My first (truely) psychotic patient

[november17, ASN, RN]

The night was going quietly. It was my second night. My coworker and I were saying to each other, "man, this is gonna be another sloooooooow night." The day before had been just...dead...all the patients actually slept through the night and were very easy to please. Excellent team!

Of course, the "curse" of actually saying "it's slow and going great" caught me. My charge nurse walked down and said, "blabla you're getting a patient from the ER. Cellulitis." I was thinking, "oh this shouldn't be too bad."

So I pull up the patients chart on the computer and quickly note that A)He came from the county jail B)He's in four point restraints C)It had taken 4 police officers and 3 hospital staff to hold him down to get him in restraints in the first place D)They tried freeing one of his hands from the restraints, but quickly had to put it back in.

I was thinking, "woo boy...I'm gonna get a live one." But usually in the past when I've had patients like that; by the time they get up to the floor from the ER they've mellowed out quite a bit.

So I took report via the phone from the ER nurse, and she mentioned that the patient was very foul mouthed and nasty. She said that the sedatives had kicked in at this point so he was more or less sleeping (I should mention he had 10mg of ativan in about a 3 hour period).

Patient got up to the floor and he was asleep. He had 2 huge police officers as an escort (per prisoner protocol). We got the 4 point restraints hooked back up (new experience for me...never had a pt in 4-points before). I got some chairs for the cops and thought, "well this isn't so bad." I noticed an N95 mask around the patient's neck. I said to one of the cops, "What's that all about? (the ER nurse didn't mention it to me)" Cop said, "Well, he's a spitter. That's actually the second one...he chewed through the first one in ER." I was a bit wary, but I thought.."aww heck..he's out of it." I took the mask off the pt, cut off some of the extra stuff off his wrists, fluffed his pillow, tried to get him comfortable. Didn't really too bad.

Anyways, having gotten this patient settled in I went up and started going through the chart, checking orders, etc. I got to the page with the inmate info in it. He was in jail for assaulting a police officer.. Also, his second diagnosis was, "schizophrenic psychosis." Didn't seem to be too psychotic at the moment to me (boy was I in for a surprise!!). I noted he had gotten 11mg of Ativan in 3 hours in the ER. No wonder he seemed so sleepy (I think the ER nurse was so happy to hand him off she missed a couple of things...she mentioned he had gotten ativan but not THAT much).

I went back to the patients room and said, "This guy assaulted a police officer?" The cop said, "yea, actually, I'm the one that he assaulted. He's pretty well known in town here." At that point both the cops looked at each other with a knowing smile..I was like, "ohhh...I see..."

Obviously the cops knew this guy very well, because they gave me a bit of background information on top of what wasn't in the chart. I gave them the pin number and a few minutes later the jail nurse called me. The first questioned she asked me was, "Did they have to taze him yet?" I was like, "whoa whoa whoa wait what????" She told me that the guy had been completely out of control in his cell for the past 2 weeks and that was the only way they were able to stop him from going nuts. Gave me some more background stuff on him. Guess the guy will not take any sort of oral meds whatsoever.

So I go through the orders. Not much, just a psych consult first thing in the morning, ativan PRN, and a foley (natch, the guy's tied to the bed).

At this point I hear down the hall some yelling.."YOU (expletive) PIGS I'll KILL YOU." My coworker and I looked at each other and I speedwalked down the hall. "What's going on, Mr X?" "(expletive) LET ME UP I KNOW MY RIGHTS!!!" I felt really bad. I hate seeing people like that. I said, "I'll let the restraint off one hand if you promise to behave." "I promise I'll behave." The cops looked at me like I was off my rocker. At this point the guy started threatening me verbally. "Get these things off my hands I can't feel my hands!! GET THESE THINGS OFF OR ILL KILL YOU WITH MY BARE HANDS" I did a circ/neuro check and the restraints weren't too tight and he was getting circulation. I decided to wait for a little bit and see if he calmed down. Alas, this was not to be. It just got worse.

My aide went in there to get his vital signs. I dutifully went with her because she was nervous. He started calling her every name in the book..."*****, ****, *****" It was almost like he had tourettes or something like that.

20 minutes later of listening to this guy and watching him violently struggle with the restraints, I told the cops, "Uhh..forget what I said about taking that restraint off." They looked relieved.

I gave him another 4mg of ativan. Didn't touch him!! (Rebound effect??). Of course, he was one of those patients that was allergic to EVERYTHING and the doc on call was NOT helpful to chill this guy out.

