Hospital staff provoking psych patient

[adamjh3]

I ran a call that really chapped my a:censored::censored: last week, and I want to get your folks input on it.

AOS to a (really bad, dark, dirty... all the nurses just came on 5 minutes ago and the time is 1346) Board and Care facility, PD is on scene. Pt. is a 275lb pound (muscular) male in his mid fifties. According to one of the officers on scene, they were called out because the Pt was being aggressive towards the staff and punched several holes in the wall along the hallway.

Pt has a Hx of Schizophrenia, psychosis, OCD, and hypertension. Pt is on a conservatorship. Facility wants Pt transported to hospital for Psych eval.

Pt is found sitting upright in a relaxed position on a chair outside the board and care facility chatting pleasantly to one of the PD officers about the super bowl.

Ax shows the Pt has several superficial lacerations on his R hand which PD wrapped with a towel from the facility. Pt is A&Ox2, he thinks it's 1986, but answers most questions appropriately while often going off on separate tangents after answering questions. VS are stable and within the Pt's normal limits (according to Hx on paper-work received from facility) Pt denies N/V, states R hand pain due to lacerations. Pt is dirty, as though he hasn't showered in several weeks, and his clothes are unwashed.

As far as Rx, we irrigated the wounds on his hands with sterile water, wrapped his hand with gauze. Tx in POC, ASPT.

Here's where my questions come up.

We arrive to the hospital, offload the Pt and get into the ER. We're informed by the charge nurse that there will be an offload delay. That's fine, we're paid by the hour.

Pt becomes very vocal, making passes at women that walk by, and speaking nonsense at a very high volume. After a minute of that I told him to quiet down. Pt states that he's been to this facility before and does not like the staff. I run my "Hey, I've been cool with you, right? I played your favorite radio station on the way down here. You don't want to get ME in trouble, right? So just quiet down until you get a bed and I'll make sure they treat you right"

Pt quiets down, for about 5 minutes, but makes a remark when a security guard passes by. One of the staff pops their head out of a room a few feet away and says "Hey, shut your mouth, this isn't the streets!"

Patient becomes vocal again, tells this person he doesn't give a :censored: etc. Staff person marches up to the gurney asks the Pt if he wants a glove in his mouth (yeah, those words). Staff person continues yelling at the patient, taunting him to get off of my gurney and swing at him. The pt starts removing his seat belts, so I jump in and put my hand on the staff persons chest and gently push him back saying "Hey, man, don't provoke him, you're being childish," And proceed to talk the patient down. Staff person looks at me and my partner and walks back to his little room.

I then find out that the staff person is one of the ER docs. Not an ER tech like I originally thought.

Not my concern, I'm there to do what's best for the patient, and having him jump off of my gurney and start swinging at a doctor is not what's best for him.

I feel I was in the right with what I did in diffusing the situation; However, my partner has a different viewpoint.

He brought up several counter arguments for what I did to include "Hey, the doctor could have destroyed your career for interfering with him" "What if the doctor was testing the patient's threshold for something?" and "Hey, if he jumps off our gurney, he's in the hospital and not our problem anymore."

What do you guys think? Did I make the right call? Should I have handled the situation differently?

 

[Shishkabob]

Honestly? Let the doctor get it in the face if he wanted it. Your job is the patient, not idiots around the patient. I'd tell the 'bystander' inciting the patient to back off, but whatever happens happens. I tend to not lay hands on anyone who isn't being aggressive towards me.





As for your partners comments on your career 'being destroyed', or it possibly being a test the doctor was giving... you partner is obviously new to EMS....

 

[JPINFV]

Hell yes. Diffuse the situation. There is no, "How pissed off can I get the psychatric patient?" test, and if anyone's career would be destroyed for that stupidity, it would be the physician's career.

By chance, would there be some place that you could take the patient that would be more out of the way? Such as close to the ambulance bay doors or a non-patient care room (like a consult room) that would have been more isolated?

 

[adamjh3]

Honestly? Let the doctor get it in the face if he wanted it. Your job is the patient, not idiots around the patient.

Isn't preventing the patient from having another one of his mental breakdowns part of caring for the patient? You remove the source of burns from a patient, shouldn't we also remove the source of mental anguish if at all possible? Just opening this up for debate.

