Am I Getting Too Old For This?

It is two days before Christmas and I am in the middle of a twenty four hour emergency on-call shift for the agency I work for. In short, my job is to respond to emergency behavioral health issues that may be called in within the region where I work. This may include talking with consumers in crisis over the phone, meeting with consumers in person, or facilitating an admission to a psychiatric unit or a substance dependency detox program. My agency is required to provide emergency services coverage to our region 24/7/365. So for extra cash I take on shifts during after hours (after 5 pm and on weekends). The work is very interesting as one is required to use sound clinical judgment in the spur of the moment during non-traditional hours. People ask if I get many calls and I say "sometimes." Some shifts nothing happens and I do not hear a peep. There are other shifts where I have pulled an all-nighter at the emergency room securing an admission for a suicidal individual. There are other shifts where it seems like it is non-stop calls and meetings with consumers. Crisis is a combination of danger (the possible lethal actions of someone in a behavioral health emergency) plus opportunity (a chance to intervene when the iron is red hot). However, the environment has changed rather dramatically from when I started doing emergency behavioral health care ten years ago. Ten years ago there were ample inpatient psychiatric beds all over the state of Virginia. If an individual truly needed a bed then there would be one available. Of course, all attempts would be made to provide outpatient care and services in the community. Today, I try to make every attempt to develop a plan with a consumer that involves them staying at home, staying safe, and getting what they need to overcome the crisis point. There are times where the safest thing to do is to seek a hospitalization. Ten years ago, when beds were more plentiful the average call (the time from meeting the consumer to obtaining the admission) for me was around two hours. Now, the same call averages around five hours. There are many reasons for this change. First, the number of available psychiatric beds both private and public have shrunk considerably. Private hospitals have also become more selective in their admission criteria. For example, they can easily say to me as I am seeking an admission for a suicidal patient that even though they have a bed the patient is "too acute" to be in their facility. I often wonder in the middle of the night how anyone could get away with this. The patient is too sick to be in their hospital. It's easy for them to say "no" to me because it is not their patient and not their responsibility. It's mine. So if something were to go wrong. It's not their fault it will be mine. I then ask myself now that I have been doing this for awhile whether or not I need the stress and the headaches of this level of responsibility. Am I too old for the strain? Am I too old for the feeling that I am liable for whatever happens? Am I too old to pull all-nighters in calls that now take me at least four to five hours to plow through? Another major change is in the public hospital system here that has been downsizing for years. State hospitals used to have back-up plans to move potential admissions to other state facilities if the local facility was full. Not anymore. If the local state hospital is full then they are full and there is no back-up. State hospitals are considered the last option. So the last option has no back-up so the patient at this point either walks or stays in an emergency room waiting. I have had both happen. So how does that feel when liability is on my shoulders? You can guess. The other issue with state facilities is that their civil beds are taken up by forensic patients from jails. Individuals in jails in need of hospitalization or a forensic evaluation have to go to a state facility. They stay longer and take up the beds that could be held for a civil patient. Thus, the number of available beds decreases and the shell game looking for a bed for a patient is at the end of their rope continues. At 2:45 am I could be sitting in a local ER playing the shell game while the weight of the patient's need, the ER doctor's expectations, and the family's desperation weighs on my shoulders. At 36, I truly feel 56 at that moment and I feel like I am truly too old for this. This is one of the key reasons why people in my field are running off. The responsibility is too great and the money not meeting the "Is it worth it?" mark. As I write. I wait for the pager to buzz so that the "game" begins.