The Art of the Snappy Comeback or How to Render a Teenager Speechless

NotReady4PrimeTime, RN

I knew even before I walked onto the unit that it was going to one of those nights. The looks on my coworkers' faces when they saw my assignment told me more than I wanted to know. Why me? I wondered, but I already knew why. As the mother of three adults including a daughter who wrote the book on acting out, I have a no-nonsense, take-no-prisoners reputation. That's how I came to meet Desiree. (All names changed to protect the guilty!)

Desiree was 16 years old and had been admitted to our PICU two nights previous after an overdose of Lioresal (although why anyone would choose that as a drug for that is beyond me). One of the adverse effects of therapeutic baclofen is psychosis and this girl had it in spades. She had been put in four-point leather restraints as she became increasingly violent, only to rub the skin on her wrists and ankles raw. The leather restraints were removed and replaced by strips of flannel sheet. In an effort to blunt the screaming, thrashing and attempts to bite or kick anyone who came near, she had been started on a Versed infusion and titrated up then up some more.

I entered the room to hear this very pretty young woman scream out that she was going to get out and kill us all. The hospital had sent a security guard to act as a sitter. The poor woman, who didn't look much older than the patient and as if a strong wind would blow her into the next county, was clearly unprepared for this experience. She cowered in the corner, making me feel all that much more thrilled.

Now, our unit rarely has this type of situation and the nurses are not well-versed in the treatment of psychotic individuals, and they'd restrained this girl with both hands at her sides. She realized quite quickly that she could shimmy down on the bed and sit up, thus bringing her teeth much closer to her tormentor. Wishing fervently for a whip and a chair, I nevertheless approached the bed and introduced myself. I calmly made conversation with her and after several minutes of straining against the restraints trying to head-butt me as I passed by and calling me names while I ignored her, she suddenly flopped onto the bed. I pounced on the opportunity to untie the hand closest to me and extend it above her head, tying it to the frame under the headboard. When she figured that out, she was even more enraged.

Time passed and the medical staff rounded, writing an order for me to start weaning the midazolam. I whispered to the attending that I'd only do it if he brought me a tranquilizer gun then did as ordered. At 2300 the security staff changed over; the night guard was a university student named Kevin, a good-looking young man of color. Our charge was sleeping when he arrived and we sat in the dimly lit room quietly going about our business.

Shortly after midnight, Desiree woke up and noticed that there was a new target for her attention in the room. For a while, she was very polite, almost flirtatious while she chatted with Kevin and even though her speech was peppered with F-sharps and other obscenities, I started to think she might actually be a nice girl underneath it all. After a while, Desiree drifted back to sleep and Kevin opened a textbook to study for class the next afternoon. While I wasn't busy, I checked out interactions between baclofen and midazolam and was very concerned to find that midazolam potentiates the adverse effects of baclofen, in particular, the more problematic psychiatric ones like hallucinations, paranoia, and psychosis. I got an order to stop the midazolam right away.

Don't let anyone tell you that midnight is the witching hour. I KNOW it's 3 am! Desiree woke with a bang and began swearing and screaming, almost incoherent in her rage. Kevin stood and asked her not to threaten me, that she needed to calm down and go back to sleep. She growled at him and then with narrowed eyes, she looked him in the face and called him a six-letter profanity that starts with "N". I got in as close to her head as I could while protecting myself from her hands and spoke very quietly but forcefully. "I don't care how many nasty words you use or how filthy your language is, but you will NOT use that word in this room. You're an aboriginal, and I know you would be very insulted if anyone called you an Indian, so I suggest you apologize to Kevin right now and never use that word again."

She gave me the most hateful look I've ever been on the receiving end of, then shouted, "What the **** do you know? You're just a white-trash whore!!" Kevin winced but stayed silent.

I gave her a shocked look then said, "Omigawd! How did you know that about me? We've only just met... you couldn't possibly know! Who told you?? Omigawd, my boss can't find out!" The look of utter confusion on her face, followed by what I'm convinced was shame, confirmed to me that I'd said exactly the right thing. She didn't say another word for the rest of the shift, and in the morning she apologized to both Kevin and me. She was transferred to adolescent psych later that day and I never saw her again.

The sequelae of that night continue on; whenever we have a teenager (or a parent) who is out of control they send in the Peacemaker, a title I wear with pride.

The Art of the Snappy Comeback or How to Render a Teenager Speechless

About NotReady4PrimeTime, RN

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