Wednesday, Aug. 25, 2004 | 11 a.m.
It's 7:15 on a weekday night.
Richard LaRiviere, a fit-looking guy in gym clothes with a big workout bag, stands in a parking lot with a prescription for something with codeine, a list of places he was supposed to be able to find housing and empty pockets.
Two weeks earlier, he woke up without knowing how he got from Colorado Springs to Las Vegas. He had done this sort of thing before, a product of disassociative disorder, a condition he has had since he was 3, when he saw his father shot. Later he was further traumatized by an uncle who would lock him in a closet.
LaRiviere sometimes blacks out, for days at a time.
In Las Vegas, he woke up in a hotel room and wanted to die. He wound up in an emergency room, a dark hallway where he watched TV and stepped outside to have a smoke from time to time. Then he wound up in the state's patient observation unit, a 26-bed version of an emergency room specifically for the mentally ill, part of the state psychiatric complex at 6161 W. Charleston Blvd.
This is ground zero for the mental health emergency the county declared July 9. On that day, more than 100 mentally ill patients filled the valley's emergency rooms. The numbers have hovered in the 60s recently.
This means about one in every four emergency room patients gets no treatment for his or her main problem -- mental illness -- until a bed opens up at the patient observation unit, which usually happens after about a five-day wait. During the wait, both the patient and the rest of the emergency room suffers.
The political firestorm since Clark County Manager Thom Reilly's declaration has included an Aug. 4 meeting where hospitals issued a position paper with language like "the following changes must occur immediately" -- referring to getting psychiatric patients out of emergency rooms.
The state provided emergency funding for a record-pace renovation of an unused building behind the state hospital to add 28 beds to the valley's care. That new unit began operating Aug. 13.
Another outcome of Reilly's announcement has been an effort to forge a new state, local and hospital funding formula for the WestCare Crisis Triage Center, a program that helps the mentally ill with drug and alcohol addictions.
On Aug. 16 the Clark County Health District's Facility Advisory Board -- which includes top-level adminstrators from the valley's hospitals -- decided to study providing its share of the WestCare funding. Local municipalities will meet on the same issue in the first weeks of September.
And Sept. 15, the Interim Finance Committee will decide on whether to recommend that the Legislature fund an additional wing of 40 state beds beyond the 150 already scheduled for a new $45 million state psychiatric hospital that is scheduled to be opened in 2006. Building and staffing the additional wing is expected to cost $15 million, said Jonna Triggs, director of Southern Nevada Adult Mental Health Services.
Assemblywoman Chris Giunchigliani, D-Las Vegas, a member of the committee, said Friday she would support the recommendation.
"This is going to be an ongoing problem, and not just a crisis right now," she said.
LaRiviere's problems are on ongoing as well. Five days after he had been released from the valley's existing psychiatric hospital -- which everyone calls by its address, "6161"-- LaRiviere had returned on his own. His migraine was getting worse and he was hungry, with no place to spend the night. He said he had felt suicidal again since being released from the state hospital days earlier, and just wanted a bus ticket out of town.
LaRiviere's story was typical, said Jim Osti, former director of the WestCare Crisis Triage Center and a member of the valley's Mental Health Coalition.
"It's happening to hundreds of people in this community ... who are dealing with a broken system," he added.
The front lines
Nearly 12 hours earlier, Maurice Silva -- head of a state-funded team that seeks out the mentally ill in washes, parking lots, street corners and cheap motels -- was twisting his torso to get a knot out of his back.
"It's stress," he said.
Most of the people on the front lines of the crisis that day showed stress on their faces, in their bodies, in their chain-smoking.
It was 8:15 a.m. and Silva's workday was just getting started. He was waiting for his team of six to grab seats in his cubbyhole of an office -- on loan from Clark County -- and discuss the day's cases.
His team "deals with the most difficult patients -- their status changes day to day," he said.
His team, formally known as the Program for Assertive Community Treatment or PACT, was designed to be a "hospital without walls" for mentally ill patients who otherwise repeatedly wind up in real hospital emergency rooms. Fully staffed since June, the team owes its existence to a 36 percent increase in Southern Nevada's mental health budget, now at $57 million. That boost came out of the 2003 Legislature.
At 8:35 a.m., the list of 60 patients began with Jesse. "He was a chronic street person ... when we first met him he was babbling on a corner," Silva said.
