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 disagree with you, Farawyn. So-called "high-risk" kicks in once the specific situation of the person has been assessed. Until then, it is just guess work. If that.
To be labeled suicidal you express the desire to kill yourself.
To be labeled suicidal you express the desire to kill yourself.
Safety comes first.
You are ignoring the fact that quite a few suicidal persons are ambivalent about their intention. You are also ignoring the fact that some people, while contemplating the idea of committing suicide, may not be necessarily seriously thinking about it. This is the want to/don't want to idea. This is were a good intervention plan comes into play. Assess the risk, come up with a course of action, and follow through.
You are ignoring the fact that quite a few suicidal persons are ambivalent about their intention. You are also ignoring the fact that some people, while contemplating the idea of committing suicide, may not be necessarily seriously thinking about it. This is the want to/don't want to idea. This is were a good intervention plan comes into play. Assess the risk, come up with a course of action, and follow through.
Dany
This does not get done in the ED. The ED is for emergency intervention. This patient was brought in as suicidal.
He was mistreated. But if he admits to suicidal ideation it is better to keep him than let him go until a plan is in place...Which is not done in the ED.
The main objective with a suicidal patient is safety first. Is the patient safe? This is Nursing 101.
We agree about this case and the way OP handled it and/or described it. Without a doubt.
We can agree to disagree about the rest.
I have to say this is one of the more creepy threads I have witnessed here.
This does not get done in the ED. The ED is for emergency intervention. This patient was brought in as suicidal.
He was mistreated. But if he admits to suicidal ideation it is better to keep him than let him go until a plan is in place...Which is not done in the ED.
The main objective with a suicidal patient is safety first. Is the patient safe? This is Nursing 101.
We agree about this case and the way OP handled it and/or described it. Without a doubt.
We can agree to disagree about the rest.
I have to say this is one of the more creepy threads I have witnessed here.
I have never worked in the ER. I have dealt with suicidal persons, but they were not inpatient. Do you believe this invalidate the points I have made?
Dany
Yes. This discussion is specific to the Emergency Department setting, an area in which you lack a basic understanding of the unique challenges of providing safe, competent psychiatric care.
Yes. This discussion is specific to the Emergency Department setting, an area in which you lack a basic understanding of the unique challenges of providing safe, competent psychiatric care.
Perhaps you would like to educate me. I would like to benefit from your insights and experience in this matter. I will agree the ED is a unique environment but only to the point that it can, as is the case here, lead to very poor practices that do not contribute to the well being of a non-violent, willing person who is seeking help because they are contemplating ending their life. Never mind the traumatic experience, or distress, and anxiety this will leave them with.
If a person verbally agrees not to harm themselves until they get a chance to talk with a therapist, there is very little risks (assuming a good preliminary assessment is done), to allow them to remain as is. They are, after, willing. You keep an eye on them until the psychological evaluation is done. That isn't to say that a combative or overly aggressive person might not require higher safety measures. A distinction must be made. Cookie-cutter solution here is not adequate, let alone acceptable.
Yes. This discussion is specific to the Emergency Department setting, an area in which you lack a basic understanding of the unique challenges of providing safe, competent psychiatric care.
I work ED and with suicidal patients in the ED and the OP's description is far, far outside what is acceptable and legal in every ED I've worked in. I realize there are regional variations in cultures of how mental health issues are treated, but this sounds more like a description of different century than it does a different area.
In a patient who's expressed suicidal ideation, but is calm, cooperative, with rationale thought processes, etc, applying "handcuffs" or really any type of restraints is highly inappropriate, even if it's for transport and no transport staff I know of would accept a patient who's inappropriately restrained. Particularly for mental health issues, each state has fairly strict regulations on what criteria justify physical restraint, and this patient doesn't meet any of them.
As for the invasive collection of urine, a patient presenting with active psychosis or other AMS neds to first be medically cleared before they are evaluated and potentially treated for a mental health cause of their symptoms which could certainly include a straight cath for a UA, this is to find an explanation for their psychosis. No active psychosis or AMS, nothing to rule out medically and therefore no need for urine.
Specializes in Cath/EP lab, CCU, Cardiac stepdown.
