A viral video from Baltimore is drawing attention to a crisis that's unfolding in emergency rooms across the country: Surging numbers of patients with psychiatric conditions aren't receiving the care they need.
On a cold night in January, a man walking by a downtown Baltimore hospital saw something that shocked him. He started recording the incident on his phone.
Imamu Baraka's video, which has been viewed more than 3 million times, shows security guards walking away from a bus stop next to the emergency room of University of Maryland Medical Center Midtown Campus.
One is pushing an empty wheelchair. The woman they left there is wearing a thin yellow hospital gown and socks.
"Wait, so you're just going to leave this lady out here with no clothes on?" Baraka asks the guards. They continue walking away.
The woman, later identified as a 22-year-old named Rebecca, staggers near the bus stop. She appears distressed and confused. She moans and shouts.
"Are you OK, ma'am? Do you need me to call the police?" Baraka asks.
Nationwide, hospitals are struggling to provide services to people with psychiatric emergencies. Between 2006 and 2013, ER visits increased by more than 50 percent for psychoses and bipolar disorders and depression, anxiety and stress reactions according to the Healthcare Cost and Utilization Project, which compiles health care data. Between those years the number of visits climbed from 3,448 visits to 5,330 per 100,000 U.S. patients ages 15 and older.
"We're just failing patients with mental illness and it's just getting worse as time goes on," says Dr. John Rogers, president-elect of the American College of Emergency Physicians.
In the viral video, Rebecca has a visible wound on her forehead, and her breath forms white clouds in the cold. Baraka calls for an ambulance, which brings her back to the hospital that just discharged her.
Rebecca's mother, Cheryl Chandler, says she happened to click on the video, not knowing it showed her daughter. "Once he focused on her face I realized it was her. And I think I went into shock initially," Chandler says.
That realization set off a desperate search. The hospital wouldn't tell her where she was. Chandler called the police. They found out that the hospital didn't readmit Rebecca, even though according to a federal regulator's report, Rebecca told workers in the ambulance, "I do not feel normal, and do not know what normal is."
Hospital staff put her into a cab that took her to a nearby homeless shelter, where family members found her the next day. She's been hospitalized on and off since the incident.
"She could have got hypothermia. She could have died. She could have been raped, she could have been killed," Chandler says. "All she wanted was treatment and they had two opportunities to do it and denied it both times."
Rebecca was clearly asking for medical care, her mother says, which ERs are legally required to provide.
"That, what I saw in the video, was my worst nightmare for Rebecca," Chandler says. Several years ago, Rebecca was diagnosed with bipolar and schizoaffective disorders. Her mom adds that she's a shy and lovable introvert who loves animals and making art.
Rebecca has insurance and had been in a residential home when she went missing, Chandler says.
The hospital has apologized and says it has already put in place measures to correct the issues.
Chandler says she hopes that means it won't happen to other patients. But she adds that Rebecca will continue to suffer from the hospital's decisions: "No part of Rebecca, because of this, is going to heal. No part. We can't make the scars go away."
James E. Farmer, a lawyer for Rebecca's family, says they're investigating now and considering filing lawsuits. "It's going to be difficult to determine the exact extent of harm to Rebecca," he says. "I could not imagine the psychological damage and harm that was done as a result of this."
The Centers for Medicare & Medicaid Services says the hospital failed to discharge the patient safely, among other breaches.
According to the federal regulator's report, Rebecca was "resistant to discharge and refused to get dressed into street clothes when requested by nursing." The hospital stated there was a "communication failure" which led to her discharge into the cold weather, though the report says it is not clear whether nursing or security staff made that decision.
Chandler says she's heard from other families with similar stories: "The only difference is it wasn't caught on video."
"They told me to leave"
Here's another story from Baltimore, about Laura Pogliano and her son Zaccaria. Zac, who had schizophrenia, died in 2015 of heart failure when he was 23.
Zac was sensitive and empathetic, and loved playing the piano, his mother says. He started to show symptoms of the disease when he was 16. He became paranoid, and started doing things like hiding kitchen implements out of fear that someone was trying to kill his family.
"His personality just drastically changed," Pogliano says. "He had a thousand rituals around things so that he wasn't harmed."
Then, as part of his illness, Zac started to think that he actually did have dramatic injuries. Like a gunshot wound or a pulverized ankle. He'd call 911.
"He got to the point where he would pick up the phone at the drop of a hat and say, can someone come and help me, I'm having a heart attack," Pogliano says.
This happened about 20 times in the two years before his death, she says. Often, ambulances took Zac to Good Samaritan Hospital, where Pogliano says the doctors would typically call her to let her know he arrived and would provide appropriate care for him. Later, hospital staff would call her to pick him up.
But one night after Zac went to the ER, Pogliano woke up hours later and got worried that she hadn't received a call.
"I just got in the car and drove over there, and he was sitting outside. It was early spring but it was still wintery, probably 40 degrees out, 45 degrees out," she says.
"All he had on was what he wore to the hospital, which was a pair of white linen shorts. I know he didn't have shoes on. ... And a hospital gown and no shirt. I said to him, 'Oh my gosh, what are you doing here?' He said, 'They told me to leave.' "
A hospital spokeswoman acknowledged that Pogliano was a patient there but says she found no indication that he was ever inappropriately evaluated or mistreated. She says she couldn't comment further because of federal privacy laws.
Emergency room doctors are frustrated at the growing gap in care for patients with psychiatric disabilities.
"We're kind of tired of waiting for legislators and regulators to act and to meet their responsibility to these patients in the form of providing funding for resources," says Rogers, the president-elect of the American College of Emergency Physicians.
Even as there is increasing demand, there are fewer resources to care for psychiatric patients. It can be difficult for doctors to find an inpatient bed — the numbers are have decreased dramatically over the decades. Rogers says there have been significant cuts to community and outpatient resources — so the emergency department is often the only place for psychiatric patients to go.
"Every emergency physician in the country knows this problem well and wants to do something about it," Rogers says.
Often the ER is not properly equipped with staff that can offer treatment to psychiatric patients. The emergency room's mission is to assess and stabilize, but the actual care they can provide psychiatric patients is fairly limited. A 2008 survey of ER doctors found that 62 percent of them said there were no psychiatric services provided while the patients were in the ER.
"And the disparity between our ability to care for a patient with a medical problem and a patient with a psychiatric problem is growing, that gap is increasing," Rogers says.
He says Rebecca's case is an outlier. More common, he says, is that ERs will hold patients for too long before they can transfer them somewhere that can treat them. In a recent poll of emergency physicians, 84 percent said that psychiatric patients are "boarded" in their departments for hours or days. Rogers says he's heard of patients being held for weeks.
And the options for where to transfer them are often limited. "And that's where it starts breaking down," he says. "The time that it takes to get someone transferred for something like that is just unacceptable....They wait, and wait, and wait."
It's a bad situation for everyone – for patients with psychiatric disabilities, and for other patients who have lengthy wait times because ERs are overwhelmed.
"They're being asked to do way too much with way too few resources," says Susan Stefan, a lawyer focusing on rights of people with psychiatric disabilities. ERs "have a specific mission, which is to provide emergency medical care, and they're being turned into essentially 24-7 social service agencies."
Stefan, who wrote a book about treating psychiatric patients in ERs, says it's common for them to transfer people to homeless shelters because they are not equipped to find people stable housing.
And there's another crucial point here: The ER is simply a bad place to treat severe mental illness, even as it is becoming increasingly central for those patients.
"The emergency department is probably the worst place for somebody in psychiatric crisis," Stefan says. "It's loud, it's chaotic and people don't take a lot of time because they don't have a lot of time."
And it's not straightforward to transform an ER into a place that is appropriate to provide treatment to people who are in the middle of psychiatric crises — although there are hospitals that are experimenting with new models to better serve these patients.
The Alameda Health System in Alameda County, Calif., is a model that both Stefan and Rogers point to. There, a doctor named Scott Zeller has set up a dedicated psychiatric emergency service — a department separate from the standard emergency room that can provide specialized evaluation and treatment for these patients.
The Alameda model reduced boarding times by 80 percent, according to a study published in the Western Journal of Emergency Medicine, and the fast, stabilizing treatment made it far less likely that the patient would need to be transferred to an inpatient bed.
If there were adequate services in place, most of the people coming to ERs for psychiatric crises wouldn't need to come there at all, says Jennifer Mathis, the director of policy and legal advocacy at the Bazelon Center for Mental Health Law.
"And much as everybody loves to talk about the need for mental health services, that doesn't translate into state policy and funding for community mental health services," she says.
The problem here, Mathis says, is political will. There's a big gap between politicians talking about mental health and actually making sure people are getting the services they need.