um yeah
Health Chatter
Pediatric ER Concerns
So for the most of us, and I can probably speak to all emergency medicine doctors, is that you always have to keep your radar on common things presenting uncommonly. So if you have a kid who's wheezing, Is it just from a virus? Is it just from asthma? And in this, we just recently saw someone who was billed as a, what we call bronchiolitis.
Health Chatter
Pediatric ER Concerns
So a virus is causing wheezing and the child ended up having heart failure. Huge heart on x-ray. It was missed initially. And so we always teach our residents to anticipate what you're going to look for, but also keep your radar on for weird things that we may see. We've seen kids who we think may have a skin abscess, and you've probably seen these videos, there's actually a bot fly. Wow.
Health Chatter
Pediatric ER Concerns
There's a bot fly because they were in a country that was endemic with bot flies. But again, Stan, that's what makes our job kind of fun.
Health Chatter
Pediatric ER Concerns
Very similar type of thing. We are a little more sensitive. I think any children's hospital is very sensitive to child abuse because that's something they're going to miss. And so we have criteria on certain age of presentation of injuries. So... You know, a three-month-old who presents with a femur fracture is child abuse until proven otherwise because they're not on a trampoline. Right, right.
Health Chatter
Pediatric ER Concerns
And so it depends. It's age-dependent. But for the most part, we will discuss any suspicious injury with our child abuse team. And our child abuse team is probably one of the best in the country. We have this physician named Nancy Harper, who's an internationally known child abuse expert. She set up protocols throughout the whole mHealth system to screen for kids for child abuse.
Health Chatter
Pediatric ER Concerns
And so she's, you know, using evidence-based medicine and quality improvement projects. You know, so if I have a one-month-old who's got a bruise on the forehead, that doesn't make any sense because how do you bruise your forehead? You know, how do you tear your frenulum on your lip? They can't do that.
Health Chatter
Pediatric ER Concerns
And so we're pretty diligent, especially kids less than six months of age, looking for markers for abuse.
Health Chatter
Pediatric ER Concerns
Yeah. Obviously, any kid who has an intracranial bleed or a skull fracture, we're always talking to the child abuse team to see how should we manage these kids.
Health Chatter
Pediatric ER Concerns
So we, we always screen kids who have mental health conditions who are being evaluated for their mental health. And I would say a majority of those kids will test positive for, usually it's going to be marijuana. Sometimes it's amphetamines. Yeah. And then we'll see kids who are actually going through withdrawals from benzos or, or fentanyl and other narcotics.
Health Chatter
Pediatric ER Concerns
Um, firearms. Yeah. Um, it, it is, it is a problem that we're, you know, that we, we occasionally will see those kids in our emergency department, but our level of trauma status is level three. So if you got hit by a bullet, you're going to end up at probably Hennepin County. Okay. Um, but we do, we will see GSWs that walk into our door. Um,
Health Chatter
Pediatric ER Concerns
And it's funny because a lot of times they're actually, you know, they're older, they're adults who walk in our door with gunshot wounds. But for kids, it's, you know, we actually looked at our data throughout the mHealth system not too long ago, just in kids in general who were involved with some kind of gunshot wound.
Health Chatter
Pediatric ER Concerns
And again, the mHealth system are level three trauma centers, but I think we did a five-year review and I think there are about 30 kids.
Health Chatter
Pediatric ER Concerns
But these were probably kids who were not seriously injured. Yeah, but still a firearm injury nonetheless.
Health Chatter
Pediatric ER Concerns
Regardless of their insurance status, ethnicity, we will always see kids who walk in our door.
Health Chatter
Pediatric ER Concerns
Care is needed. And we'll figure out all the logistics later. We do figure it out later. And if they have to admit it with no insurance, we still admit them to the hospital.
