Do you work in a barn?

As they say, first impressions are lasting. Most will attest to the fact that customer services can be the most pleasant and helpful or abrasive and frustrating experiences known to man. There is usually little gray area. From the employee perspective, either you enjoy what you do, what you provide and respect customers or you don't and won't attend to their needs because you can't keep your eyes off the clock.

Most of us know how to behave when we get poor customer service - we ask for a manager, file a grievance, get loud or give back what we received. Those who are vulnerable and have difficulty managing themselves,their families or their immediate situations do not have the knowledge, energy or ability to advocate for themselves and end up being steamrolled by the very systems established to help -iatrogenic care.

As an intake worker for four non-profits, three for-profits and one governmental agency and, of these, three community mental health agencies, three hospitals, one addiction treatment center and a county probation department - front-end service delivery winds up dead last in importance. Without exception, it is most poorly run, underutilized, understaffed, exploited and inadequately funded department found in organizations. The reasons are many and simple - intake functions do not fit neatly into clinical, administrative or financial domains and do not consistently produce billable activity that can be pored over or bean counted. Not recognizing its value is akin to leaving your front door open because it doesn't wash your clothes, chill or heat your food, entertain your guests or feed your family. But a good, solid front door helps with heating and cooling expenses and provides some measure of privacy and security, not to mention a host of other supports.

I have spent my entire career advocating for greater support for front line workers in mental health settings and have been largely ignored. A few years ago, a group of university professors at the University of Wisconsin-Madison got a clue and established the Network for the Improvement of Addiction Treatment (NIATx) to reduce waiting times and no-shows while increasing admissions and treatment retention. Organizations and providers would do well to check out the great work they have been doing with applying process improvement to the helping profession and utilizing proven solutions to identified challenges.

Now, go show your front door some love. Unless you've decided you didn't need it after all.

What Doesn't Kill You Makes You ... Injured.

Each of us is scarred in some form or fashion. Me, I kind of pick at my wounds daily to open up the old wounds and remind myself how I made it this far. Don't get me wrong, I am not miserable. In fact, far from it. I realize that things are not as they seem. It just gets hard convincing others that there is more to life than pushing things off your lap on to another's plate.

Healthy doses of fantasy keeps me sane. Reading and daydreaming help me to manage insane tasks in an insane world. And I can thank my parents for recognizing the benefits of interactive media.

As a shy child, I preferred books, video gaming and computers to social outings. Interactive media, as opposed to non-interactive media like books, movies, music and the like, gave me opportunities to go where I've never been, do what seemed impossible and create in limitless ways. I still have fond memories of the political intrigue in Spycraft and CyberJudas, time travel in Millenia: Altered Destinies, dungeon adventuring in Darkstone and the car combat of Interstate '76.

That was so long ago and the platforms, technology and sophistication of interactive media is now so impressive and affordable. And I understand some of the concern about the objectionable content that appears in a lot of interactive media products.

But, in the grand scheme of things, I would much rather for my child to be using interactive media at home, school or in the community, with friends or responsible adults, in a safe setting rather than hanging out on the sidewalk attracting lead mosquitoes. Drive-bys would be more challenging if there is no one to shoot at.

What we need are community centers, arcades and recreational venues for children and adults to play, learn and have fun sponsored by corporation dollars. If families have opportunties to use interactive media and want products for their home, they should be able to purchase them as subsidized or for a sliding scale. Anything we can do to encourage adults to spend fun and quality time with children should be encouraged, rewarded and subsidized.

Not only will killings, maimings and interrupted futures be reduced, but families will experience realities beyond their neighborhoods, doorsteps and their own noses.

Retrospect

As many of us mourn the loss of one of the greatest entertainers ever, I can't help but realize that I have some Michael Jackson in me and, probably, always will. I came to this realization after viewing a 360 panoramic view of his arcade room at the Neverland Ranch. I saw the X-Men game, Jurassic Park: Lost World, Terminator and gobs of Star Wars memorabilia. It was after I saw the poster of the Marvel Universe when it hit me like a sack of Sacajaweas.

