“You need to assess this patient RIGHT NOW! I put in the consult an hour ago! He’s making a racket in MY ER!”
I sigh inwardly and look up at the emergency room staff who is yelling at me, oblivious to the fact that he is making a bigger racket than the patient he’s referring, then I peer over his shoulder at the tall angry middle-aged man with dark sunglasses pacing at the entrance of the psychiatry emergency room.
I say: “I’m reading his chart right now, and will see him as soon as I’m done”
“That’s not good enough! I want to know EXACTLY when you’ll see him!”
Wow..sorry I missed the memo about me being your slave.. (of course I don’t say this out loud, but I think it) I look up at the clock on the wall, it’s 9:50 pm. “I’ll see him in 10 minutes” .
“OK” he puffs, looking a little deflated and disappointed he had no excuse to keep yelling. He marches off to his next poor victim-uh I mean- patient.
After he leaves, I roll my eyes behind his back (I know-shame on me!) and smile at my team of two. He’s not ruining our shift. The nurse, Jack shakes his head and laughs. He has more experience than I do in this ER. Jack is funny and usually relaxed, and a good advocate for our patients- I’m always relieved to find him on duty when I’m on call. Bonus, he is tall and well built, and when in the ER, it never hurts to have team members with more muscle than you do-just in case physical strength is needed.
Peter, the med student, was the other member of our team tonight. It was the first time I’d worked with him, but I could tell, he was one of those students who actually shouldered some of your load. I could delegate to him, and I could trust him.
To him I take a”teaching moment” to say: “never just give in to pressure to see a patient quickly without going in armed with all the information you can get. Rushing may give you the feeling that you are getting things done quickly, but trust me, reading the chart is a good investment of your time, especially when you’re dealing with a potentially dangerous patient. Your interview with a patient like this is mostly a mental status exam. Honestly, what information will you get from a screaming patient anyway? You need to enter the interview room with a preliminary idea and plan”
You learn these things from experience, from the lucky “near-misses”. In my first month in psychiatry, I spent over an hour alone in a room with a patient, totally clueless that he had a history of violence and antisocial personality disorder. The last time he had graced our ER with a visit, he had thrown and broken furniture in the very room I sat with him! When the staff -who knew him- realized I was interviewing him, he was kind of horrified, and took me off the case. “I’ll deal with him, don’t go back into that room!” he had barked.
I had to hit my forehead with the heel of my hand-again-for my naiveté. I had been totally taken in by the patient’s heartbreaking story, and had not picked up on the antisocial part at all! What can I say? It’s my fatal fault, my achilles heel. I trust. I believe. One day after getting back a positive tox screen for a patient, I said to the staff: “but how can this be? she said she didn’t use any cocaine this weekend!!” The psychiatrist teaching me chuckled, looked up at the heavens and said: “Wid, have I not taught you anything during your time in addictions and personality disorders? PEOPLE LIE Wid. people lie”
So, back to the current situation. Let’s call our patient Mr.Maxwell. He is pacing the hallway like a caged animal. We are so busy with other consults that I decide I can’t afford to take the student or nurse with me to see him. Better divide and concur, I thought. In hindsight, this was my first mistake.
I invite him into the interview room, and that was my second mistake-why for the sake of protocol, even for the sake of privacy, cage in someone already wild with anxiety or anger? I think I at least kept the door behind me slightly open.
“Hello Mr.Maxwell, sorry to have kept you waiting. I’m the doctor on call tonight. What’s going on? You obviously don’t want to be here, so how’d you end up here tonight?”
He starts talking. It’s often a good idea to let people talk for a few minutes at the beginning of an interview, and listen with all your senses. In seconds I’m thinking: this guy is not just anxious or angry, he’s manic. No I mean MANIC manic. And psychotic. Not good.
There he is, leaning back in his chair, all smug, 3 days of stubble on his face. He emanated grandiosity. He thought he was God’s gift to mankind..or womankind. He spoke so fast, it was hard-and pointless- to try to follow everything he said.
“….I want to get out of here. How long is this going to take? How old are you anyway? Do you know doctor, I bought a motorcycle recently? and a guitar? I could show it to you, I could sing for you..
Goosebumps. Distant alarm bells started to ring, the hair on the back of my neck was raised, my spine tingled ever so slightly. I ignored it. (ding ding ding.. mistake number 3) I’m a brave resident aren’t I? I can handle this. I’m no coward. Who else is going to do this job if I bail? I’m not bothering the staff at home.
“That’s Ok Mr. Maxwell, no need to sing for m-“
He started singing in a low voice
“..And girl I’m a bad boy so I gotta do what I gotta do
Risk my life
In the late night
Cause girl I’m a bad boy yeah..”
He was wearing those mirror sunglasses, did I mention that? even though we were indoors. I couldn’t see his eyes but I knew he aggressed me. A woman always knows. It’s like a physical punch in the gut. I felt sick, and stood up, backed away to the door saying:
“Oh look at that, my pager just buzzed, I’ll be right back. So sorry to cut our interview short”
He was not happy I had cut him off.
I rushed to the nursing station, “Jack! that guy is gonna explode on us. He is floridly manic and needs to be kept against his will, but he will FREAK. We’re going to need the code white team present before I tell him I’m signing a confinement form”
Jack smirked: “Who, that guy? noooo” he waved his hand dismissing my concern, “I know him, he’s been here before, he’s ok. He scared you? I can handle him”.
In my head: yes he scared me. On the outside, I was a bit embarrassed. maybe I am a scardy -cat -girly-girl-coward after all. But I don’t like the way this is going. Not wanting to appear uncool, I cave in (mistake number..oh who’s counting?)
“Ok, Jack, just be careful if you go talk to him. I still think we should call the whole team first”.
“Nah, I said I’d handle him”
I sat inside the somewhat protected area of the nursing station. It’s sort of like a glassed in cubicle where we write our notes. The whole upper half of the walls is made of glass, and it’s “semi” sound proof.
I was on the phone updating the psychiatrist on call with me, and filling the form needed to keep this man in hospital -unfortunately against his will-and through the glass window I kept an eye on the two men talking.
Suddenly Mr.Maxwell takes a dive at Jack! and they disappear from my view and onto the ground. Between punches Jack is yelling: code white! call a code white!
-which I did with shaking hands and voice, then waited for an agonizing minute for the team to rush over to us. I hate that feeling of utter paralysis when I’m faced with violence.
Eventually the team came, and the patient was restrained and medicated..things calmed down. Neither Jack nor Mr.Maxwell were badly hurt, and I was fine.. but you don’t forget a night like that. . another near-miss. If Jack, who was physically more than a match for this patient , was attacked in an open hallway, I shudder to think what could have happened to a 5 foot 2 inch wisp of a girl like me in a closed interview room just moments before.
The lessons I take from this experience, the ones I teach students I supervise:
trust your gut
don’t let others make you doubt your perception
your safety comes first
don’t have to prove yourself to anybody
don’t rush into labile situations unprepared
don’t succumb to outside pressure
Note: All the names/characters have been changed in this story, though the essence of it is very true. Also, please don’t think that people with mental illness are violent. They are more likely to be the victims of violence than the perpetrators. In this situation, the patient is the one who suffered the most, and it wasn’t his fault. Sometimes the violence is just the result of anxiety, or bad situations like this one.