Navigating Behavioral Health Emergencies in “Zone C”

Categories: Medical Center News
Behavioral Health Crisis
Zone C is one of the few places in the state that can provide emergency care for children’s behavioral health issues, and it is the one to which many pediatricians and family doctors refer patients.

Over the past several years, Connecticut Children’s Emergency Department (ED) has witnessed a significant increase in behavioral health emergencies and has become the go-to hospital across the region for children in crisis. For children across the region, Connecticut Children’s “Zone C” is often the first stop on the road to recovery.

Steven Rogers, MD, the Director of Emergency Behavioral Health Services at Connecticut Children’s, says patient behavioral health emergency visits have risen dramatically over the past two decades. “In the year 2000, we saw 652 kids who needed behavioral health treatment,” Dr. Rogers said. “In 2015, we saw 3,300, and in 2018, we saw almost 3,700. It’s gone from hundreds to thousands. It grows about 5 to 10 percent a year,” he said.

Indeed, behavioral health crises among children and young people across the United States are on the rise, and the statistics are staggering. Nationally, suicide has become the second-leading cause of death for young people between the ages of 10 and 24, second only to death by unintentional injuries. Between 2006 and 2016, the number of children and young adults presenting to emergency departments with suicidal thoughts increased by a formidable 106 percent.

That’s why Connecticut Children’s created Zone C, a safe area of the ED devoted to caring for children having a behavioral health crisis, one of the few such places in the state. In the patient stories that follow, we get a glimpse inside Zone C on a typical day and a snapshot of pediatric behavioral health issues that often go unseen. (Some details of these patient stories, like names, ages and towns of residence, have been changed to protect the confidentiality of the patients.)

9 a.m.

Behavioral Health Zone C
James, a security guard in Zone C, plays cards with a girl who had cut her wrists. Every child who comes into Zone C is screened for their risk of suicide, which is one of the leading causes of death among adolescents and young adults.

“Sharon” is crying. She’s sitting in the tiny consultation room in Zone C, and through her tears, she’s talking about her daughter, “Melissa,” who she brought in last night. Melissa has been having a tough time with life. “For the past year, she’s been feeling overwhelmed by everything,” Sharon says. “She had anxiety for a while and has been having episodes. Yesterday was over the top, though. She had a rough day at school—nothing out of the ordinary, but for her it was overwhelming, and she was crying as she came off the bus. The crying escalated to screaming. She was saying, ‘I hate myself,’ ‘I want to stab myself,’ ‘I want to kill myself.’”

She’s 9 years old.

That’s when Sharon brought her to the emergency department and she was placed in Zone C to ensure her safety. Sharon tells her story with a sense of disbelief, and her tears reflect the helplessness she feels—this problem is terrifying and bigger than anything she can deal with. But between the tears she is smiling, reflecting the sense of relief that her daughter is, in fact, getting the help she needs here. That’s a big thing, because the nature of “here” can be challenging.

While Sharon is telling her story, she has to raise her voice because of the screaming and loud banging coming from the room next door. A boy in that room is severely agitated. We can hear the medical staff soothing the boy and working to calm him. For the rest of this day, a clinician will sit outside his open door, monitoring him.

Zone C is not a treatment facility, just as the general ED does not keep patients who require ongoing care. Like the larger ED, Zone C is for kids who are having a health crisis—but behavioral rather than physical. If they pose a danger to themselves or others or are significantly disrupting school, they come here where they can be kept safe and supported until the crisis passes. Once they are stabilized, they are discharged with an appropriate individualized treatment plan. Staff working with Sharon will help determine the best next steps for Melissa.

Safety First in Behavioral Health Crises

Howard Sovronsky, Chief Behavioral Health Officer, Connecticut Children's
Howard Sovronsky, Chief Behavioral Health Officer, is the most recent addition to the behavioral health team. He brings more than 30 years of behavioral health leadership expertise in New York and Connecticut.

Because these children are in crisis and may not be able to control their behavior, their safety is of paramount importance. And Zone C reflects that physically. Zone C is a secure area of the ED. Visitors must press a call button that allows Zone C staff to view and speak to the visitor before entry is granted. There is a security guard on duty inside the doors. Additional staff are added as the number of patients increase, and the nurses station is enclosed in plexiglass with locked doors. Every cabinet has a keypad lock on it, the patient rooms are furnished only with a weighted, plastic platform bed that can’t be easily moved, along with a chair and a TV that is encased in a heavy metal enclosure with plexiglass covering the screen.