I tend to not lay hands on anyone who isn't being aggressive towards me.

To clarify it wasn't a "hands-on" situation with the doc. You know when your buddy grabs your shoulder and pulls you back from doing something stupid? It was more like that, not actively pushing him out of the way, more of a physical suggestion, if you will. If that makes a difference, I don't know, just throwing it out there.

As for your partners comments on your career 'being destroyed', or it possibly being a test the doctor was giving... you partner is obviously new to EMS....

He's actually one of those "I've been here for x years I know everything there is to know about EMS" guys

By chance, would there be some place that you could take the patient that would be more out of the way? Such as close to the ambulance bay doors or a non-patient care room (like a consult room) that would have been more isolated?

The incident was at one of the smaller county ERs, it's pretty much all hallway from the bay doors over to the waiting room doors, with beds all along the side. I've only been to this hospital a few times, so it's possible there was somewhere, but I didn't even think to put him somewhere like that. I will keep that in mind for future similar incidents.

 

[Shishkabob]

To clarify it wasn't a "hands-on" situation with the doc. You know when your buddy grabs your shoulder and pulls you back from doing something stupid? It was more like that, not actively pushing him out of the way, more of a physical suggestion, if you will. If that makes a difference, I don't know, just throwing it out there.

Someone touches me that I don't want touching me, it's battery and they get a fist to the face. That's not e-peen, that's fact.


(Though, patients that do it tend to get benzos and sleepy time)

 

[jjesusfreak01]

Someone touches me that I don't want touching me, it's battery and they get a fist to the face. That's not e-peen, that's fact.


(Though, patients that do it tend to get benzos and sleepy time)

To be fair, they were assaulting your patient, moreso if they knew it was a psych patient. And it is your patient until you have given report to the staff and transferred care.

 

[firetender]

so I jump in and put my hand on the staff persons chest and gently push him back saying "Hey, man, don't provoke him, you're being childish,"

That was where you made yourself vulnerable. In some places, they'd try to call that "battery".

You would be justified in saying; to ANYONE, including the CHIEF of Staff, "This is my patient. He's on my gurney. When he's on your gurney, I'll back down, but until then, you're upsetting my patient putting us all in danger. Please step away or I'll ask a Police Officer to intervene."

 

[lex]

Aside from agreeing that you definately have to be careful making physical contact with anyone, but otherwise it sounds like you handled the situation very well.

I know I have steped on hospital staff members toes, and on a couple of occasions the cops, when it comes to my patients wellfare, especially with psych patients, and patients who aren't in a position to speak for themselves.

You mentioned in your post that you "talked your patient down". I know that it depends a great deal on the situation and the patient that you are dealing with at that particular time, but any tips for a provider who's still learning how to "talk down patients" herself? Working in a very rural area there are times when I've talked patients down in situation like you mentioned, but even more so am looking for advice for more long term situations, with patients who want to refuse service but who are not competent to do so.

Thanks!

 

[mgr22]

To the OP, sounds like a tough situation that needed some intervention during that confrontation you described. If I'd done exactly what you said you did, the only thing I might be second-guessing myself about is adding "childish" to your response to the ER doc. You might be right about your characterization, but it's still a value judgment that isn't needed, and could exacerbate the conflict.

I wasn't there, I might have done the same, and I've certainly done worse, but...you asked.

 

[adamjh3]

Thanks for all the feedback, everyone. So in summary: Any physical contact, even if it's not with the intent to harm, is a no go. And keep my opinions to myself.

Lex, as far as "talking patients down" it is, as you said a very situational thing. A lot of times I try to find something I can relate to the patient on, then use that when they start getting out of hand;or if you hold an ongoing conversation it keeps them from actively thinking of much but the subject I've found that works really well on people who have a lower mentality, like folks with some form of mild but functional mental retardation.

Another thing is to just break them out of whatever they're focused on by asking a random question. "Hey, Paul, what's your favorite food?" It will generally break their train of thought at least, giving you a chance to think of something else to do.

These won't always work, so don't use them as a substitute for good SA or keeping up with knowing how to defend yourself.