My head is still spinning. Working ED, when a 25 y/o male is referred (by his friends) for suicidal ideation. I walk pt. back after initial screening. Complaints? As pt. elaborates (over-elaborates) My jaw almost drops! Nothing he's done, but what has happened to him in the past 24/48hrs/week of his life is CRAZY! Feel totally bad for him; want to tell him that he maybe making a mistake - but it's not as though he's reporting himself...others are concerned... Yeah, sometimes it doesn't go unnoticed, but in this particular instance it would be impossible not to notice/to ignore: he's adorable. Male techs enter room and I tell them that they're not needed. Pt. is cooperative; not violent. They leave. Vocabulary is very intelligent; pronunciation (although soft and somewhat monotone) is clean/sheer; very pleasant voice. All the more so making it surreal when it is time to tell pt to disrobe. I actually say "undress." "Everything," I say, "including socks and underwear." Why did that feel so awkward?!?! This is my profession! Why am I even reminding myself of this, I wonder. I'm not being sadistic - it's not even a word in my vocabulary. So why do I feel this way? Why is it the only thing that comes to mind then/now?? Nothing. Did he hear me?? For goodness sakes (all occurring in split seconds') but it was hard enough (awkward, compelling?) for me to say it once already, now I have to repeat myself?!?! Remember: Logic over emotion. I say it again. This time: "I need you to to..." Stressing the "I need" part while staring directly into his eyes. I detached while doing so. Logic over emotion. If this sounds crazy, not two minutes ago, this individual bore his soul to me, and now I'm ordering him to strip naked with all the conviction of a Starbucks employee asking a person for their order... Yeah, it's my job. No, I'm not a psych nurse. And no, either I've not had enough experience to automatically (in my mind) consider this person a threat, or I just don't believe he is, but it's protocol. I begin to assist. I feel power. I feel embarrassed by - not the act- but for the power I'm feeling. Make it quick. Avoid eye contact. Start with non-intimate. Shoes, socks. Wow! Nice feet! Is that a pedicure?? Seriously!?! Anything to take my mind off, I guess... Why?? Because this is so surreal?? The socks must've made a connection to "socks and underwear" that I muttered moments earlier. "Oh...sorry" he said. "What?!?!" Another lightbulb/total realization. I repeat for a third time: "....everything...underwear...it's for your safety...it's our policy..." I explain. I step away, shifting my focus on fetching a gown from the corner basket. Pt. proceeds to undress himself. Male tech enters; looks at pt, then to me, then back to pt. Monumentous moment. I look at pt. Pt. had paused, momentarily, then as if succumbing/accepting the humiliation of it, continued to undress. Safe room. That's what the tech had to say. That pt needed moved to a safe room - as he grappled with his captivation. Again, I turn my attention. Look for gown, grab one, hand to pt in a manner consistent with wanting to end show. Did not notice it was child's size. CRAP!! The three of us walking through ED, down hall to safe room. Feel all eyes on pt; feel eyes on me; don't dare look. Safe room. Finally. Relief. Nothing. Empty room. Sad. Lonely. Isolation. Too small gown. Leave. It's over. Finally. Yeah, right.... Can't get my mind off. Nervous. Shaky. WHAT IS WRONG WITH ME?!?! 15 minutes. A lifetime. Look in on Pt. Why am I staring at his bare soles? Conveyance of something... Feminization?? No, that's the damn gown! Something...something... Vulnerability?? That must be it. "Hi...how are you doing?" Feel stupid. He looks at me like I betrayed him. At least that's what it feels like. "Ok" he says. Leaving room, he stops me. "What's going to happen?" I tell him a professional, evaluation, blah, blah... "Then what?" "I don't know." "Just be honest." Later. F-you eyes with following checks. "You think I'm crazy?" "No." Off duty. Stick around. Girls at desk commenting on pt. A catheter?!?! Can't go. Urine screen. Seriously?? A damn catheter?!?! Yes! Going to facility. Led away. Handcuffs. Barefoot. Open back, too short/tight/small gown. Near naked. Still on my mind. Still thinking of him. Wondering what will happen to him..
I'm going to guess that you are a very new nurse, and very new to the ED.
Please discuss with your preceptor, immediately:
1. Why do we insist that those who present with suicidal or homicidal ideation remove all clothing? Hint: it's not about the patient harming him/herself with underwear - it's about what objects can be hidden in clothing that most definitely can harm the patient, you, and anyone else. And do not underestimate the usefulness of seemingly innocuous objects, including underwear, to someone who unfortunately is motivated to do harm.
2. Educational resources for you to review to familiarize yourself with common responses to trauma and stress, and the common sequelae to these destabilizing events. That you appear to have some empathy is positive, but you have an immediate need to develop better boundaries so that you can manage the situation clinically, which is your job.
3. We are all human, and yes we notice where an individual patient falls on the spectrum of features that we personally find attractive. But if you are properly focused on the clinical situation, that notice lasts for approximately 2 seconds. Dwelling on it for any longer than that ... means that your attention is not where it should be.
4. How can you better prepare for your next patient with a psychiatric complaint? What supplies should you gather at the outset - appropriate-sized gown, socks, scrub/pajama pants, urine cup for specimen, etc. - to streamline the process?
When a gown is too small to cover a patient's backside, the problem can be solved by giving them two gowns, one to wear forward as a gown and one to wear backwards as a robe.
I give that patient alot of credit for going to the ER to get help, but why do objects have to be taken away when for example ,the patients plan was to jump off the golden gate bridge?
Do you really think taking away objects and stripping down is gonna prevent him from jumping off the golden gate bridge?
I know they have to take away shoe loses to every psych patient admitted but how will that persuade them from jumping off a bridge?
I always wondered why Seattle has the highest suicide rate and its not cause of the weather, its because there's to many bridges!!
How do you think you would react if he was an older, unattractive man, or a woman?
I did give you the benefit of the doubt, thinking you were stressing about a patient being treated this way, but the more you say I'm thinking it wasn't the patient, I'm thinking it was, in fact, this patient.
I would have still felt just as bad for the patient, for what they were going through, for what had brought them to the ED in the first place. No difference in those regards if they were unattractive. I'm sure I wouldn't have cared to have asked him to change into another gown, though. You have to consider the nature of my patient's complaint in this scenario. Yes, his attractiveness definitely compounded the intimacy of the situation; but it was different from asking a patient to remove clothing, help them, or do it for them if they were unable when actual medical attention was required. Without the physical injury, it didn't feel natural, and (thinking back) I think it felt (to me) like asking him to completely undress created this superior/inferior context… Something like that… Like I either felt slightly dominant by doing so, or felt the need to distinguish myself in that role. I think that is what I first confused as feeling sadistic – even though I'm not anything like that. And then, immediately, I felt embarrassed for feeling that I had that authority (power) over him. Then it became stronger while we walked through to the safe room. That is when it felt like I was in control of him, that he was like my property? It may have just been more of that authority feeling, accentuated by parading him through ED in that skimpy gown. The superiority/inferiority feeling became more apparent whenever I was with him in the safe room. Just minutes earlier, there had been a brief moment immediately after his opening up to me that I think we both felt like equals, reciprocal (like him needing someone to listen, and me having been that person) and maybe this mutual attraction, like equal in those aspects. Worthy?? Like he would have possibly feared/valued my judgment, rather than someone he felt beneath him?? And now, same two people, only he barely has anything on, and has essentially, temporarily, lost his freedom – and I'm the one who it would seem like I them from him… My property, like I said before…
Because the patient couldn't provide a urine specimen. A urine specimen is required by the inpatient psych facility, to rule out drug intoxication. The inpatient unit will not take the patient until the results are back.
Why couldn't they have straight cathed him for the specimen ? You only need 10 ml.
I would have still felt just as bad for the patient, for what they were going through, for what had brought them to the ED in the first place. No difference in those regards if they were unattractive. I'm sure I wouldn't have cared to have asked him to change into another gown, though. You have to consider the nature of my patient's complaint in this scenario. Yes, his attractiveness definitely compounded the intimacy of the situation; but it was different from asking a patient to remove clothing, help them, or do it for them if they were unable when actual medical attention was required. Without the physical injury, it didn't feel natural, and (thinking back) I think it felt (to me) like asking him to completely undress created this superior/inferior context… Something like that… Like I either felt slightly dominant by doing so, or felt the need to distinguish myself in that role. I think that is what I first confused as feeling sadistic – even though I'm not anything like that. And then, immediately, I felt embarrassed for feeling that I had that authority (power) over him. Then it became stronger while we walked through to the safe room. That is when it felt like I was in control of him, that he was like my property? It may have just been more of that authority feeling, accentuated by parading him through ED in that skimpy gown. The superiority/inferiority feeling became more apparent whenever I was with him in the safe room. Just minutes earlier, there had been a brief moment immediately after his opening up to me that I think we both felt like equals, reciprocal (like him needing someone to listen, and me having been that person) and maybe this mutual attraction, like equal in those aspects. Worthy?? Like he would have possibly feared/valued my judgment, rather than someone he felt beneath him?? And now, same two people, only he barely has anything on, and has essentially, temporarily, lost his freedom – and I'm the one who it would seem like I them from him… My property, like I said before…
He's not your property and you aren't his "dominant", you know that, right? He's a vulnerable, suicidal patient.
This sounds like it is all about your feelings, which you are still feeling intensely a few days later it sounds like. Please talk to EAP, like suggested earlier.
I give that patient alot of credit for going to the ER to get help, but why do objects have to be taken away when for example ,the patients plan was to jump off the golden gate bridge?
Do you really think taking away objects and stripping down is gonna prevent him from jumping off the golden gate bridge?
I know they have to take away shoe loses to every psych patient admitted but how will that persuade them from jumping off a bridge?
