Psychiatric Social Work in the ER by Candy Elson, LCSW

As some of you know, I work in a local emergency room as a “psychiatric liaison” a couple of week-ends a month and sometimes I get called in for four hours of an evening is someone calls in sick and they need coverage. You never know what to expect and it is amazing the number of mental health, substance use, and psychosocial problems that lead people to the emergency room. At a glance down the list of chief complaints in the electronic health record – suicidal – gravely disabled, panic attack, assaultive, 5150 (involuntary commitment), are as frequent as the medical issues – nose bleed, vomiting, gun shot, miscarriage, flu symptoms, bleeding, back pain, prescription refill etc.

At this emergency room there is the “psych liaison” role who deals exclusively with psychiatric referrals and a “social worker” who deals with every other psycho-social issue – homelessness, substance misuse, child and elder abuse, grief counselling, discharge planning etc. When a case over-laps, we collaborate.

This ER is among busiest 5% in the nation so it is always busy.

This blog represents one four hour period on a recent evening. I walked in to a bunch of assessments. (All identifying information has been changed on all patients to protect their confidentiality) First of all I get organized and prioritize by checking the change of shift report,  patients’ chief complaint, how long a patient has been in the ER, is the patient medically cleared, the drug screen, insurance status , our bed availability, do we have any history on this patient from previous visits.   I then proceed to the ER to do my rounds.

That night there was a 96-year-old Hispanic male, with a diagnosis of dementia, brought in from a nursing home after punching another resident and ejecting him from his wheel chair.  Two teenagers – an 11-year-old Caucasian boy who had assaulted his mother, siblings and the cat and a 16-year-old who had taken an overdose at school. The records on the 11-year-old were extensive and indicated he had a history of abuse and neglect in his biological home from age 0 to 3 years.  A 27-year-old African American male who was grossly psychotic. He was brought in by sheriffs on a 5150 – he was gesturing in the air, talking to unseen others and chanting quietly to himself. A 35-year-old Hispanic woman, also diagnosed with schizophrenia, who was virtually catatonic. Her parents had called 911 when she had walked into traffic arms raised, responding to a “vision”.  Lastly, a 56-year-old homeless female, addicted to heroin who was suicidal.

My task and “lens” are very focused and there are 3 possible outcomes after my initial assessment – admit to the psychiatric unit – discharge – or re-assess after medication or when the patient is no longer intoxicated on alcohol or any other substance.

The pace is fast – my engagement, assessment, intervention, termination and evaluation are condensed into a 15-20 minute period. Clear communication with the multi-disciplinary team is important – the ER doctor, psychiatrist on call, nurse taking care of the patient are all involved.  Writing up your notes in the electronic record before you leave is vital.  The cell phone is constantly ringing and you need to keep 100% focused on task, or you are going to sink into “overload”.

I enjoy what I do. You manage to do a little bit of good, most days, although you realize you are placing a band aid on a gaping wound much of the time. You have to have good boundaries and understand that what you can achieve, is often very limited. There are many gaps in the mental health system of care and the safety net for meeting people’s basic needs is a long way down. The emergency room is often the point of call for people in crisis.

If I had a wish list- and could “Change the World”, with my magic wand, I would wish that parenting classes, substance abuse prevention and treatment, accessible mental health care, relationship skill building, (to prevent domestic violence) affordable housing, food, clothing, shelter and employment were available to everyone!

I am glad we are training 200 MSW’s and 110 BSW’s who just graduated – society needs you!


Candy Elson LCSW is the Field Director for the School of Social Work: