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Virginia EP Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment and change the way Virginia handles mental health admissions.

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Dr. Debra Perina

Dr. Debra Perina lives a double life. Her “day job” is Professor of Emergency Medicine and Director of the Prehospital Care division at the University of Virginia. In this capacity she has risen to national leadership, serving as a past president of ABEM and CORD. She was recently elected to the Board of Directors of ACEP. Dr. Perina’s second life is as a state appointed medical examiner. In that capacity, she responds to the scene of unexpected deaths, decides manner of death, and determines whether there is a need for an autopsy or other forensic evidence collection.

Perina’s two lives began to intersect several years ago when, as a medical examiner, she began to see a troubling trend. Patients with mental illness who had been evaluated in EDs and then released were going on to harm themselves and/or others. Looking at these cases closely from both angles, she saw a system in which something desperately needed to change. Thankfully, her unique experience put her in a position to identify exactly what that was.

It all came to head with a particularly troubling case. Dr. Perina was called as the medical examiner in the case of a dead 16-year-old boy, who two days earlier had been brought to the ED by a police-initiated emergency commitment order. The police had learned at that time that the boy had threatened to kidnap his girlfriend, explode a pipe bomb at school and then kill himself. There was actually a journal in which these plans were recorded which was brought with the patient to the ED. Both the treating ED physician and a consulting psychiatric resident recommended emergency commitment of this disturbed and potentially violent patient. The psychiatry resident had written an admission H&P.

Unbeknownst to both of them, a CSB (Community Area Mental Health Services Board) representative had convinced the magistrate to rule against commitment, and let the patient go without any mandated follow-up. For many years in Virginia, by statute, those requiring involuntary emergency psychiatric evaluation were brought under an emergency commitment order (ECO), to an emergency department, where Emergency physicians were expected to provide “medical clearance”. Further recommendations regarding continued psychiatric treatment or commitment, by statute, rested solely with a representative of the area CSB. The CSB is a state run collection of mental health agencies strategically located throughout Virginia. They are most often staffed by social workers with additional training. The final decision on man- dating further psychiatric care and ongoing commitment, by longstanding precedent, was then made by a magistrate based on the opinion of CSB only. There was no provision in the system requiring the magistrate to consider any physician input, even when medical opinion was at odds with CSB.

The glaring gap in this system was exposed when, a day after he was released, the 16-year-old patient made good on this threats and kidnapped his girlfriend. A statewide manhunt ensued and on day 2, the patient was sighted holding the girlfriend hostage in his car. A police chase occurred that ended with the 16-year-old being shot by a police officer as he tried to run him down with his car around a road block, all the while brandishing a gun. The girlfriend was unhurt, but seriously traumatized, as was the officer.

The case incensed Dr. Perina – both the needless death and the flippant way in which CSB ignored the advice of physicians – and spurred her to action. This broken system had placed this patient, the girlfriend, the school, the police, and the community at large in danger, and something had to be done to change it.

Disagreements between the CSB and treating physicians over choices to admit were hardly a new problem. This system has been a source of frustration to Perina and other Virginia emergency physicians for years. Dr. Perina recalled one case where she, as the treating ED physician, disagreed with CSB recommendations regarding commitment. When discussing her reasoning with the social worker, she was told “You have nothing to say about it, the entire authority for this decision rests with me.”

Due to these mounting frustrations, Dr. Perina began to research the issue. She found that similar systems exist in a handful of other states, though in contradistinction to Virginia, most others give the opinions of the treating physicians great deference. Dr. Perina was inspired to begin collecting cases in which there was disagreement between physicians and CSB from her region, and where the ultimate decision resulted in patient harm or harm to others perpetrated by disturbed patients who had been released by a magistrate based on the recommendation of CSB representatives and, essentially, “against medical advice.”

After researching the relevant state statutes, Perina contacted several other emergency physicians and the sheriff in her home county asking them to enlist others in the endeavor. Together they created a delegation of five emergency physicians and five Sheriffs who together met with their legislator, Delegate Rob Bell (R, 58th), asking for his help in getting the system changed. Dr. Perina was fully aware that this would not be an easy task, because this system had been in place for many years, and there was strong state-backed financial motivation behind keeping psychiatric patients out of hospitals. In reality the CSB was originally created largely to serve this very purpose, and had worked so well at keeping costs down that the system had become something of a ‘sacred cow’ in Virginia. Indeed, the psychiatric community had experienced a failed attempt to alter this situation legislatively in the past, and felt that changing it might be a lost cause in this state. Dr. Perina was unable to accept this, and, as the delegation organizer, led the discussions with Delegate Bell. To his credit, despite his well founded political misgivings and the great potential for backlash, Bell agreed to help. Dr. Perina then worked with his staff to author the bill he introduced at the next session of the legislature that would ultimately change this situation.