Now, instead of occupying a bed in emergency rooms or the state psychiatric hospital, Jesse is in a state-run group home that costs about $1,000 a month for housing, transportation, counseling and other services.
Then there's Douglas, who's "slipping back into mania," said team member and clinical social worker Robert Benedict. And Rodney, who was in an emergency room and became No. 52 on the waiting list to enter the state hospital. There was also Michael, who has been in the state hospital, on the streets and was now in the emergency room at Sunrise Hospital.
The list goes on -- testimony to the heavy caseload Silva had hoped he could avoid when he began the project last October. For about one out of every four names on the list someone in the room says simply, "He's doing fine."
Psychologist Patricia Brassfield says, "The problem (with the team's work) is we're only getting the tip of the iceberg."
At 10:30 a.m. the meeting's over. Team members pair off and head to their cars.
By 11 a.m., Silva and psychiatric caseworker Deanna Martell are in a wash off Boulder Highway, a scrub forest of sorts next to a major public works project busy with tractors and haulers lining a flood channel with concrete. Dust was rising in the heat.
A few steps into the scrub and the 21st-century machines meant to tame nature's excesses give way to primitive lean-tos strapped together from branches and blankets.
Inside one of the makeshift shelters, there is a woman who said her name was Chris, and then, Lorraine Richardson, who is 51 but looks a decade older.
Silva and Martell wanted to see Richardson because she was a no-show for an appointment they had brokered days earlier with Clark County Social Services.
Silva -- as with most people working in the mental health system -- has to be a jack-of-all-trades, searching the Clark County Detention Center's Web site as easily as he interprets clinical data or applications for housing.
He was trying to get Richardson to Social Services because the agency has a voucher program that could get the homeless woman into housing, and housing would make treatment of her mental illness more effective.
Professionals on the front lines of the mental health emergency variously estimated the number of homeless psychiatric patients in the valley's hospitals at anywhere from 5 percent to 40 percent.
Richardson's psychiatric condition became apparent shortly after Martell coaxed her out of the lean-to with a bottle of water and rescheduled her appointment, one step in a series of steps Silva's team may have to take before achieving any progress.
"I hear voices in my head that ... make me want to crawl into a fetal position," she volunteered.
Then a few facts -- her mother dead in 1994, on the streets ever since, a husband once, a lost cat and dog -- and the rest unravels.
"Did it happen in the future or is it the past coming back now?" she wonders aloud.
Richardson is clear on one thing: "I will never be in a mental institution again. ... Me and mental institutions don't get along."
Now almost noon, Silva and Martell are back in the car, back on the streets, another part of working with the mentally ill amidst the crisis, since they are all over the valley and the inadequate services to treat them are also all over the valley.
Further west along Charleston Boulevard from Silva's office near Interstate 15 and off to 6161.
There, Steven Hart, a clinical social worker, is the face of another team born of the region's recent budget increase -- the Mobile Crisis Team.
In the ERs
While Silva's team tries to catch the mentally ill before they fall into emergency rooms, Hart and five others cover the hospitals of the valley in the hopes of getting patients out of emergency rooms as quickly as possible and into programs such as group homes or drug treatment centers.
Of course, there are not enough of either -- the state has a freeze on spending for group homes and WestCare is just about the only center capable of handling so-called dual diagnoses, the mentally ill on drugs or alcohol.
"Dual diagnoses are rampant in this valley -- especially with methamphetamine and alcohol," Hart said.
Hart then offers a tour of the hospital where there are not enough beds -- 86 to be exact, a number that is only a little larger than the waiting list in the valley's emergency rooms on most days.
The building, though 16 years old, was recently spruced up for a visit by Joint Commission on Accreditation of Healthcare Organizations officials, and its cream-colored exterior and spidery shape belie the stereotype of a blocky 1950s institution.
Reproductions of Monet paintings are on the walls inside. And on the second floor, a door labeled "Group E" displays a hand-lettered sign that says, "A.W.O.L Risk." Keys are needed to enter or leave any part of the hospital, including the elevator.
From there Hart heads across the valley to Henderson's St. Rose Dominican Hospital, Siena campus. As if to prove Hart's earlier point about the prevalence of patients troubled by both addictions and mental illness, the upbeat counselor checks on a patient who arrived at the emergency room stoned on mushrooms and methamphetamine the day before.