Anyways, he quieted down FINALLY an hour later. A minute after that one of the cops came out, "Hey, uh...he pulled that catheter off, just thought I'd let you know" (it was a texas style catheter).

I had an order in hand for a foley, which I had been waiting to do since he had the texas style on (I didn't really think he'd manage to get it off or anything). My coworker doubtfully said, "You gonna try to get it in?" "CAN DO!"

I walked in and the guy was saying all kinds of stuff, "(expletive) THAT let me out of these restraints! Mind you, this guy was in 4 point restraints and it still took the two cops and my coworker to hold him down while I did the procedure as fast as I could. As I bent down to try and get the foley in, he started urinating all over, trying to urinate on me. Fortunately I had already and was able to redirect the flow off the side of the bed away from me. Cop 1 suppressed a smile and said, "That wasn't a very nice thing to do!!" Patient said, "you pig I'll urinate on you too."

Got the foley in, and immediately got a 500cc return (wow he did have to pee). Needless to say the patient immediately managed to halfway sit up on bed somehow (in 4 points), twist his abdomen to his hand and tried to yank it out!!! So he had to hold back down again by the two cops while I redid the restraints limb by limb; so in the end he was lying spreadeagle like superman about to take off.

After that I was probably in his room for the majority of my shift. He was struggling and cursing the entire time. Of course I had the rest of my team to look after as well, and every single one of my other patients was very alarmed by hearing this stuff going down (even with the doors closed it was LOUD). They were like, "That's your patient? Are you okay?!" I was saying, "I'm fine I'm fine, I'm REALLY REALLY sorry about this I'm so sorry; everything is fine." I just kept apologizing because it didn't seem right that they had to hear this happening. And of course I couldn't say a thing to them about the patient, so I just tried to reassure them that everything was okay, the situation was under control, and joked around and told them that he was upset because he didn't like the hospital food (lame joke, I know, it's all I could think of).

Of course I finally got sitting down to get my charting done at some point and I see the phlebotomist walk by. The first phlebotomist took one look and chickened out. The second was bit more adventurous. I was about ready to just draw the blood myself just to get it over with. At that point he had chewed through the second mask and had tried to spit on the cops, so I had N95 mask #3 on him. He managed to get it off his face with his tongue during the draw so I threw a sheet on his head just so he wouldn't spit on anyone. I won't even go into it but it took 3 to hold him down just to get a blood draw, which hemolyzed and had to be redrawn so we had to do the whole thing over again 30 minutes later.

I honestly felt really bad for the guy when I left. I know he was not in his right mind. I hope I did everything right. I've never had a patient like that before...it was very challenging. I could write more about the events... but it is exhausting just to even think about it.

[NotReady4PrimeTime, RN]

Holy cow, what a horrible experience. I had one similar but not quite so bad a few years ago. That's when I learned some important lessons: baclofen and benzos are a BAD mix, agreeing with a psychotic person sometimes surprises them enough that they shut up for a while and the secret to effective four point restraints is that you pull one arm over their head and anchor the restraint at the head of the bed and the other one to the side. They can't roll over, they can't sit up, they can't slide down and grab for anything and they can't get their bums off the bed either. Pillowcases work for the spitting if you can't keep a mask on them... but don't leave it on for long and don't leave them unobserved. If all else fails call the zoo and get their tranquilizer gun.

[italianrn07]

Sounds like you had one heck of a night! I have had an experience on night shift with a psychotic patient, but not quite as bad as that! I commend you. Sometimes you just have to not say "wow it's quiet night" :)

[Virgo_RN, BSN, RN]

Wow!!!!

[Mannursemike]

Oh my!!! What an adventurous night you had! All i can say is thanks for the humerous write-up! I laughed a few times throughout that read!

[EmmaG, RN]

My coworker and I were saying to each other, "man, this is gonna be another sloooooooow night."

That will teach ya!

I know it isn't funny, but

[november17, ASN, RN]

Holy cow, what a horrible experience. I had one similar but not quite so bad a few years ago. That's when I learned some important lessons: baclofen and benzos are a BAD mix, agreeing with a psychotic person sometimes surprises them enough that they shut up for a while and the secret to effective four point restraints is that you pull one arm over their head and anchor the restraint at the head of the bed and the other one to the side. They can't roll over, they can't sit up, they can't slide down and grab for anything and they can't get their bums off the bed either. Pillowcases work for the spitting if you can't keep a mask on them... but don't leave it on for long and don't leave them unobserved. If all else fails call the zoo and get their tranquilizer gun.

