When the E.R. is the only option
With North Carolina's mental health treatment centers full, teens in crisis often spend days in emergency rooms
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Today, we are continuing with a series of articles in partnership with North Carolina Health News about North Carolina’s teen mental health crisis. Find out more about the series here.
More children are landing in the hospital with mental health emergencies. Three families share their real-life experiences of going to the E.R. for help; ‘It was just crushing’
Parents often take their teens who need immediate mental health care to Atrium Health’s behavioral health emergency room on Billingsley Road near Grier Heights. Others go to the E.R.s at children’s hospitals. North Carolina doesn’t have enough mental health providers, outpatient treatment programs and inpatient psychiatric facilities to treat all the kids who need help.
By Michelle Crouch
Co-published with N.C. Health News
Grace, 11, still has nightmares about the emergency room.
After she tried to take her own life in May, Grace spent three days at Atrium Health Brenner Children’s Hospital in Winston-Salem.
The other kids in the E.R. with her were mostly older, Grace said, and some were violent.
One repeatedly banged his fist into the wall. Another kept yelling the lyrics to ’90s rock songs. And a third boy had to be tranquilized after he tried to hit a security officer. The next day, Grace said, she watched a law enforcement officer lead him out of the hospital in shackles.
“I was terrified,” said Grace, who asked to use her middle name to protect her privacy. “You’re supposed to go there to get help, but it feels like you did something wrong. After a while, I thought I was really losing my mind.”
Chaotic E.R. not ideal for mental health
Since the pandemic, emergency departments in North Carolina and across the country have been overwhelmed by adolescents in crisis. Many end up stuck there for days or weeks waiting for a spot in an inpatient facility.
Although there is widespread agreement that a hospital E.R. is not an ideal place for a child in mental health distress, the state doesn’t have enough mental health providers, outpatient treatment programs and inpatient psychiatric facilities to treat all the kids who need help.
For parents worried they can’t keep their kids safe at home, that leaves the E.R.
“An E.R. is not conducive to someone in crisis. It’s a place that’s chaotic. It’s a place where a gunshot wound or laceration takes precedence over someone with a mental health diagnosis,” said Victor Armstrong, former director of mental health at the N.C. Department of Health and Human Services who is now at the American Foundation for Suicide Prevention.
He added: “If you have a child who goes into the emergency department and doesn’t meet the criteria for inpatient treatment, after they sit there for three days, they will probably meet the criteria because their behavior will deteriorate.”
Amanda McGough, a psychologist at Base Cognitive Behavioral Therapy in Charlotte, said some of her clients have PTSD simply from being in the E.R. [edited 9/6/23 to correct name of McGough’s practice]
“In the E.R., kids and adults can see some scary things: people screaming, people coming off a substance or physical aggression,” she said. “You can have a really unwell adolescent, screaming and psychotic. And then you have a child with anxiety who has had a fairly innocent life being exposed to these people.”
In an emailed statement, Atrium Health acknowledged an increase in such incidents in health care facilities across the country: “Too often, patients and visitors subject those around them to verbal and physical abuse — especially in emergency rooms.”
The hospital system noted the severe shortage of psychiatric beds, locally and statewide, and said it would continue to “implore the state to take immediate action and meet its obligation to these patients and their families.”
Doctors and nurses agree that the E.R. is not the best place to treat adolescents with mental health problems. In August, three national groups of emergency medicine providers released a joint statement noting that the number of children with mental health problems was overwhelming emergency departments nationwide.
The statement called on local communities to provide more mental health support and resources.
As the number of young patients with anxiety and depression grows, many are forced to spend time in emergency rooms while awaiting space in health facilities that are better suited to treat them.
Colleen Kochanek, executive director of the North Carolina College of Emergency Physicians, said emergency room doctors can stabilize kids in crisis and treat them medically, but they aren’t equipped to provide the next level of care.
“We’ve got to have places for kids to go and get treatment, whether it’s inpatient or outpatient,” she said. “If there are no services, you can’t send this poor kid who’s really struggling out into the community with no support.”
She said she sent letters to state legislators asking for more community-based mental health services.
“It’s a crisis,” she said. “The state has all this money right now, and we have kids sitting in the E.D. [emergency department] … It’s just unconscionable.”
For parents and for kids like Grace, going to the E.R. for a mental health crisis can be a frightening experience. There’s no “quick fix” for most mental health problems, like there is for a broken leg. And kids and their parents often feel ambushed by the extreme steps hospitals take to keep kids safe.
N.C. Health News/The Charlotte Ledger asked three families to share what it was like going to the E.R. for a mental health emergency.
To protect their privacy, the three families asked to be identified by pseudonyms. Together, they hope their stories can help other families who might face a similar ordeal and shed new light on a problem that health care providers say desperately needs more attention.
‘I woke up every day, and someone was sitting there, staring at me.’ — Ed, 17, of Charlotte
Ed spent 10 days in the E.R. observation unit at Atrium Health Levine Children’s Hospital in spring 2022 after his parents found a suicide note in his room.
For the first few days he was in the E.R., Ed was furious. Ed, who was 16 at the time, remembers cussing out his parents and feeling trapped.