Health Chatter
Pediatric ER Concerns
Yeah, I think parents need to know and families need to know and kids need to know that their expectations when they present to the emergency department with mental health crisis is that we will always take care of their kids the best of our ability to keep them safe. But because of limitation of space,
Health Chatter
Pediatric ER Concerns
We may need to board them in the hallways, at least for my facility, but they will be assessed by a mental health professional in a timely fashion as best we can. And this kind of goes out to the community for the people who are presenting to our emergency department with medical conditions that you will see patients sometimes in the hallways.
Health Chatter
Pediatric ER Concerns
And that's just the reality of where we're at right now. Versus if you present to a different hospital, it may take a long time to be seen because they put their mental health kids in rooms. which is, I think, amazing thing to do, but wherever you're gonna go, you're gonna deal with mental health conditions in any emergency department.
Health Chatter
Pediatric ER Concerns
You need to expect that hopefully it won't happen, but there may be violence in the emergency department. I don't wanna scare people away, but this is a reality of what we deal with every day.
Health Chatter
Pediatric ER Concerns
So thanks for having me, Stan. So yeah, there's two biggest issues that we're still enduring in the emergency departments. And these are the emergency departments in general, from our facility to other facilities in the Twin Cities and throughout the state, is the increased numbers of both mental health kids with suicide ideation, aggressive behavior, homicide ideation.
Health Chatter
Pediatric ER Concerns
And there's a subset of those kids who are our residential placement kids who also have these mental health, problems, but they are not deemed to be eligible for admission to mental health inpatient units. But either the foster parents or their parents can no longer care for them at their homes or facilities cannot care for these kids at home because they're now too violent.
Health Chatter
Pediatric ER Concerns
And so they come to our emergency department And just for safety issues, we just can't discharge them. So they board in the emergency department. So both mental health kids who don't have an admission just yet to go to inpatient facilities and the residential placement kids, are also boarding our ER for placement. So those are the two biggest issues right now.
Health Chatter
Pediatric ER Concerns
It's relatively new for... from the impact of COVID. And it's a multifactorial issue and it affected everyone across the country. I have medical director colleagues throughout the country and we all have the same problems in varying degrees. And if you recall, when COVID hit, there was the, what was it called? I can't remember specifically, it was called where you couldn't go to work, right?
Health Chatter
Pediatric ER Concerns
Locked to lockdown. And the lockdown affected everyone, right? Not only small businesses, but hospitals. And I've been thinking about this a lot last night. Matter of fact, I probably didn't get much sleep last night about the whole frequency, the timetable. So when COVID hit, there was a lockdown and a lot of things that would generate money or productivity for the hospitals went to zero.
Health Chatter
Pediatric ER Concerns
The ORs closed, inpatient units closed, critical care units closed. And so when you lose money, you have to start laying off people. And you lay off people, And then all of a sudden the lockdown ends and then a combination of being locked down and virtual school and social media, we saw a huge spike in mental health kids that we've never seen before.
Health Chatter
Pediatric ER Concerns
In our emergency department, we used to, in fact, my emergency department was never meant to, as well as most emergency departments, we are never meant to manage mental health kids at this volume. Literally, instead of one a day, we're seeing 15, 18 mental health evaluations a day.
Health Chatter
Pediatric ER Concerns
And that just burdened the whole system because with the influx and the rise of mental health kids, now there's a problem of inpatient bed units. And we have to remember that when COVID hit, a lot of the inpatient units basically closed down for a while and they lost consciousness. And now we have a problem of trying to hire physicians, nurses, mental health techs back into the unit.
Health Chatter
Pediatric ER Concerns
And they're having problems filling those beds, filling those units with the proper number of people. So then you got a backlog of everything. They can only take, only half the unit was full and they couldn't take any more until they hired more people. And we don't have space, then you start boarding the ED.
Health Chatter
Pediatric ER Concerns
Is that correct? Right. And you're absolutely right. Emergency departments were never meant to manage mental health in a sense that to make the patient safe and then go home. We deal with acute problems, chest pain, burns, we manage them, we stabilize them, and then we transfer it to the inpatient units. And fairly, and most of the time within a timely fashion.
