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prnanxiety · 2 days

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4/28/24

Really, really proud of my team today. Beyond excellent response to a potential disaster scenario this morning.

Turns out overnight we got an admission to our unit who was just banned from, apparently, every other hospital in the area. At an outside hospital we occasionally accept patients from, he assaulted 3+ staff members; multiple new assault charges against him. They didn't want him anymore, so they sent him to us in 4 point restraints. He was knocked out from a sedative the night before, currently sleeping in his room.

Always fun to hear someone say "Yeah they just seriously attacked like four or five other people. Alright Gomdy, it's your turn!" As soon as report was over, I updated the security guard on the situation, called the security department to be aware of the pending need for backup, and very, very politely informed the doctor on call of the very, very important need for his prn injection to be strong enough. We were not taking any chances.

Guy wakes up an hour after report is over, walks into the hall, asks me where he is. I calmly answer his question, he shouts "FUCK!" and goes back into his room. Security and I are already watching each other closely, and he calls for back up just in case.

For the next twenty five minutes, the guy is just asleep in his room. I hear him cough and hock a loogie, so I walk in and talk to him a bit. Denies knowing why he's in any hospital to begin with, says the police kidnapped him. He agrees to breakfast. I bring it to him in his room. I am not fucking around with "No, you need to eat out here with everyone else." Not today, not like this. Someone who gets special privileges on the acute psych unit is someone who is not doing well.

While all this is going down, I'm constantly, constantly keeping everyone in the loop. Resident doctor? Let him rest, come back when he's ready for her. House Sup? Meets us in person to discuss the security risk. The security officer present at the time is the same guy who was hurt several months ago with one of my other patients, so he deserved to see that I was doing everything I could to make sure there wasn't going to be an event, and if there was, that it would be quick and decisive.

After I bring the patient his tray, what, fifteen minutes pass? And i hear a clatter. I go in there and find his food half eaten and spread lying against the wall, a few feet from him, clearly thrown. I ask him what happened, he says "I dropped the tray." Yeah okay. I ask him "Will you help me clean it up so I can get it out of here?"

The thing some people may not realize is, that's a valid assessment question, and his answer was "yeah." He immediately started helping me pick the food up off the floor and put back onto the tray so I can take it to the dirty food cart thing. I ask him if there's anything I can help him with; he wants to speak with "whoever's in charge." I tell him I'll contact the doctors, etc.

That was the moment I started suspecting it; that "emotional outburst" syndrome, or whatever its called. Where someone has a brief episode of losing their shit completely, and then regains control again soon after. That comes before the probable meth addiction. As far as I'm concerned, if he didn't have the former, he wouldn't have the latter.

But that's getting away from myself. Someone calls, and it's his mom. She asks me if we have a patient with his exact name and description; I put her on hold, and check if he knows the lady; He does. I quickly and quietly ask him to file the form that says she's allowed to know who he is and why he's here, and what does he do? He complies! Perfectly cooperative, he rights himself, takes my pen, signs the form, plops back down in bed.

I go back and tell his mom "Yeah he's here." She's quieting down a cat in her house, then asking me for details. "Assaulted a bunch of staff members." That gets an "oh, oh, ohhhh oh dear," from her, the kind only a little old lady can give. She's gotta be his enabler, I think to myself.

This whole morning, he's got that standard affect I've come to find in men with severe anxiety disorders and drug addictions; brief, one word answers, feigned lack of knowledge of a subject, guarded/masked disclosures, and desperation to discharge. All his interactions with me, when they're cooperative, are filled with desperate and practiced self control. One that doesn't come with a deeper feeling of inner peace, but instead from having learned "if I lose my cool now, I will be worse off for it."

The resident and the head physician come by, and as soon as they're on the unit I make sure the security guard calls for back up. Once the two doctors are ready to go talk to the guy I tell them, "Hold on, I've been building a rapport with him. Let me go in there first, and let me introduce you two."

And they do it. We go in, and he's talking with them from his hospital bed. All the standard questions anyone wants to know when they're an involuntary admission. "What's going on? Why am I here?" The doctors start asking him what he remembers, and he reveals he of course knows a little bit more than he let on. He remembers feeling "parasites" all over his skin, and telling his mom he wants to die. He fully well remembers all of it, I'm sure. Just doesn't want to admit it, out of fear of being punished. And at one point he asks "And my cat! Where is my cat?" That was when I interrupted the doctors. "I spoke with your mom briefly on the phone this morning, and she was quieting down a cat who was mewing loudly. Does that sound like your cat?" Immediately, the guy's face relaxes. My god, I think to myself, that was a really fucking lucky phonecall.