“You’re in this tiny room, you have someone watching you at all times, you can’t even get up and go to the bathroom without asking,” he said. “On top of that, there’s no help. No therapy or anything. And nothing to do. Think about not seeing daylight for 10 days.”
The hospital staff took his phone, his clothes and the bracelet he was wearing. He said he had to wear grippy socks “like you wear at a trampoline park” (to reduce the risk of falls) and pine-green scrubs that marked him as a mental health patient.
Ed said his room had a glass door, a bed and a recliner where his parents could sleep. A small TV chained high on a wall provided his main source of entertainment. During his 10 days, Ed said he watched about 30 children’s movies.
Ed wasn’t allowed to interact with other teens in the unit, but he could hear some of them yelling. “One kid kept banging his head into the wall all night long,” Ed said. “I could hear it. It was really sad.”
A hospital “sitter” sat outside the room and monitored Ed at all times. “I woke up every day and someone was sitting there, staring at me,” he said. “I’d be lying in bed, and they were staring. It made it hard to sleep.”
Ed said the doctors and nurses were nice, and the antidepressant they prescribed helped him feel better. After his 10 days, his parents moved him to a residential program in Florida, where he spent 60 days getting the help he needed.
Ed, who is thriving now, said he wishes he could have gone straight to the Florida facility and skipped the time in the E.R., which was the “worst part of the whole experience.”
But he said he’s still thankful his parents took him there. “Honestly, I don't know if I would be here talking to you right now if my parents hadn’t found that (suicide) note and brought me to the E.R.,” he said. “They changed my life forever, and everything I have that’s good in my life now is thanks to that.”
‘You aren’t going to let me say goodbye to my child?’ — Michael’s mom
Michael, 14, of Charlotte, spent seven days in the Atrium Behavioral Health E.R. in Charlotte in 2021
Michael was already being treated for depression and anxiety when he woke his parents early one morning, saying he had a strong desire to end his life.
He was clearly in crisis, so his parents took him to the Atrium Behavioral Health E.R. in Charlotte, which specializes in psychiatric care, said Michael’s mom, Kimberly.
After they arrived and registered, a nurse in a triage room checked Michael’s vitals, asked some questions, and then said she was going to have him evaluated by a psychiatrist, Kimberly said. That’s usually the first step when children arrive at a hospital with a mental health condition — to talk to them privately to determine if they are a danger to themselves or others.
Kimberly remembers saying something like, “See you in a minute” to her son as the nurse led him away.
A short time later, the nurse returned and told them the psychiatrist had determined Michael needed inpatient treatment. Michael would stay in the E.R. until they found him a bed in a psychiatric facility, the nurse said.
Michael’s parents didn’t protest; they knew he needed help. But when they asked to go see Michael and give him a hug goodbye, the nurse said they couldn’t see him again, citing Covid restrictions. (At the time, vaccines were widely available, and school was back in session, Kimberly said.)
Kimberly couldn’t believe what she was hearing. “You aren’t going to let me say goodbye to my child?” Kimberly asked.
Kimberly and her husband were desperate to see their son. They begged. They said they didn’t want to sign the paperwork consenting to treatment unless they could see Michael first.
That’s when Kimberly learned the hospital didn’t need their consent. The nurse told her that bringing Michael home was no longer an option. And if Kimberly and her husband refused to sign the paperwork, the nurse said, the hospital could get the court system involved, and they could temporarily lose custody of their son.
What the nurse was referring to was a legal process called involuntary commitment, or IVC.
Not only would it force Michael into mental health treatment against his will, it would also take away their right as parents to make health decisions for him. (NC Health News reported in 2022 that the use of IVCs for mental health patients in North Carolina increased by 97% over a decade.)
Devastated, Kimberly and her husband felt like they had no choice but to sign the papers and leave. In the parking lot, overwhelmed with emotion, Kimberly collapsed onto the pavement.
“Knowing your kid is going through the hardest point of their life and you can’t see them, you can’t talk to them and look into their eyes, you can’t offer any comfort. And you don’t even know if anyone is doing those things. That powerlessness — it was just crushing,” Kimberly said.
(Atrium said Covid safety protocols were still in place in the fall of 2021, including visitor restrictions. Now, “in most cases, parents are able to interact with their child,” the hospital said. In response to a question about the hospital’s IVC policy, the hospital referred a reporter to state statutes. “Ultimately, for us, our goal is to ensure the safety and well-being of the patient,” the hospital said.)
During Michael’s time at Atrium Behavioral Health, his parents said they talked to him by phone or Zoom a few times, but he shared few details.
He told them he slept in a recliner in one big room with other teens who were sad or depressed. Violent patients were separated into a different room. (“Thank God,” Kimberly said.) During the day, Michael mostly played video games and card games with other patients. He also had group therapy and an hour outside in a courtyard each day.
After a week at Atrium Behavioral Health, his parents found him a bed in an out-of-state treatment facility that took their insurance. The program helped Michael recover, his parents said.
Today, almost two years later, they rarely discuss what happened. “He doesn’t like to talk about it,” Kimberly said. “He tells me that the whole period is just too hard to talk about.”