Health Chatter
Pediatric ER Concerns
With mental health, the issue is we can acutely manage the mental health crisis with mental health assessors and whatever else we need to calm the patient down, we keep them safe. And then our mental health assessors will evaluate the child and then they'll say, okay, yeah, this patient needs to be admitted, but we have no beds.
Health Chatter
Pediatric ER Concerns
And now we're stuck because we don't have the resources to continually to continue the treatment of mental health in the emergency department. And that's the biggest issues.
Health Chatter
Pediatric ER Concerns
In the beginning of the influx of mental health kids, we'd have, I think it's across the board, all the hospitals, we'd have 12 kids who were unsafe to go home and they were boarding the emergency department, but they weren't getting therapy.
Health Chatter
Pediatric ER Concerns
They would sit in the ED for how many days it takes to get a bed in some inpatient unit somewhere in the state of Minnesota, sometimes in Wisconsin, sometimes in the Dakotas. And, you know, five days of just us watching them, make sure they don't hurt themselves or harm other people. It puts a burden to the emergency department.
Health Chatter
Pediatric ER Concerns
But again, we're not, we're not, we've never had training in this before.
Health Chatter
Pediatric ER Concerns
Yeah, and that's, so you both, thank you for bringing that up. And it comes back to my training. I was never trained to manage acute crises of mental health, in a sense, right? How to decompress these kids, how to calm them down. What medications can you use to calm them down? And then, the addiction problem really started to arise, started to increase in the prevalence of kids with mental health.
Health Chatter
Pediatric ER Concerns
So we're not only dealing with kids with withdrawals from fentanyl, but a lot of mental health kids have substance abuse. And most mental health inpatient units have two separate units. There's one unit that just takes care of pure mental health issues, suicide or aggressive behavior. And then there's the suicide kids or aggressive behavior kids who are on drugs.
Health Chatter
Pediatric ER Concerns
And the problem is, is that there's such a huge number of kids with mental health disorders who are using substances that those beds are always full. And so we'd have kids in our emergency department who have suicidal ideology, who are chronically using marijuana or chronically using alcohol. And those kids need a special unit, not just a regular unit.
Health Chatter
Pediatric ER Concerns
Especially, well, yeah. I mean, it comes down to there's just not enough beds in the state of Minnesota for inpatient treatment centers, right? It's a limitation of the bed space.
Health Chatter
Pediatric ER Concerns
But even that, we were still having issues because the length of treatment it takes for inpatient kids, inpatient mental health unit kids who have substance abuse on top of their behavior kids, they may take longer to be at a point to go home or to go to a residential placement. And so this is backlogged still.
Health Chatter
Pediatric ER Concerns
I think, you know, so we have mental health assessors at the University of Minnesota, which they're very good at what they do. But, you know, when you talk to them, Especially in the beginning, you'd have only a few assessors to try to evaluate 10, 15 kids. And they can't work 24-7 because they're getting burnt out too. And where our facility is at is on the West Bank.
Health Chatter
Pediatric ER Concerns
They not only assess the adults, but they assess the kids. So the adult side has a plethora of mental health people too because they're dealing with their influx. You remember that in the beginning of when our emergency department opened up, we used to just walk the mental health kids straight across to the West Bank because they have all the specialty folks over there.
Health Chatter
Pediatric ER Concerns
But now they're so full that my unit, my emergency department had to flex and manage these mental health kids. And it's for the safety of the kids because now we're seeing kids as young as five or six years old who are aggressive. And the parents don't feel safe with these kids at home.
Health Chatter
Pediatric ER Concerns
And you can't put a five-year-old on the adult mental health, you know, and the West Bank ED is just not safe for those kids over there. So we tend to take kids 12 and younger. And then if the adult ED is too full, then we'll see older kids up to 18 with mental health stuff.
Health Chatter
Pediatric ER Concerns
What's the average amount of time? So in the beginning of the surge of mental health, and we're talking just pure mental health, it was anywhere between three to seven days. And we may have five to seven kids in the emergency department boarding. And over the two years or so, we've developed more processes to move these kids out of my ED and move them to the West Bank or to get them...