Hart decides to check on him again the next day, to see how much of his anxious behavior is due to drugs, as opposed to any psychiatric condition.
Kathy Sneed, assistant manager for the emergency room, circled the emergency room without coming across Hart's patient. After coming full circle, almost back at the entrance from the waiting room, she pointed off to the side.
There, in a hallway leading to the radiology department, were the psychiatric patients -- 6 in all, more than a quarter of her capacity for adults at the time, since five of her 28 beds are meant for children during afternoon and evening hours.
Sneed used words like "stressful" and "frustrating" to describe what it's like working an emergency room under such conditions. She said that's because she can't help psychiatric patients, and they also don't make her job any easier.
"All we're doing is giving them a bed, a hot meal, and protecting them," she said.
"And some of them become violent, or verbally abusive."
The main line of defense against such outbreaks, she said, were the "sitters."
Sitters are certified nursing assistants who "sit there all day" and "let us know if any patients start to act out," Sneed explained.
Getting a bed
The psychiatric patients in St. Rose's hallway that afternoon could have gotten there by any of several routes.
Police, social workers and mental health professionals may encounter mentally ill people who appear to be dangerous to themselves or others and, under state law, they can take those patients to the emergency room, where, also according to state law, the patient first has to be medically evaluated before he or she can be psychiatrically evaluated.
Patients can also effectively admit themselves by telling emergency room personnel they want to commit suicide.
Up to 10 percent of all psychiatric patients may be taking advantage of that provision in the law to beat the system and get free beds and meals, when in fact they have no underlying condition, said Wanda Roper, who oversees the Mobile Crisis Team.
No matter how they get to the emergency room, however, once patients are medically cleared, the problem is that there is no room for them at 6161 W. Charleston. If the wait to get from an emergency room to the state psychiatric hospital is longer than 72 hours from when the patient is medically cleared, then the patient's stay can be extended through a process called the mental health commitment court.
The court is at West Charleston. So if the patient hasn't gotten into one of the 26 beds in the patient observation unit before then -- the first stop before getting into the hospital itself -- he or she must be taken in an ambulance to the court. At the court, a hearing master looks at the patient's psychiatric evaluation and decides if continued treatment is necessary.
If it is, and there are no beds at West Charleston, then the patient goes back to the emergency room and waits.
Jon Norheim, hearing-master for the court, said his work is frustrating.
He has seen his calendar grow by about a third in the last year and sees about 40 cases a week in the two days court is in session -- Wednesday and Friday.
"We hold our hearings and do what we're supposed to do," Norheim said. "(But) there's nothing we can do to make more doctors and beds."
In the car ride back to the mental health center, Hart, who got his degree in clinical social work from the University of Nevada, Las Vegas, reflected on his days in emergency rooms. "It's like Johnny Appleseed -- you don't ever know the impact you have on people," he said.
But as for the larger picture -- the crisis itself -- he said he is "pessimistic about reaching any solution soon."
Too many patients
Back at the West Charleston facility, near 5 p.m., Linda Edwards, the evening nursing supervisor was watching over the patient observation unit, where patients are evaluated to see if they can be treated as outpatients or need to be in the hospital. Four of five patients are released within about three days,
As Edwards spoke at the front desk, patients in hospital smocks ambled around the large lobby. About 10 watched an action movie on TV. Some spoke on phones attached to the wall.
In back of Edwards, a magic-marker board on a far wall bore testimony to moment-by-moment changes.
A name was erased.
"You leaving? Hope you don't have to come back," a woman on the phone shouted to a man clutching a bag as he headed for the door.
Within minutes, a fax on the front desk brought news of additional patients to come. It said three psychiatric patients at University Medical Center's emergency room were waiting for a bed at West Charleston.
They became numbers 62 through 65 on the list, Edwards said.
"Some have been waiting (in emergency rooms) as long as seven days," she added.
About an hour later outside the observation unit, LaRiviere is telling a staff member he recognizes that he couldn't find a place to stay, that he was out of luck and at his wit's end.
The staff member gave him another agency name to look up, another acronym. The information would be of no immediate use since it was past 5 p.m.
LaRiviere headed to the parking lot.
"I just want to go home again," he said.