OP this is just my opinion but from the read I got it almost sounds like there were some professional boundaries that were crossed and for futures occurrences you might want to ask for a switch in assignments for the patients sake.
Just the way you wrote your first post and the constant references to attraction, adorable, and power, gave me the impression that you almost wanted to protect him in a "I claim you" steamy novel, territorial way while noting his vulnerable exploitable scared animal role. It seemed as though you were caught between a momentary throes of passion moment mind frame of attacking and defending this vulnerable, attractive, adorable, sad patient but was caught up with nursing stuff along the way. Kind of like oh yeah, I got my nursing things and nursing worries too. The picture that I have is of a lioness escorting baby Bambi with the internal struggle of I will protect you from some hyenas while eyeing hungrily at the baby deer at the same time. Lion king and Bambi reference.
It just kind of gives me a weird vibe and you definitely do not want that patient or your co workers to get that same vibe from you. I feel that you would benefit from some self reflection and knowing when a potential professional boundary may be crossed. If you even have a slight thought of it occurring, then don't risk yourself or your patient and ask for a swap.
I work ED and with suicidal patients in the ED and the OP's description is far, far outside what is acceptable and legal in every ED I've worked in. I realize there are regional variations in cultures of how mental health issues are treated, but this sounds more like a description of different century than it does a different area.
Let me be clear. I am not defending the OP's description of events. I think the OP's description of events is creepy. What I find disturbing isn't that the patient was gowned or placed in a safe room or that urine studies were collected or that the patient was transported via secure transport, but rather, the OP's self-described thoughts and feelings toward the patient.
In a patient who's expressed suicidal ideation, but is calm, cooperative, with rationale thought processes, etc, applying "handcuffs" or really any type of restraints is highly inappropriate, even if it's for transport and no transport staff I know of would accept a patient who's inappropriately restrained.
We don't know the level of risk this patient was determined to pose to himself, as the OP's version of events is unreliable, vague, and self-serving. Also, the OP wrote that the patient was handcuffed for the transport to the inpatient facility - NOT in restraints in the ED (if she is to be believed). Secure transport most certainly ARE allowed to use restraints if deemed appropriate.
As for the invasive collection of urine, a patient presenting with active psychosis or other AMS neds to first be medically cleared before they are evaluated and potentially treated for a mental health cause of their symptoms which could certainly include a straight cath for a UA, this is to find an explanation for their psychosis. No active psychosis or AMS, nothing to rule out medically and therefore no need for urine.
Psychosis or AMS most certainly are not the only indications for urine studies in the patient presenting with suicidal ideation. Assuming that urinary catheterization did take place, the patient could have given his consent for the procedure. People do consent to in-and-out caths; it's not unheard of (and if he was so cooperative as the OP would have us believe, maybe he did consent). The OP did not witness and was not a part of this, and once again, her account of events is unreliable.
Nowhere did I state that I thought this situation, as described, seemed appropriate to me. In fact, I think the original post is downright creepy, and I think I've expressed that sentiment already in this thread.
I don't know how it works in your ED, but in the two different ED's in which I have worked, the patient is screened for risk in triage, and assigned a risk level based on the screening results. These risk levels can be low, moderate, or high. The threshold for placing a patient in a safe room, in a gown, and removing personal belongings is fairly low. These are basic safety precautions that are put in place until more is known about the true level of risk the patient poses to their own safety, as determined by a qualified mental health professional. Urine studies and restraint for transport can be ordered based upon that evaluation, policies and procedures of the ED, as well as the policies and procedures of the accepting institution.
We do not know what level of risk this patient posed. We only know what the OP wrote, which was that the OP was attracted to him and engaged in an erotic dominance/submission interaction with him, which is totally, thoroughly, completely inappropriate and downright creepy.
Although we can't know for sure, based on the information that the patient was transported to an inpatient facility, this would indicate that the patient did pose a risk to himself. I don't know about where you live, but where I live, getting an inpatient bed is darn near impossible, and you have to be pretty high risk to meet admission criteria.
Dany - we've had patients who have come in of their own volition, verbally agreed to not harm themselves or others, and were very cooperative suddenly do a runner, get out a locked door behind somebody who had a key, and be found 15 minutes later by PD. Dead.
