'Nowhere else in Canada'
St. Paul's is unique in the country in having to serve a concentrated population of mentally ill, often addicted patients - 1,489 of them last year - often brought in by police
He's male, 20 to 25 years old, and psychotic. He may be talking to the walls, or screaming and pounding walls, or sitting quietly focused on the delusions swirling through his brain. Quite likely, he's addicted to crack, and possibly heroin and alcohol. If he's been smoking crystal meth, he may be raving, and dangerous. He may have HIV, and hepatitis C.
He's the typical psychiatric patient in the St. Paul's Hospital emergency department. And there are many, many of him.
"They can be paranoid. They can be hearing voices, seeing hallucinations. They're often very irritable and agitated. They can be threatening or violent," says Anna Nazif, director of emergency psychiatry at St. Paul's. "Our system is nonideal for psychiatric patients. We're basically always doing the best we can in less than ideal situations with less than ideal resources.
"We have a population that everyone agrees exists nowhere else in Canada."
Admissions of mentally ill patients at St. Paul's emergency have risen steadily, to 1,489 in 2011 from 813 in 2005.
Because the hospital serves the Downtown Eastside, people having psychotic episodes from mental illness, drugs or frequently both are often picked up by police then trans-ported to the hospital's emergency department.
There, a doctor may certify a patient as mentally ill, allowing two days' detention in hospital. Another 30 days can be added upon another physician assessment.
"You're taking a fundamental right away," Nazif says. "We don't take that lightly."
However, psychotic patients may pose a threat to them-selves, the public and emergency department staff.
"You don't ever want to get within reaching distance because you'll get assaulted," says psychiatric nurse Shirley Wingo, who has been attacked half-a-dozen times in her 11 years at St. Paul's. "The worst was when a lady tried to snap my neck. She grabbed the sides of my head and tried to snap it.
"You can't let your guard down in this type of work. If you show fear, they're going to try to use that against you. It's not unusual that patients, anti-socials, will threaten to kill you."
Emergency psychiatric staff work in a high-stakes environment where the wrong clinical decision can lead to tragedy. "You can't get cocky about it because you're dealing with people's lives," psychiatric nurse Mary Shervin says. "Nobody wants anyone to leave here and kill themself or some-one else."
Patients come from all walks of life, suffering from illnesses such as depression. Often, a desire for suicide, or attempts at it, are triggered by alcohol or drug abuse, Nazif says.
"No one's immune. I see West Van teenagers who come from great families, with lots of support, [who are] homeless and living in a park and using heroin."
Nazif, during a Province visit, was inside a "seclusion room" beside a paranoid schizophrenic crystal-meth addict. "I was probably taking a risk," Nazif says. "He didn't seem agitated, he didn't look drugged out. He was settled. I was thinking when I was there that he could just grab me."
Although treating mentally ill and addicted patients is difficult and dangerous, the St. Paul's doctors and nurses do the job because they want to, Nazif says. "At this hospital you have wonderful people who have chosen to work with this population, and who like the people," she says. "Mental illness and addictions are chronic illnesses, but they're treat-able. The stigma of mental illness starts with the underfunding of treating it."
Staff compassion only goes so far when the treatment facilities are insufficient, Nazif says. The main psychiatric-patient room in emergency is a windowless box where the clock is stopped at 1: 36. Four doors open off this room into isolation rooms, green-painted cells with a mattress on the floor and a steel prison toilet.
"If this isn't stigma," asks Nazif, gesturing toward a cell, "what is?"
Sometimes, an elderly patient suffering from dementia will have to be put in a room next to one containing a raging addict. "You have them beside a 25-year-old guy with drug psychosis who's screaming and screaming and banging on the walls," Nazif says. "That's a scary situation."
A suicidal patient could spend two or three days in one of the cells, with none of the fresh air, natural light and interaction with other patients that help mentally ill people recover from psychotic episodes in other North American hospitals, Nazif says. "Fresh air and natural light - these things go a long way toward settling people without medication or restraint," she says.
Vancouver's concentration of low-income housing in the Downtown Eastside turns many mentally ill people into drug addicts, Nazif says. "The low-cost housing that mentally ill patients who are on disability can afford happens to be near all the drugs."
St. Paul's vast numbers of "dual-diagnosis" patients who are men-tally ill and addicted require treatment on multiple fronts. "You're not dealing with just mental illness," Shervin says. "They're homeless, they're hungry, they're using [drugs], they're not taking their meds."
The stigma around mental illness and consequent underfunding hampers advancements in the emergency psychiatric department, Nazif says.
"Addictions are a mental illness - they have a genetic basis. They occur in people that have other psychiatric problems. We still give patients exceptional care, but there are things we'd like to do for them that we can't. When these people are treated well, they can overcome these illnesses. We have the capacity to be world experts in this area if we had the resources."
Heartbeat is an eight-month series for which The Province has been granted special access to St. Paul's Hospital. The series runs for a week each month until November.