I always wondered why Seattle has the highest suicide rate and its not cause of the weather, its because there's to many bridges!!
Keep in mind that he went to the ER semi-willingly (friends brought him there). He probably thought he'd get a chance to talk to a therapist or something; sort out his feelings. I bet he had no clue of what was about to hit him. Talk about being blindsided.
ETA: Of course by the time he realized things were about to get real uncomfortable ( for lack of a better term ), there was no way he could have backed out of it. Hook, line, and sinker.
I give that patient alot of credit for going to the ER to get help, but why do objects have to be taken away when for example ,the patients plan was to jump off the golden gate bridge?
Do you really think taking away objects and stripping down is gonna prevent him from jumping off the golden gate bridge?
I know they have to take away shoe loses to every psych patient admitted but how will that persuade them from jumping off a bridge?
A person who is determined to harm his or herself can change their plans according to the circumstances. Pills, weapons, or sharp objects can be hidden in clothing.
The goal of the initial encounter in the ED is not to persuade the patient not to self-harm. It is to make the patient and the staff safe, and bring in a professional assessment to determine if the patient is safe to discharge or needs to be admitted to an inpatient setting for further treatment.
Patient and staff safety is achieved by removing clothing and personal items that can be used for self harm or as weapons, placing the patient in a room with no cords, tubes, heavy objects, or other items that can be used for self harm or as weapons, and frequent observation at regular intervals.
Active suicidal ideation is a medical emergency. Just as we undress the victim of a car crash, for example, who is at risk for death or disability and must be rapidly and thoroughly assessed for injury, the suicidal patient is also at risk, and we are obligated to take steps to ensure the person's safety.
It has nothing to do with power, control, dominance, humiliation, or any of the, quite frankly, disturbing attributes with which the OP is painting her experience. I'm really kind of speechless, actually. It has everything to do with keeping the patient and the staff safe, and nothing more.
A person who is determined to harm his or herself can change their plans according to the circumstances. Pills, weapons, or sharp objects can be hidden in clothing.
The goal of the initial encounter in the ED is not to persuade the patient not to self-harm. It is to make the patient and the staff safe, and bring in a professional assessment to determine if the patient is safe to discharge or needs to be admitted to an inpatient setting for further treatment.
Patient and staff safety is achieved by removing clothing and personal items that can be used for self harm or as weapons, placing the patient in a room with no cords, tubes, heavy objects, or other items that can be used for self harm or as weapons, and frequent observation at regular intervals.
Active suicidal ideation is a medical emergency. Just as we undress the victim of a car crash, for example, who is at risk for death or disability and must be rapidly and thoroughly assessed for injury, the suicidal patient is also at risk, and we are obligated to take steps to ensure the person's safety.
It has nothing to do with power, control, dominance, humiliation, or any of the, quite frankly, disturbing attributes with which the OP is painting her experience. I'm really kind of speechless, actually. It has everything to do with keeping the patient and the staff safe, and nothing more.
Not all suicidal persons have the same level of risk to self harm. Unless the person is in severe psychosis, there is always ambivalence at play. Especially with someone who recognize their own feelings, determine that they need help and set about to seek that help. And that assessment ( of the risks to self harm) is done by simply talking with the person.
This cookie cutter approach used here implies that every person who thinks about suicide is a time-ticking bomb waiting to explode. Not so. A majority of depressed people are in fact non violent.
To insist on striping someone of his or her dignity, under the guise of safety, might precipitate a peaceful situation into possible violent acts. All this when said person only wanted to explore their own feelings with a professional therapist.
I will say it again, safety is not the end all be all. Comon sense must be applied.
Read Rhonda89 story. The girls at the desk remarked that the patient was going to the Psych Unit with a " Catheter" because he couldn't "give a specimen"
Altra, BSN, RN
6,255 Posts
I'm going to guess that you are a very new nurse, and very new to the ED.
Please discuss with your preceptor, immediately:
1. Why do we insist that those who present with suicidal or homicidal ideation remove all clothing? Hint: it's not about the patient harming him/herself with underwear - it's about what objects can be hidden in clothing that most definitely can harm the patient, you, and anyone else. And do not underestimate the usefulness of seemingly innocuous objects, including underwear, to someone who unfortunately is motivated to do harm.
2. Educational resources for you to review to familiarize yourself with common responses to trauma and stress, and the common sequelae to these destabilizing events. That you appear to have some empathy is positive, but you have an immediate need to develop better boundaries so that you can manage the situation clinically, which is your job.
3. We are all human, and yes we notice where an individual patient falls on the spectrum of features that we personally find attractive. But if you are properly focused on the clinical situation, that notice lasts for approximately 2 seconds. Dwelling on it for any longer than that ... means that your attention is not where it should be.
4. How can you better prepare for your next patient with a psychiatric complaint? What supplies should you gather at the outset - appropriate-sized gown, socks, scrub/pajama pants, urine cup for specimen, etc. - to streamline the process?