This morning marked the first shift that Linda Berwick ought to be working but wouldn’t be. No one mentioned her absence or made any remark to me. Karen was my partner today and I went about my business reviewing the notes and assessing the single person held over in the department while Karen began the process of telephoning the folks that Tom had seen over the weekend and sent home to wait for our follow up calls. The young man waiting for assessment was a young guy, twenty-nine years old, named Rick Morris. He was apparently in a fight yesterday and made threats against his ex-girlfriend and himself. He looked a little worse for wear. His clothes could use a wash and his hair hadn’t seen a comb in a while. A shiner was well established under his left eye. “Did you win or lose?” I opened.
His glare suggested the latter. “Sorry. I shouldn’t have joked.” I attempted to recover. “Hi Rick. My name is Hattie Crawford. I’m one of the crisis workers on duty today.”
“I’m ready to go home.” The glare persisted.
“Hmmm. First, we need to know that sending you home is the best plan. I understand you were making threats to hurt other people as well as yourself. The notes suggest you were in a fracas and made some threats. The police brought you here. Can you tell me a bit more about what’s been going on?”
He turned away dismissively. I let it sit for a long minute. “Its kind of a light morning here.” I mused, taking a bit of a risk. “I can sit here and wait, or I can come back in half an hour…either way, your departure relies on my assessment. Do you have a preference?”
Nothing. “OK. I’ll be back.” At the care desk I asked Kim, one of the nurses, about Rick.
“He has been cooperative all night. Just laying there. The head-injury-routine shows no outstanding neurological issues. We haven’t been able to get much out of him but what he says is generally coherent and oriented.”
“Who’s the duty doc?”
“Dr. Burton was here all night. I think he’s still in the back room. Dr. Marshall is coming on duty.”
“What do you think is going on with our friend Rick? I asked Kim.
“Honestly, I don’t know. I’m good at assessing if he has a head injury but I’m not the best judge of his…of what’s going on inside his head.”
“Do you know if Dr. Burton did the Form 1?” A Form 1 was an application for psychiatric assessment, which meant a person could be held, more or less, until a psychiatrist either said they were okay for discharge or decided they needed further involuntary care. Because we have our own mental health unit and psychiatrists on staff, our emerg didn’t need to send folks along to the psychiatric hospital the way some smaller hospitals did but that still didn’t mean that it was always so easy to get a psychiatric assessment on someone in emerge.
Before I tracked down the duty doc, I decided to take one more run at Mr. Morris. “Hi again Rick. It’s Hattie.” I started again. “I know you want to go home and I want that for you too but I just need to understand a little more about what happened yesterday.”
When Rick rolled toward me, his demeanor was different. The edge was gone. “Listen, this is hard for me. I can’t really tell you what happened because I was drunk. My girlfriend walked out last week and I found out one of my so-called buddies was banging her.” I tried to stay focused on his words. “I called him up and when he came over I punched him in the face.”
“…and he punched you back….” I ventured.
“And he punched me back.”
“Strange as it seems, I understand that part.” Start where he is. “It sounds like a bit more went on though. Otherwise, I think you would be somewhere other than a hospital…”
“I told you I don’t remember.” The edge had returned.
Time to backtrack. “The police officer who brought you in agreed you’d been drinking. I’m not sure he knew you were so drunk you wouldn’t remember what happened. But he told the doctor that you said you would ‘take her out’ which the doctor assumed was your girlfriend and ‘take out myself’ which he expects is you.” He sat up abruptly and I took a quick step back away from the bed.
My reaction caught his attention and he presented a more reasonable nature. “Listen, this is all blown up. I’m not taking anyone out. I was drunk and I said some stupid things. Now get me out of here!”