Michael was not the picture of mental wellness and, in fact, seemed to have a tenuous grasp on this earthly plane with ordinary mortals. He was a genius, but a scarred and flawed genius nonetheless. He had a painful upbringing and did his best to recapture what he felt was lost - his innocence, naivety and sense of wonder. But he did his best to remain a child.

I, too, had a difficult childhood, for different reasons. Being bullied leave scars that stay with you long after abusers have ceased their terror campaigns. I have decided that I will remain childlike because living as an adult ain't all that. Sure, I realize that I need to take care of my family, contribute to my community and pay my taxes but these responsibilities do not preclude, gut-laughing whenever I can, playing after a job well done, singing off-key and not caring who hears and dreaming of adding value to the world.

Thanks, Michael, a job well done.

Tragedy and closure continued

The more I read, the angrier I get about how far people will go to protect their jobs and the BS they will feed others in order to do so. This family will never after closure after burying their ten year old shining star but the least that the school district and the police can provide to them is the truth.

Reports now say that he did not tell a school official about his thoughts of suicide but told one or more other students. Could one of these students been one who was suspected of bullying him?

Listening to the 911 calls, I noted that he was found in a third floor boys bathroom. If I was an angry, unstable, troubled and impulsive pre-teen boy, I would probably stab myself with a pencil or throw myself down the stairs or off the railing before I would hang myself from a hook in the bathroom until I bled from my nose. And why did the medical examiner not mention this as well in the report?

As hard as they may try, this will not go away under a pile of rapidly shifted papers. I was always told by my elders, the more lies you tell, the more you have to tell and the more you have to keep up with. Look at Illinois politics and you'd have to agree.

Tragedy and closure

OK, so I'm trying to teach my fifth grade students and one boy is giving me a hard time. I scold him, he gets upset and says he going to kill himself. I send him to his gym class. The next thing I know, he is found dead hanging in the boy's bathroom.

OK, so I'm the police officer called to the scene where the boy was found. I'm taking statements, I'm looking at the torn clothing from where the boy hung from a hook in the stall and a footprint on the toilet seat. I give my information to the medical examiner who determines that the boy committed suicide. Case closed.

Looks like a few juicy bits for the next blockbuster detective series, doesn't it? Only thing is that this really happened, in a suburb of Chicago, in the first part of 2009. And, although the information is factual, the explanations are most likely fictional.

OK, so the teacher has been placed on administrative leave. Probably because he/she  did not follow proper procedures and, basically, they need someone to burn at the stake. But let's look at what really happened, thoughtlessly or not.

Most people who find an unresponsive person and do not panic, will attempt to render lifesaving measures such as checking, pulse, respiration and rending CPR. They will not think about the fact that they may be compromising a crime scene and destroying evidence.

Other people who have responsibilities for supervising and monitoring children will immediately go into CYA mode - "I just turned my head for a second," "He said he'll be right back," or "I was attending to a more urgent matter."

How about the commonly held ideas about suicide such as a person will make several statements and even attempts before they successfully kill themselves, they will choose a location where they will, more than likely, not be found until it is too late, they will attempt less painful methods first and they may have had a plan and let someone else know.

Or even the school's responsibility to respond to a crisis. If anyone says they will kill themselves, act like it. Call an emergency contact person, place them in a secure location with constant line-of-sight monitoring, engage the emergency response plan that is in place.

A tragedy such as this creates many more questions than answers? Why were officials so quick to determine that this young boy killed himself? Because it is easier. Easy for the police because they can close their investigation. Easier for the school because they can chalk it up as another troubled kid from an unconcerned family. But there is nothing easy about sending your child to school in the morning and identifying his body that evening because of gross negligence.

Other thoughts to consider, most ten year old boys are not impulsive enough to decide to kill themselves while in line for gym class, not inventive enough to think of the hook in the bathroom stall, not strong nor agile enough to lift their weight on to the hook and not resolute enough to stay on the hook until they pass away.

