Posted by: Kate | October 30, 2008

Delayed Response

I knew this patient was going to present a unique situation before I ever laid eyes upon him.

As soon as I entered the Emergency Department, a nurse scurried over, clenching his chart and wearing a pained expression.  “I am so glad you’re here,” she whispered.  It is never a good sign when they are that pleased to see me.  She ushered me into the office so that she could close the door and share her dissatisfaction at a more satisfying volume.  “This guy is such a jerk.  He has tried to bolt twice already.  We had to call the cops in to keep him here.  He snuck a cigarette in the bathroom.  I’m so over him.”

Meanwhile, I was clearing off my workstation, which inevitably gathers junk mail and coffee cups because the doctors who share the office have strikingly little concern for anything that can be relegated to their peripheral vision.  I arranged a clipboard with the necessary forms and a pen.  I asked her a few questions about how it was that we came to be graced with this man’s presence.

“He had at least one suicide attempt last night.  He cut his arm pretty bad.  He also drank and took benzos, but we’re not sure if that was part of the attempt or if it came after.  He said he went out deliberately to buy the razors first, though.  Not sure who called 911, but here he is.”

I heard a very similar story from the patient, once he woke up enough to chat.  He had lots of mumbling, lots of finger-pointing and minimization of his own role in his problems, but generally seemed to be an articulate and reasonably intelligent guy.  He is my age, give or take, and works a heavily physical sort of job, so when he said that he was prone to “random acts of violence, where I do some real damage,” I believed him.

Yes, he had tried to kill himself last night, and no, he didn’t feel safe to go home now.  But he would only consider going to one specific hospital.  If there were no open beds, he would just go home and sleep it off.

In the moment, I nodded benignly and decided not to challenge him on that point.  I knew that, given the severity of his actions the night before, home was not a realistic destination.  But timing matters.  There was no need to thwack him upside the head with that little tidbit just yet.

I left the room and started making phone calls.  There were no beds at his Facility of Choice.  Or perhaps he’s on the Super Secret Unacknowledged “Do Not Admit” list there.  In any case, it was a firm “No.”

My next decision was unequivocally right.  I called the police.  I asked that two officers come and stand outside the door while I informed the patient that not only was his preferred placement unavailable, but I was also going to involuntarily admit him to the state hospital due to high flight risk.

In almost every assessment I have done, I have been alone in the room with the patient, with the door closed.  There have been a few exceptions, due to patient preference, overcrowding, or severe body odor, but those are rare and less effective than an interview with some privacy and minimal distractions.  My first talk with this patient was one-on-one in the room, and it went fine.

Thus it was that, when I returned to the room, I closed the door behind me and sat in the chair beside the bed.  The police officers were in the hallway, but out of the patient’s line of sight.  I didn’t have my clipboard this time, just myself and some news this man did not want to hear.

His immediate response was to lurch out of bed – away from me – and punch the wall.  Then he began to pace, and swear, and threaten, and generally demonstrate that all remaining traces of the sedatives he had taken the night before had been flushed out by adrenaline.  He wasn’t specifically blocking my exit at this point, but the layout of the room was such that he could have easily won a race for the door.  I decided to remain exactly where I was, back straight, hands in my lap, and just watch.

Within seconds, the police officers moved so that they were side by side in the doorway: a wall of black uniforms and serious faces on the other side of metal-reinforced glass.  The patient spun around to look at them, and displayed his gratitude for their public service with a two-fisted one-finger salute.  He marched over to the door, wrenched it open, and made a physically possible but highly unlikely sexual declaration to the smaller of the two officers, who replied with a suggestion that he sit down and shut up.

He opted not to comply.

Instead, he attempted to simply walk through the officers, perhaps intending to rearrange their atoms a la Charles Wallace in A Wrinkle in Time.  It didn’t work.  He threw a punch.  They caught it, and repeated their requests for him to be seated and silent.  I was doing my best to lead by example, with careful posture, mild facial expression and closed lips, all to no avail.

The patient turned and took a half step away from the officers.  He made no threats toward me, made no obvious movements in my direction, but my friends the policemen decided to limit his options regarding movement and verticality.  I appreciated their caution.

I waited until they had left the doorway and were arranging more suitable, horizontal, accommodations for the patient.  (This simply meant getting him to recline on the hospital bed, an officer on each side, while much of the fight drained out of him and he began to weep.  No handcuffs or face-meets-floor action today.)  Then, very calmly and quietly, I stood up and slipped out the door to complete the process of the patient’s transfer and involuntary admission to the state hospital.

Throughout the encounter, I never had an adrenaline rush.  I never felt threatened or intimidated.  I also didn’t feel perfectly at ease amidst the competence of the police and the immediate presence of qualified medical personnel.  I didn’t pay much attention to my own thoughts and feelings at all.  I was paying attention to the patient, absorbing his responses, trying to hear his words so that I could better understand his actions.  After it was all done and he had left the building, I just finished up the paperwork and moved on to the next thing.

It wasn’t until several hours later that I had time to reflect on the morning’s events and have some appreciation of the potential danger of it all.

I’m glad to have Thursdays off.

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Responses

  1. Ah geeze, Kate….I got all nervous for you just reading this.

  2. You definitely have a tough job. I’m glad it turned out okay.

  3. Girl, you are good. Your instincts are right on and since you never felt fear or anger the patient could not detect that in you. Amazing. You seem fantastic at your job despite the morons you have to work with.

    Once again, I salute you.

  4. It’s amazing how frequent this sort of thing is! Every time I’ve been in an emergency room, there has always been at least one person being supervised, restrained, sedated, or otherwise kept from injuring himself, the nurses, the mental health staff… every single time. And I’ve been to the ER a lot — not so much for myself, but because I tend to be the one who ends up taking friends, roommates and family members in need. And I’m always incredibly impressed by all the people who deal with this sort of thing on a daily basis. Thank you for doing your job… but make sure you’re safe, OK? No being alone in the room when sharing bad news with someone who has admitted to being prone to harming others!

  5. And he exhales, releasing the blue in the face heart thumping gasp. Miss Kate you are one in a brazillian. thump thump….thump thump…. ahhhhhh. I’m glad the situation didn’t degrade to where it could have gone and I’m happy you are safe and sound with your Thursday dayoff.


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