So that is why all psych patients get undressed and have their belongings removed from the room with the exception of a cell phone (and that's really me bending the rules slightly). They aren't allowed to pull the curtain or the shades on the door, because we do keep an eye on them. Labels that only make sense to the staff are put up on the door. The minute that the decision is made to make them an involuntary hold, security is called to come do a 1:1.
In short, we do use cookie-cutter interventions because that has shown to be best practice in every facility that I've worked in. Innocent until proven guilty is not the sentiment we are going for here, ensuring that the patient is safe is. (Non-psych patients get into a gown, and we will let them pull the curtain or shut the blinds. Sometimes. But I prefer not, because while I won't go into every single room every 15 minutes, I can't sit still so I do laps around the department and simply eyeball patients as I go by.)
Now, that doesn't mean that we are out to humiliate them. If I can prepare a room, then I make sure to have an extra gown and a few blankets all ready to go. I help them change like I help any patient change, and I make sure to fold their clothing and have it be neatly in clearly-labeled bags that I then keep at the nurses station. I offer them something to eat and drink - no, they don't get a metal can, but not a lot of my patients do. It's not just psych. If we need to transport, then they go by ambulance...they look like a medical patient, not a psychiatric patient.
OP, here's the problem. You made that entire interaction about you. Not the patient. Mental boundaries that should have been there were shattered, and you went from empathizing with the patient in a healthy way to feeling sorry for him in an unhealthy way.
Perhaps you would like to educate me. I would like to benefit from your insights and experience in this matter.
Okay. The process is that when the person presents to triage with a chief complaint of suicidal ideation, a risk assessment based on current evidence/best practice is performed by the triage nurse, and based upon the level of risk, the patient is assigned an acuity level and either roomed in an appropriate room, or in the case of a person who receives a low risk score, sent back to wait in the waiting room if there are more acute patients that need roomed. A moderate to high risk would be assigned an ESI level of 2 and placed in a safe room, while a low to moderate risk could be assigned a 3 and placed in a medical bed or as previously stated, wait in the waiting room for a bed to open up.
I will agree the ED is a unique environment but only to the point that it can, as is the case here, lead to very poor practices that do not contribute to the well being of a non-violent, willing person who is seeking help because they are contemplating ending their life. Never mind the traumatic experience, or distress, and anxiety this will leave them with.
Agreed. That's why there are standard practices and protocols in place. Everything is based upon evidence-based, best practices, not the feelings or intuition of staff. I'm certain there are EDs that do not follow current best practice, and they are opening themselves up for a world of hurt, should there be a bad outcome as a result.
If a person verbally agrees not to harm themselves until they get a chance to talk with a therapist, there is very little risks (assuming a good preliminary assessment is done), to allow them to remain as is. They are, after, willing. You keep an eye on them until the psychological evaluation is done. That isn't to say that a combative or overly aggressive person might not require higher safety measures. A distinction must be made. Cookie-cutter solution here is not adequate, let alone acceptable.
Actually, there is no evidence that verbal no harm contracts reduce the likelihood of suicide. Even a calm, cooperative person can hide objects on their person, and a resourceful person can find something in the room with which to cause harm. People have successfully committed suicide while in the ED. As an RN, I am not qualified to perform a psychological evaluation and determine the true level of risk the person poses. I only have the screening tools I am given to work with, and base my actions upon the results of those screening tools.
While one can argue that it is a "cookie cutter approach", which can have derogatory implications in the mind of the uninitiated, standardized practices are really at the backbone of most everything we do in the ED, from treating sepsis and AMI, to psychiatric emergencies.
Failing to take appropriate precautions with a patient presenting with suicidal ideation who's assessed risk is moderate to high because the RN determines it's not necessary is akin to failing to undress the trauma patient and examine their entire body for injury because we want to protect their privacy, or failing to get an EKG on the chest pain patient because we don't want to expose their chest.
In the words of one of the docs I work with, sometimes we can "Nice them to death", meaning that there is a very real danger in failing to take adequate precautions to ensure safety simply because we want to be nice to the person.
Farawyn
12,646 Posts
To be labeled suicidal you express the desire to kill yourself.
Safety comes first.