The family said that he had plans for the future, was a happy child and got along well with others, all contra-indicators for suicidal behaviors. They did report that he was being bullied at school which is not difficult to believe. All school districts have policies against bullying but most do not follow them, at least most of the ones that I have worked with. Many children in psychiatric crisis at school have been provoked by bullies and we end up addressing the symptoms and not the source.

If he had said he would kill himself, where was it documented? Teachers know to keep anecdotal records, especially for students with behavior learning challenges and parents who want proof of their child's disruptive behavior. Why was he not held in the classroom or taken to someone's office for constant monitoring and observation? Did someone call his parent about what he said? Unfortunately, they may have waited and called to say what he did.

Heal thyself, o helper of others

I did not realize how difficult it is to maintain an online blog. I have traditionally only been able to pump out the text when depressed or ached, don't like to talk just to hear the sound of my own words as I think I sound kind of nasally and don't like to blahblahblahblog. My goal has always been to inspire, educate and minimally inform. By the way, did you know that women on their monthly cycle can have a positive lab result for urinary tract infection? Unfortunately, I learned it this past weekend attempting to transfer a young adult to a psychiatric bed. After eighty and a half hours and fourteen hospitals refusing, it was done and her mother called to say how she appreciated the work I had done.

I should be asleep, one, because I'm exhausted and two, it's four in the morning. But after rolling around so much and realizing that I didn't want to disturb my wife, I figured it'd be a good time to put my finger down my creative throat and spit out whatever I have trouble keeping down.

It has been a difficult start to the ninth year of 2000. I have a good friend rehabbing his broken bones after arguing with a slippery sidewalk and losing and another friend who just lost his father in a horrible fire and is supporting his mother who dealing with being unable to save him. I pray that things this year will not be a syndication of 2008 as it was not a good year for many. I lost a niece and a cherished cat but gained a brother. And I believe that I have learned not to question as things unfold that I may think are unfair or unjust. And I know that all things will be revealed in the end. But, sometimes, faith can be a little slippery in my season of discontent.

I now pronounce you ... medically cleared.

Emergency room (ER) staff hold a special fondness for psychiatric patients. Overt psychosis, statements to kill self or others, inability to care for one basic needs or imminent risk do not classify as serious enough to be treated before minor physical maladies. And, even though mentally ill patients do not appear to be in distress, they require the same basic diagnostic procedures as all other patients.What does it mean to be "medically cleared?"

• I screened a "medically cleared" 10 year old on stimulant medications in an ER and recommended transfer to a freestanding psychiatric hospital. When the receiving hospital asked for the patient's results from the lab screens, they were informed that no lab tests were done.
• A few days ago, a crisis worker met with a "medically cleared" young adult who ingested 25 to 30 ibuprofen tablets a few hours before presenting to the ER. Fifteen minutes into the screening, the patient began vomiting uncontrollably and asked that the interview end because she was in too much discomfort.
• An adolescent patient "medically cleared" from an ER vomited eight times in route to a freestanding psychiatric facility. He arrived dehydrated and was sent to another emergency room and medically admitted to a telemetry unit for two days.
• I have been asked to assess "medically cleared" patients from pediatric intensive care units (PICU) prior to transfer and admission to other psychiatric hospitals. The most recent lab results were from tests taken 2 days prior to the request for assessment.

Medically clearing a patient is largely based on where the patient will be in the next few days and what supports will be immediately available during that time. Most hospitals require basic lab  screens including blood alcohol level (BAL) and drug for adolescents and adults, pregnancy screens for females and others tests to address a patient's history of diabetes, hypertension or other chronic illnesses. In cases of drug ingestion, a period of 48 hours observation on a medical unit is required prior to transfer. Intoxicated patients cannot be interviewed until their BAL is below 100 as they are medically compromised and may be hallucinating, delusional, aggressive, suicidal or homicidal because of an alcohol-induced acute episode. Patients with acute eating disorders frequently present not only as underweight but as dehydrated and fluid imbalances which may require monitoring on a telemetry or intensive care unit. Self-injury patients may present with wounds at risk for infection, inflammation or damage to major arteries, tendons or organs. 

The purpose of medical clearance is not for CYA; it is to increase the patient's chances in being able to successfully engage in the next level of prescribed care.