Psyched in the E.R.: She's Pregnant and Shooting Heroin?

So I answered the phone and the details were tough to hear. Yes, one of those cases that requires a gut-check before making the scene. Seems a woman, seven-months pregnant no less, was about to inject her daily heroin fix when her fiancé intervened and called the police. Out they came to the house, arrested the woman, and stopped by the E.R. for a medical assessment before taking her in for booking. By the way, I found out later that one of my colleagues got the first call; however, she asked that I be contacted because she was so angered by the report she didn’t feel comfortable handling the case. Kudos to her, passing the baton was the right thing to do.

Upon arrival at the E.R. I was briefed on the case by the woman’s attending physician. I also talked with one of the two police officers that were waiting outside of her room. According to all parties the circumstances were pretty much as I’d heard on the phone. And, of course, I had to listen to all sorts of editorial remarks from the E.D. staff regarding what an awful woman and mother the woman was. Now, I’m not condoning her behavior by any means; however we’re in the helping professions –right?

As I entered the woman’s room, I saw a patient in her mid-20’s dressed in a hospital gown with an I.V. in her arm. She was visibly agitated, crying profusely, and pacing as much as her I.V. line would allow. She greeted me with a desperate expression, intense weeping, statements of great fear and sorrow, a face scarred by running mascara, and a good deal of nausea and G.I. distress. In spite of everything else with which she was dealing, it was obvious she was in the beginning stages of heroin withdrawal, which could certainly account for a large portion of her presenting physical and emotional symptoms.

Not surprisingly, the woman formed an immediate emotional attachment to me. And all things considered that’s not so hard to understand. Let’s see - she’s frightened to death, seven months pregnant, withdrawing from heroin, knows she’s the object of contempt, may well have a deformed baby inside of her, may lose this baby and her family, and believes she may well be incarcerated. Wow, huh? But in spite of recognizing and understanding her attachment I had to keep it in check. No doubt, she needed support; however, my immediate task was to get answers in an effort to formulate a psychiatric disposition in her best interest. This wasn’t the time to be toasting marshmallows and singing “Kum Ba Ya.” But it also wasn’t the time to be an iceberg. Just the right mix was the order of the day.

As the interview commenced the woman confirmed the circumstances of her arrest and transport to the E.R. And she confirmed that she’d been using heroin on a daily basis for the past nine months. And, remember, she’s seven months pregnant. She was actually arrested for possession of drug paraphernalia and possession of cannabis, a small amount found in her purse. Who knows what happened to the heroin.

Due to the woman’s ongoing crying, hyperactivity, and physical distress, this was no doubt a tough assessment. And making it all the more difficult was the medical staff’s comings and goings as they conducted a variety of procedures. I mean, I had to stay focused and on course, making sure I got the answers I needed. And it was important that I went beyond ascertaining the details of her substance abuse and dependence. I needed to assess her potential for self-harm and harm to others. And, oh by the way, I needed to know who was going to care for her two very young children should she be incarcerated or hospitalized. There was a ton on the line here and I had to keep moving forward and make sound decisions amidst the chaos.

Well, long before I completed the assessment I was pretty sure there would be nothing from a psychiatric perspective that would stand in the way of the woman’s transport to the police station. And this supposition was confirmed as I finished the interview. At any rate, protocol mandates my touching base with the on-call psychiatrist. That I did, and she concurred that though the woman definitely required substance dependence treatment, there were no criteria for immediate hospitalization that would trump the coming legal proceedings. Of course, the psychiatrist reminded me to notify Children and Family Services.

So off I went to give our disposition to the E.D. attending and the police. Then I stopped by the woman’s room to share the disposition, give her some referrals, and say good-bye. No doubt it was tough, as she hadn’t emotionally stabilized and was still presenting with all sorts of desperation and the hope that I could somehow stay and talk for a while. And as much as I might have liked to it just wasn’t the thing to do at the time.
After saying good-bye I went to a near-by computer station to enter my formal assessment. Out of the corner of my eye I caught a good bit of commotion in front of the patient’s room. Her mother dropped by to see what had happened, and the police had to intervene as her mother tried to get at her and inflict some physical harm. Amazing. But the upside of her mother’s visit was her commitment to care for her grandchildren. Oh – and when I spoke with Children and Family Services I found out that several parties had beaten me to the draw.

Interesting tale, don’t you think? I mean, I’m left with all sorts of feelings. Absolutely, I’m disgusted by someone shooting heroin throughout her pregnancy. And, indeed, what kind of mother would daily use heroin when she has two very young children at home? But on the other side of the coin I know how devastating substance addiction is, and how its biochemical foundation can make it almost impossible to challenge. But yet, we all have our “stuff” and it’s our responsibility to step up to the plate and manage it.

These are the cases that help me grow as a person and a professional.