Thanks for the reply. I don't feel so bad about putting the sheet over his head now. I just didn't know what else to do while we were trying to hold him down (I only had one arm free). My (more experienced) coworker actually suggested the one arm down one arm up position you just described (i did the superman position instead). I guess they just beat it into your head about how restraints are so horrible/wrong/violate human rights...I tried to be as non-restraintive as possible but it was just out of the question! Also, he had a long history of IV drug use which is why I was extra paranoid about the spit/blood/needles stuff; I use universal precautions but go ahead and sue my ass off if I go beyond that because there's no way I'm gonna catch some lifelong blood infection for $26 an hour. I freely admit that I'm no martyr-like florence nightingale/mother theresa.

Sounds like you had one heck of a night! I have had an experience on night shift with a psychotic patient, but not quite as bad as that! I commend you. Sometimes you just have to not say "wow it's quiet night" :)

I learned my lesson!! I've never been superstitious about that kind of stuff. It's funny because I was telling the charge nurse the other day about how much I enjoy ER admits (the teaching, the suspense until the consult comes in, etc)...hahhaa..

Oh my!!! What an adventurous night you had! All i can say is thanks for the humerous write-up! I laughed a few times throughout that read!

No prob I wish I had the heart to write more. I'm glad you got a laugh out of it. I try to be lighthearted about everything. If I let everything get to me, it'd eat me up.

That will teach ya!

I know it isn't funny, but

Honestly it is kind of funny! The "coworker" in the article and myself are the only male RNs on the unit and we happened to be working together (lucked out!). In all honesty we laughed our butts off each time we left that guy's room. I'm not saying we are callous jerks, but sometimes in high-stress situations it is best to see the humor in it. It's kind of twisted, dark humor. I guess many people wouldn't see the humor in it, but anyone who has been in a similar situation may see what I'm talking about.

In all honesty, my hands were shaking like leaves the entire time whenever I was in that guy's room. I was trying to play it cool but I was nervous as hell. Not just because of the situation, but I've just never dealt with restraints like that before...it scared the crap out of me (Since they teach restraints are such a HUGE NO NO in school). Wow.

[Katie91]

I know this may sound a little strange, but what a wonderful experience you had!! This night will be one of many you'll remember and share with co-workers for many years to come.

I can totally relate to your story, as I was once night shift charge for many years. It's been my experience that once a patient reaches that state of acute psychosis, the adrenals kick in with the fight/flight response, so anxiolytics and anti-psychotics rarely work. This is evident with your patient who had 11mg of ativan on board.

What I have found to work is exactly what you did; agree with the patient using a soft tone to your voice. Tapping in to your inner psych nurse will have a positive effect on the health and safety of your patients. I'm not advocating having a text book therapeutic conversation here (spare the psycho-babble), but it's all about common sense.

I'm not sure I agree with the sheet/pillowcase thing. This sounds very unsafe to me. I would maybe chose a duck bill mask for a spitting patient ~ you know how tight they are, and unless he/she can get their tongue up to the bridge of their nose, it would be extremely difficult for the patient to get it off. I would alter it a bit by cutting small holes in the mask to allow air in, but away from the patient's spit zone.

[Nuieve]

I was reading your story like a real sc-fi book! :)

[JanessaG, BSN]

Thank you for this post and to all who have responded! Not only was it entertaining , I learned a few things that I will use should the occasion ever arise.

I hope I do as well as you did, if this situation should present itself to me, and I'm sure one day it will!

[november17, ASN, RN]

Just a quick update: I went back to work after having the last week off. I guess he actually had to be tasered at a couple points during day shift the morning after I got off. Wow. I was so stressed out after that shift I literally got sick for 2 days with diarrhea - way to spend my days off. I know it was an experience, and it won't be so bad next time (I'm a "learn by doing" kind of person).

I changed my ringback tone to "take this job and shove it" and assigned it to the hospital's caller ID for when they try to call me in though!!

[Katie91]

Just a quick update: I went back to work after having the last week off. I guess he actually had to be tasered at a couple points during day shift the morning after I got off. Wow. I was so stressed out after that shift I literally got sick for 2 days with diarrhea - way to spend my days off. I know it was an experience, and it won't be so bad next time (I'm a "learn by doing" kind of person).

I'm so sorry to hear you got sick after this experience. We truly allow these things to effect us somatically. It is very difficult to "leave it at work", as our Patients have such a profound effect on our psyches.

I changed my ringback tone to "take this job and shove it" and assigned it to the hospital's caller ID for when they try to call me in though!!

Hillarious!!!