Every aspect of the physical facility and every action of the staff has one purpose: to keep these kids safe and reduce risk of self-harm or attempts to hang themselves. For example, the showerhead in the bathroom is a small, smooth half-dome, and the shower doors are vinyl-covered foam rather than glass—no shower-curtain rod. The towel hook is a stainless steel post on another half-dome. Any weight greater than a towel—say, a body—will cause the post to drop toward the floor. All of these features make the facility, in the language of behavioral health, “ligature-proof” to avoid self-harm. For the same reason, the facility’s door handles are all flush with the door surface and ride in a raised channel—no gaps anywhere. The place is Spartan and stark because that’s what safety requires with children experiencing a behavioral health crisis. All of these modifications conform to the highest level of safety standards.

This wing of the ED is laid out in an “L” shape. The nurses station is in the center, with a long hallway running parallel to it and a shorter hallway on the other side running perpendicular to it. There are patient rooms on either side of the hallways and the halls themselves have reinforced locking doors that can be used to shut off either section. There is an open space in front of the nurses station, with chairs for patients and parents. The consultation room where Sharon told her story is the only nod to anything like office space, and because it’s frequently in use, clinicians often have to talk to parents in the hallway outside Zone C. That’s far from ideal in terms of privacy, but as with every aspect of behavioral health care here, the scale of the need is greater than the systems designed to address it.

11 a.m.

Behavioral Health Nursing Station
The nurses station in Zone C is always a hub of activity, with everyone multitasking and working hard to find the best possible care for the children who are in Zone C.

Zone C has 11 beds in it. But on an average day during the school year, there may be as many as 35 patients needing care. Some wait in the hallways of Zone C (always with an observer), and some are cared for in rooms in the general ED.

Right now, one of those patients in the general ED is a high-school-aged boy with autism. Richard, one of the patient observers, is standing in the doorway talking to the boy. They are separated by a chest-high folding screen made of vinyl-covered foam, a tool used when there may be a question of needing to control a patient. Richard is remarkably kind and gentle with the boy, and their relationship seems very companionable.

Then, in an instant, the boy stiffens and lashes out, violently grabbing for Richard’s neck. Richard works to immobilize the boy’s wrists, but the boy is strong and thrashing, and rips off his ID badge. Carol Erickson, APRN and Lead for the ED Advanced Practice Providers, is standing nearby, and she rushes into the room to help Richard. Now both of them are trying to hold the boy back. They are both straining, using their whole bodies to try to hold him and are still not making any headway. The boy is flailing. Glasses go flying. Carol’s hand is bleeding. Three more staff members join the fray, including two security guards, and finally they are able to calm the boy.

Two minutes later, the boy is composed again and Richard is talking to him, exactly as they were before the commotion, as though nothing had ever happened. Richard says that the boy was sent here from school because he was being disruptive, and his aggression was the result of being told he was going to go back to school. The staff in Zone C see many more patients during the school year than during the summer or over holidays.

The remarkable thing about this whole incident is how, even in the midst of an intense physical entanglement, there is no hint of anger or aggression. No resentment, no judgment, not even irritation. The staff members’ faces are calm even as their bodies are pushed to the limit, and throughout, Richard is speaking to the boy in a reassuring way. The staff in Zone C are very special professionals who are highly skilled and compassionate. There is nothing but patience, understanding and caring. That’s the most striking thing about Zone C: the presence of extreme conditions and absence of extreme reaction. The kindness and care shown to this boy in Zone C is evident in every interaction, no matter how challenging.

You might think that these kinds of circumstances would result in a high staff turnover, but, in fact, that isn’t the case. “People who choose this work know what to expect,” says Ryan O’Donnell, MSN, RN, the Nurse Manager for the ED. “This is what they want to do.”

You can see that perspective in James, the security guard on duty today. An hour ago, he was playing cards with one of the patients.

1 p.m.

“Barbara” has driven all the way from Westport to bring her 16-year-old daughter, “Clare,” to Connecticut Children’s. “We drove by Yale and several other hospitals to get here,” Barbara says in the little consultation room, “but our doctor said this was the best place.”

Clare’s trouble started with vaping. It damaged her lungs, and she developed severe pneumonia in both lungs. “It nearly killed her,” says Barbara. “We took her to our local Emergency Room, and she spent a week in the hospital there.”

One of the ways the doctors treated her pneumonia was with very large doses of a steroid, which is believed to shorten the length of the illness and promote healing. But that drug can have the side effect of facial and body swelling, which, for a teenage girl, is devastating. Clare decided to stop eating to deal with that. One of the other rare side effects of the drug is mood changes, including serious depression, and Clare suffered from that, too. Sitting on the bed in her room in Zone C, she explains what that has been like: “In school,” she says, “I feel like, ‘How can you keep your [expletive] together? Willpower keeps getting lower and lower.’”