The next step was for Debra to collect resources, champions and allies, which included the Virginia ACEP chapter with its lobbyist, other emergency physicians, psychiatrists, and the sheriff’s association. She also identified potential adversaries, including the consumer advocacy and civil rights organizations (who often oppose anything that may infringe on personal freedoms such as commitment laws), and the State Mental Health department itself, which clearly had a vested interest in the system staying the same. She was actually told that if emergency physicians were given the ability to have input into these decisions “they would quickly fill all the mental health beds in the state.”

Dr. Perina spent many hours over the next five months researching and writing a white paper on practices in other states in order to assist and educate Representative Bell, helping him to provide critical information to convince other legislators. She personally lobbied potential supporters, including other legislators, the Chief medical examiner, and the sheriff’s association. She testified before the state house and senate subcommittees, encountering resistance each step of the way from the state mental health department, along with Virginia Coalition of Community Area Service Boards, and the National Alliance on Mental Illness (NAMI), who gave opposing testimony as to why the proposed change was not necessary.

Ultimately, the state legislature did change the statute, so that now the magistrates must take into account the opinions of the treating emergency physicians, along with CSB information, to determine the need for commitment.

This statute, Virginia 37.2-809, went into effect in July 2007, which was just four months after the shootings took place at Virginia Tech. “If this law had been in place in the Spring of 2007, that event would not have occurred,” says Dr. Perina. “The shooter in that case had been evaluated under an emergency commitment order just a few days prior to the shooting and been judged by a magistrate on the advice of CSB to not need emergency commitment, over the objections of the treating emergency physician. With the new law that never would have happened.”

Dr. Perina notes that while the new law helps, it does not go far enough. “At the time,” she stresses, “going further was not an option, as the bill would have met with too much resistance to have passed.” So progress in this, as in all things political, would need to be incremental.

In January 2014, another tragic event took place in Virginia, in which the son of a state senator took his own life after stabbing his father. This took place closely following an ECO and an emergency psychiatric evaluation. As a result, there is currently a flurry of activity in the state to tighten the laws and to attempt to prevent needless tragedies of this sort. Virginia ACEP has been front and center, holding conference calls and supporting key legislation. Dr. Perina is heavily involved in these efforts and working with many other groups now seeking reform.

Was it worth the effort? “Absolutely,” says Dr. Perina. “It was a big commitment, but if something hits you in your gut like this, if you are in a position to do something about it you pretty much have to. Otherwise, it is hard to look into the mirror the next time something happens.” To other physicians who may find themselves in similar circumstances, Perina recommends a few things: research all sources of information and resources, identify both potential allies and enemies before planning a course of action to attempt to correct the problem. This could require looking outside “the usual suspects,” or building a coalition (even one of unlikely bedfellows) in order to succeed. For example, your local legislator, whose political persuasion and backing might be considered adversarial, must be considered (and may become a key ally). Your state ACEP chapter, your local and state medical society (both of which may have a lobbyist or even a subgroup that could become a source of information and much needed manpower to assist) should be approached even if you are not a member. The EMS or law enforcement community could become very strong allies. Even law associations might have an interest in the cause. Sometimes there are community advocacy groups (for example, MADD), which may be galvanized around a separate but related issue, That could be very helpful. Educational institutions might provide “student power” to pursue research or publicity. ACEP, the AMA or AAEM might also have explored similar issues and have information or re- sources, such as lobbyists or a PR mechanism that could be helpful to your cause. But be prepared that some potential allies might end up on the opposing side, such as in this case, where emergency commitment issues can invoke civil liberties concerns.

“Don’t give up just because longstanding laws, precedents, powerful adversaries, the Old Guard, or the odds seem against you,” advises Dr. Perina. “If you are persistent, and the system is wrong, the balance will ultimately shift; and it may surprise you how much one person with passion can accomplish.”

Or as Margaret Meade put it so eloquently, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”

 

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