‘I was terrified I would end up back there.’ — Grace, 11, of Yadkinville
Grace spent three days in the E.R. at Atrium Health Brenner Children’s Hospital in Winston-Salem in May 2023 after a suicide attempt.
Grace, the 11-year-old who was upset about the violent patients, said she got to the E.R. about midnight. She remembers she kept falling asleep, and the nurses would have to wake her to answer their questions. The paper scrubs they gave her weren’t comfortable. “They crinkled,” she said.
Like Ed’s room in Charlotte, Grace’s room had a bed, a chair, a TV behind plexiglass and a recliner where her parents could sleep. Grace asked if her mom could bring her favorite star blanket, but the hospital staff said she couldn’t have any personal belongings. Her mom wasn’t even allowed to bring her own phone into the room.
Grace said the hospital provided a coloring tray with sheets and crayons labeled safe to ingest. One time, they gave her a puzzle she completed on the floor.
It was hard not being able to go outside or even to see sunlight through a window, Grace said: “At home I’m always outside. I’m a very nature-loving kid.”
To go to the bathroom, “you tell the nurse, and they take you back and they watch you while you go,” she said.
When she wanted to take a shower, a nurse and a security officer escorted her to a small bathroom. “The whole floor is a drain so you can’t drown yourself,” Grace said. “They let you close the door, but every now and then they open the door and check in on you.”
After Grace’s first day, the hospital staff told Grace’s mom, Audrey, that they found a bed for her in a psychiatric facility about six hours away. They said they were making plans to transfer her there. But when Audrey looked up the facility online, she saw articles about poor care, including an accusation of sexual assault.
“I was hysterical,” Audrey said. “I said, ‘My kid is not going there.’ They told me, ‘Look, we can have another meeting, but here’s the deal: She is going, and there’s nothing you can do to stop it.’ Like they didn't quite say it like that, but that's pretty much what they said. They had taken my rights, and I did not know it.”
Grace had already been involuntarily committed, Audrey said. She spent the next 24 hours calling everyone she knew in health care, asking for help to keep her daughter from being transferred.
Audrey didn’t share all of that with Grace, because she didn’t want to scare her. But she told Grace she might have to go to a psychiatric treatment center without her, and that the sheriff’s office would have to take her there in a van with other patients.
Grace said she remembered the conversation well, because “it was then that I just broke.
“I was crying. I was shaking. I didn’t know what to do,” Grace recalled. “I was mainly worried that I would be in the van with violent patients — like the kid who was punching walls and hit the officer. There was another girl who ran over to the front desk one time and tried to hit a nurse.”
In what Audrey believes was divine intervention, a nurse in Grace’s pediatrician’s office happened to know the hospital psychiatrist and reached out on her behalf. To Audrey’s relief, he said he could make room for Grace in the pediatric behavioral health unit upstairs at the hospital.
Grace spent four days in the unit, where she received daily therapy and the doctor figured out medications that helped her feel better.
Grace said she is grateful for the doctors who put her on the road to recovery, but she is still scarred from her time in the E.R.
“For a few weeks after I got home, I couldn’t shower alone,” she said. “I’d have to have someone sit in the bathroom with me. I don’t know why. I think I was just terrified I would end up back there.”
Michelle Crouch covers health care. Reach her at mcrouch@northcarolinahealthnews.org.
This article is part of a partnership between The Ledger and North Carolina Health News to produce original health care reporting focused on the Charlotte area. We make these articles available free to all. For more information, or to support this effort with a tax-free gift, click here.
➡️ Have a teen who is severely depressed, anxious or experiencing another mental health condition? See our list of youth mental health resources for kids in crisis.
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‘The Kids Are Not Alright’ series on teen mental health, from The Charlotte Ledger and N.C. Health News
TODAY: North Carolina emergency rooms are being overwhelmed by adolescents in crisis
COMING THURSDAY: Colleges are focusing on mental health as students return
COMING FRIDAY: Mental health providers are launching programs to help fill the gaps in care — and hoping for help from the county and state
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In brief:
Bar owners’ suit: A split state court of appeals panel ruled 2-1 that North Carolina bar owners can proceed with their lawsuit challenging Gov. Roy Cooper’s decision to shut down bars during the pandemic in 2020. A three-judge trial court panel will now consider whether the state Emergency Management Act that Cooper used was unconstitutional. (Carolina Journal)
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Murdaugh case continues? Alex Murdaugh’s attorneys are calling for a new trial after they say the court clerk told the jury not to trust Murdaugh’s testimony and pressured the jury to come to a verdict quickly. Murdaugh is serving life without parole after being convicted of shooting and killing his wife and son. (WSOC)
Trauma kits for teachers: Charlotte-Mecklenburg Schools teachers were given trauma kits last week to treat students during active school shootings or other violent events. The 11,000 Go Bags contained emergency survival items like bandages, gauze, a tourniquet, glass breaking tool and rope. (Observer)
Pickleball mania: Mecklenburg County operates 49 pickleball courts and has plans to add up to 55 more. The county declined to say how much it has spent on pickleball courts, and how many of them are new vs. being converted from tennis courts. (Axios Charlotte)
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