At home, Clare suffered from extreme anger and extreme sadness. When she started talking about killing herself, Barbara got her in the car and drove her to Connecticut Children’s. Sitting on her bed, Clare looks distant and sad and a little angry. You can see the swelling effect of the drug on her face. For her, the next step is inpatient psychiatric treatment. As soon as that is lined up, she will leave Zone C. But there are few beds available—too few for the number of patients needing help.

For a significant percentage of Zone C patients, like Clare, behavioral health issues are tied to or associated with physical health issues of one kind or another.

3 p.m.

Steve Rogers, MD, Director of Emergency Behavioral Health Services, Connecticut Children's
Steven Rogers, MD, Director of Emergency Behavioral Health Services, stands in one of the hallways of Zone C. Behind him is the mobile station of a patient observer, used when a patient needs to be under constant immediate observation (every room is monitored with a video feed to the nurses station).

Nine new patients have come in over the past hour, and most of them are sitting on chairs in the hallway in front of the nurses station. As each child comes in, he or she is given pajamas, a Johnny to wear over the pajamas and a blanket for their shoulders; all of their clothes and possessions go in a bag that is stored in a locked closet. Most of the children are with parents, all are hunched in their seats, with their heads down. One younger boy is sitting sideways in his father’s lap, leaning against his father’s chest. The father is cradling him. Both of them look defeated.

The patients and parents in Zone C today are as diverse as Connecticut: from wealthy suburbs and working-class city neighborhoods. There are kids from Stamford, Hartford, East Lyme, New Britain, Granby and many other towns here today.

There are kids who are not functioning at all, not taking care of themselves, not participating in their own lives. There are children who are sad, children with anxiety, children from struggling families and children who are intellectually challenged. There is a 9-year-old who has been in and out of residential facilities, a nonverbal boy with autism and a child who tried to hang himself. There is one who is suicidal, one who was out of control and throwing things at school, one who exhibited sexualized behavior in a school classroom, one having hallucinations and one who attacked a fellow student with a knife. “We get kids who are 6 and who have seen more trauma than you or I would see in three lifetimes,” says Ryan O’Donnell.

While the kids in the hall are quiet, the nurses station behind them is bustling with activity. Inside, it feels like nothing so much as an air-traffic-controller facility. There is a bank of computers down each wall, and a psychiatrist, social worker, nurse or other clinician at each one, looking at records, researching a case or finding outside care. Most are also on the phone, talking to other doctors, schools, state agencies, behavioral health facilities or family members. And there are conversations back and forth across the room. Each person is dealing with three things at once, from asking about a patient’s bedding change to dealing with a government agency. But there is no tension. Again, there is that uncanny ability to handle stress and extreme challenges with composure.

One social worker is on the phone with a behavioral health provider trying to find a placement for a 17-year-old girl they are treating who had been at Connecticut Children’s. The girl has been involved in sex trafficking, drug use and crime. She needs to be in a secure residential facility, but, as the social worker points out to the clinician on the phone, she has already been treated at the top facility in Connecticut, and there really isn’t anywhere else to put her.

5 p.m.

Jenifer Long, RN
Jenifer Long, RN, displays a personalized note from a former patient in Zone C. The sentiment is one indication of the love and caring that pervades the facility.

A teenage boy is ready to leave Zone C. Someone gets a wheelchair for him, and someone else hands him his bag of possessions. The boy’s parents are there to walk out with him, and everyone is smiling, including the staff (kindness, caring and love simply radiate out of this place). The security guard uses his badge to open the doors, and they all head home. A happy ending for one family, at least for now. The other patients will likely be spending the night here and maybe tomorrow, too.

Where the average stay in the general Emergency Department is measured in hours, the average stay in Zone C is measured in days. That’s partly because it takes time for a behavioral health crisis to pass and partly because the state’s healthcare system isn’t really geared to address the demands caused by the steady increase in children, adolescents and their families seeking care—there simply aren’t enough community-based resources to provide ongoing care.

Click here to learn more about Connecticut Children’s new Transitions Clinic.

Some of the children here will go back to school, some will go home and some will be placed in residential or inpatient facilities for longer-term care. Many of them will take advantage of the help offered by Connecticut Children’s new Transitions Clinic.

If you would like to help Connecticut Children’s provide essential Behavioral Health services for children in crisis, won’t you please consider a gift today? Please contact Aliza Elwell at the Foundation at 860.837.5737, or email aelwell@connecticutchildrens.org.