By Kevin Johnston, AGPC-NP, RN
Neurological Health is complex and often underdiagnosed. They challenge healthcare systems worldwide. The impacts on individuals physical, emotional, cognitive and quality of life (Ningrum & Kung, 2023). As a nurse for many years and as a Nurse Practitioner, providing quality care for patients with neurological disease and injury has been challenging. Add the complexity of insurance coverage and reimbursement, shortages in trained specialists, and the ongoing effects of the COVID-19 pandemic and it becomes a near perfect storm against getting the care needed.
I have spent many years in practice working in assisted living and skilled nursing facilities. I have treated and/or observed several hundred cases of Alzheimer’s, Dementia, Parkinson’s Disease, traumatic brain injuries (TBI) and neurological birth defects (Understanding Mental Disorders, 2015). Working in primary care during the pandemic required that I become very familiar with diagnosing and treating mental disorders.
I had many patients walk into my exam room that were undiagnosed with obsessive-compulsive disorder (OCD), Attention-deficit/hyperactivity disorder (ADHD), severe depression, Bipolar Disorders, Schizophrenias, Anxiety disorders, post-traumatic stress disorder (PTSD), eating disorders, disruptive behaviors, and neurodevelopmental disorders (Mental Health, 2024). The isolation and uncertainty of the pandemic and corresponding extended shutdown of most social activities heightened the intensity of the disorders. As a primary care, I would normally refer these patients out to mental health providers. I found that the time from referral to actual appointments could vary from weeks to months of the patient not being able to find a single provider that accepted their insurance or had such high per appointment charges that they could not afford the services.
I had one instance wherein a middle-aged Latina woman presented to my office for an exam and medication refill. While she was established at the office, I had never met her previously. She presented to me in tears with her three young children in tow. She did not speak English and through my medical assistant/translator (MA) she told me that she could not take being with her abusive husband anymore. She was undocumented and was covered by a basic state insurance policy. After a brief physical exam, I started asking the Patient Health Questionnaire (PDQ-9) questions (PHQ-9 Questionnaire, 2024). This standardized test asks 9 questions with scores of 0-3. She answered every question with severe- it was the first and, so far, the only 27-point response I have ever received. Once she spoke of being suicidal, I asked if she had a plan, how would she commit suicide, had she made arrangements for her children, when she would do it, and how she thought others would react. She told me that she would wait until her husband had passed out drunk tonight (she had purchased a bottle of tequila for him on the way to the doctor’s appointment), and sneak in and slit his throat and stab him in the heart to kill him. She knew that her kids would be devastated by this so she planned on smothering them with plastic bags and pillows so that they wouldnot have to suffer. She then was going to lay down in the tub and slit her wrists and throat. She demonstrated how she planned on doing this. She had done her research to ensure that she would bleed out as quickly as possible with little possibility of being saved. She had given away all of her prized possessions to friends and mailed letters to her family in her country saying goodbye. To add to this, she then pulled a large, serrated carving knife out of her sock to demonstrate what and how she was going to do these deeds. I asked her why she had come to the office today, knowing that she was not expecting to be alive after tonight. Her response sent shivers down my spine- she wanted to make sure that I agreed that these were the best methods of committing a murder/suicide and to see if there was an alternative for her children. She did not really want to kill her children, but she felt that there were no resources available. She also told me that she was not allowed to leave the house with a valid reason. Her husband tracked her every movement with her cell phone and if he did not see her moving with the tracking, he would immediately call, and she would be beaten if she did not answer the call.
My response was to ask her to hand me the knife, remove it from the room, have the MA take the kids to a separate part of the building, and tell her that I would get her help. I remained calm and once the children were out of the room and the knife was secured, I gave her a hug and told her that we could get her away from him, allow her to keep her children, and protect her. She would need to get medical help and financial assistance. The staff call 911 and I remained with her until responders arrived. This was during the height of Covid, and two police officers were the first to arrive. They came into the room, one with his gun in hand and the other with a taser aimed into the room. They wore gloves and masks. Neither spoke Spanish. I now had to de-escalate the situation, explaining that she was no longer armed and that she needed to be taken to the hospital for a 72-hour psych evaluation/hold. Social services would have to take the children to safety and that her husband should be arrested for domestic abuse (during exam, I noted multiple bruises and injuries to her arms, legs, head and torso, in varying levels of healing. She also had burn marks on her buttocks and poorly healed fractures.
The ambulance arrived with a paramedic and the volunteer fire department with their chief. My area has county police and local volunteer ambulance corps that are typically attached to the local volunteer fire department. As I was a volunteer firefighter myself, I know that these volunteers are good hearted and but often lack extensive training. None of the responders had any special training in mental health crisis management. As an NP, my training consisted of 3 courses in general and adult mental healthcare. We spend one semester in a mental health clinic (a half-way house in my case) for a total of 120 hours. I also have the added experience of growing up with a mother that worked in a state mental hospital for 15 years as a ward charge. I also have several family members and friends that are undergoing treatment for several mental disorders. While this was the most intense (and terrifying) mental health crisis that I have had to manage.
The ambulance crew did eventually adhere to my recommendations, and she was admitted for evaluation. In such a severe case, she did receive some care- she was medicated and provided temporary housing and financial assistance through a privately funded battered woman’s center. Her husband was arrested and deported to his home country. She did return to my office once several months later. She had lost some weight and seemed much happier. She did mention that she had not been able to start counselling outside of the housing. Because she was the victim of a violent crime, she had been granted temporary residency. She did not know what the future held for her. She was with her children and was trying to relocate someplace that was “safe” for herself and the children. She had no close family or friends that she felt she could trust. I was unable to refer her to a professional for immediate care because she did not have a permanent address and her insurance would not cover her care. She had no skills and little possibility of earning a living wage. Her husband had snuck across the border several times and she had no doubt that he would come back to New York searching for her. She knew that if he found her, he would kill her without hesitation.
This case is the worst example of resource shortages in neurological and mental health care that I have personally experienced. As a primary care provider, we are expected to be knowledgeable in every specialty and general practice. Our education is very general, and most providers are choosing to specialize because you are reimbursed better and can concentrate your knowledge base on very specific diseases or body systems. In general care, the next patient walking through my door can have just about any complaint. I am constantly reading and studying on the latest diseases and medications. As a member of the Plus One Foundation, I now have the opportunity to improve my knowledge base on neurological injuries and injuries, as well as mental disorders.
References
Mental Illness (2024). Mayo Clinic Foundation for Medical Education and Research. As downloaded from Mental illness - Symptoms and causes - Mayo Clinic.
Ningrum, D. N. A. and Kung, W. M. (2023). Challenges and perspectives of neurological disorders. Brain Science, 13, 676.As downloaded from https://doi.org/10.3390/brainsci13040676.
PHQ-9 Questionnaire (2024), Patient Health Questionnaire (PHQ-9) Overview, National Institute of Health. As downloaded from PHQ-9 depression scale.pdf (nih.gov).
Understanding Mental Disorders (2015). Your Guide to DSM-5. American Psychiatric Publishing. As downloaded from APA_Understanding-Mental-Disorders_Introduction.pdf (psychiatry.org).