"When can I leave?" That last one is the one that tests everyone, and I don't envy them for being asked it. They tell him "Not today," and "we'll see how you respond to treatment," or something like that. Guy's already clearly desperately controlling himself. Asks for permission to go use the patient phone on the unit. They tell him "yes," and he gets up to go use the phone.

At this point, I've been watching him closely enough to go "Okay, yeah, that phone call is not going to go well." I take the opportunity to warn another nurse, who's already watching, what I'm sure is about to happen, and then go pull meds from the med room. While I'm in there, I hear an unmistakable banging sound; Guy's smashing the phone against the receiver. Yup, needs something to calm down before he attacks.

I thought that morning when I called the doctor to ask for a stronger dose I got one, but the head doctor on the unit who saw him stopped me and told me "No, up the haldol dose. Make it stronger." Kinda surprised me, but in a good way. They understood exactly what I was trying to avoid. I had to go back and get more haldol in a syringe, but whatever works.

I had two syringes of sedatives ready pretty quickly all things considered, but we still waited for more security to arrive before doing anything. The patient had already gone back to his room after getting whatever bad news he heard on the phone, it turns out, so we were just preparing for the worst before doing anything.

It ended up being a party of, what, eight people? Three nurses, a technician, and four security guards to go into this guy's room. Each of the guards agree on what limb they would grab if it came to that. But I stopped them up front and said "Hey, before anything happens, let me do the talking. I'm gonna go in there, introduce myself and explain what we're here for, and we'll go from there."

So, when we went in there, I politely explained "I see you want to calm down, we have some medication to help you with that." And what does he do? He willfully complies! Just rolls over onto one side and exposes his shoulder for me. I give the injection pretty quick, apply my bandaid, and allow the other nurse to get his other shoulder. The guy was clearly forcing himself to manage his anxiety in the moment, but he wasn't attacking anyone or screaming. Nobody even needed to lay a hand on him.

And he just slept like that for the rest of the shift! Not totally sleeping, mind. I'd leave lunch and dinner trays in his room, and come back an hour or two later to find them half eaten. He knew food was there, he knew we were letting him rest, and he wasn't fighting us on it. No violent outbursts, no nothing. Just some angry phone treatment and food to clean up off the floor.

This event could have so easily been another security guard out on leave, or a nurse out, or what. But it wasn't, because everyone communicated and worked together. Completely avoided any events entirely. I don't want to pretend we did better than that other hospital did, because I'm pretty sure we were on the latter half of withdrawal, but I won't deny we displayed some true skill in our interventions this morning. I know it's going to happen eventually, but so far I've never been assaulted on this job.

I don't want to write all this without talking about the patient, though. I think the root issue with guys with his presentation is basically, the anxiety. They don't have an internal locus of control, beyond "Shut up and calm down." They can't examine themselves effectively; it's either not part of their thought process or its too painful. So when they've got a thought, or a feeling, or a situation, causing them so much pain and fear, they can only tell themselves "I can't lose my shit right now" to get through it. Nobody can survive on "just keep it together" forever.

Without any understanding or guidance, they're just going to stay in a bad situation as it gets worse. Eventually turning to drugs like meth to try to make the pain go away, which of course only makes everything exponentially worse. Eventually they snap, in whatever form that takes. But when they regain control, they don't experience that release of tension, or fear. They just go back to keeping that internal storm barely under control.

My heart goes out to this population. I don't know how to help them, beyond my job. And my job is really only to help him through the withdrawal and get him out of the crisis state of wanting to kill himself or hurt anyone else. After he leaves here, If the social worker can't help him effectively, he goes right back to whatever resources he has available to him. And he's in this situation because those have already failed him. Lots of people say "patients in these situations don't get better until they accept that they need to get better." But how does someone like him reach that point?

Hey, but that security guard has come to appreciate me a lot though. He frequently tells me he likes working with me, because I'm so "By the book." Well damn dude, I'm so thankful you're here to let me do my job safely! Can't believe administration tried to tell us we didn't need a full time security presence on this unit. Buncha fuckin chumps.

#nursing #psych #psychiatry #dear diary #diary entry #psychosis #nurse #schizophrenia #cw: drugs #cw: addiction #cw: meth #amphetamine #mental health #addiction #assault

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