“Before we go there, I need you to bear with me while I ask you a bit of history.” Rick Morris was not warming my heart this Monday morning. His clipped answers did not establish obvious evidence of suicidality but did reveal a pretty high index for aggression. He casually noted two short hitches in jail for assault. He denied partner abuse, despite acknowledging he had been ordered to a treatment program typically intended for men who abuse the women in their lives. I didn’t have a good feeling about this guy. “Okay Rick. Thanks for helping me out with this info. Dr. Burton was the physician you met last night. He still might be here but if he’s not, I’ll share what you’ve told me with Dr. Marshall and he’ll come and see you.
I found Larry Marshall gnawing on a bagel in the room behind the care desk, listening to Mickey Burton describe the events of last evening, specifically the patient with a “nasty” GI bleed that he sent off to Kempenfelt for emergency surgery. “Hattie.” Mickey interrupted himself. “…Did you see that guy yet?”
“Rick Morris.” I reminded him. “Yup. Just finished. I don’t have much more than you though.” I turned to include Larry, the on-coming duty doc. “Did you know he has a history of assault and incarceration? He says he never abused his girlfriend but he said he was ordered into the PPA program…” I answered Larry’s question before he asked. “Preventing Partner Abuse. It’s usually a court ordered program for guys who are violent and abusive to their girlfriends.”
“Suicidal?” Larry queried.
“He wasn’t a compliant candidate with the standard assessment but I don’t have that impression.”
“Homicidal” Larry countered
“Angry, aggressive and historically violent. But I don’t get the impression he is homicidal at the moment.” Which was just my opinion. “We do have a protocol to follow when we feel a woman is at risk from a partner though….I just need to pull it up.”
“Well, Larry…I gotta get going now…” Mickey slunk toward the exit.
“Stop right there, Pal!” And Mickey did.
“You’ve been at this longer than me. What are my options here?” Larry asked.
Mickey described the option of a Form 1; essentially relying on a psychiatric opinion regarding the guys risk of harm to himself or others. If that risk was present, it was possible to restrict a person’s liberties. “But there is one other option, based on Hattie’s information.” Now I was curious too.”
“I only know this because we did it last week in the city.” Mickey Burton worked part-time relief as an on-call physician at St Germaine Hospital in Toronto so he saw situations that were more exaggerated to our typical fare. “Call the police and see what the charges are. Depending on their answer, they could request a forensic assessment. I think we would just need to confirm that he is not suicidal, then they would keep him until a judge ordered transfer to the locked unit over at Carter North. Hattie, tell us more about this protocol…”
We re-read the protocol I had pulled up on the computer screen. I was clear that in a situation where we as care providers were aware that a woman was at risk for violence from her partner, we must engage police and notify the potential victim. Even though the police were already engaged, technically, we all agreed we needed more in-depth consultation with them. After that, we would connect with the potential victim, the ex-girlfriend. The discussion worked its way around to a psychiatric assessment first, which I agreed to facilitate. Since knowing how the police wanted to proceed might affect the outcome of the psychiatric assessment, Larry checked in with the police first to determine their thoughts on the matter.
I also advised Larry that the policy was clear that now that he was on duty he was the most-responsible-physician, or MRP, so he was the one to call Rick’s ex-girlfriend and warn her, unless Mickey was prepared to stay and do so. We both leveled a glace at Mickey who shrugged off his coat and sat back down. Again, it might be helpful to talk with her and hear more about the incident than we seem likely to get from Rick before the psychiatrist conducted his or her assessment. I suggested he give the woman our crisis number as well as the number of the local shelter and let her know I was here all day, so if she wanted to call she could ask for me.
Larry thought the charge might be “uttering threats’ based on Rick’s history. Then, based on where the two points of legal and mental health interest collided, we would mobilize resources to consider specific risk assessments. Mickey finished his calls, reported back to us that the girlfriend already knew what was up. She reiterated what the record already showed. Rick showed up at her place, punched her new boyfriend and said he would ‘take out’ her and himself. She now had Hattie’s contact number and the police had already given her information about the local women’s’ shelter. She seemed ok for now. Then Mickey made hay.