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..
Ok, I just want to clarify a few things... The patient was given a straight cath. Why anyone would assume otherwise confuses me. Nothing in my op insinuated that the patient "left with a cath." So, whatever... The patient was not handcuffed until they came to transport him. I clarified that in one of my follow-up posts, by there it is again. More than one (three, I think) persons to reply has questioned why the patient wasn't given socks... The reason he wasn't, was the same reason his clothes were taken in the first place... I would think that would be obvious, too. Someone suggested that it was because I was still "admiring" his feet. True, they were nice, but my later mention (focus at the time) of his bare feet was in relation to his vulnerability.
Saying the OP was extremely creepy is about the nicest thing I can say about it. I think there is the real possibility that the only thing which was accomplished in this scenario is to guarantee that the next time this patient feels suicidal, the LAST thing he will do is reach out for help. And that is a true tragedy. This is a case of winning the battle but in doing so, potentially losing the war.
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.
Nonyvole,
Thank you for taking the time to provide your thoughts. I wonder at what point during the procedure your "runners" decided to take off (if that information is available). Also, I wonder if these are the statistical minority. I cannot imagine this happening on a regular basis.
What happens if a patient refuse to undress? Again, let's stick with a low risk case, someone who's coherent, non-violent and cooperative. Well, right up until they are told to undress. What then? Does the ED staff escalate?
It doesn't matter, in my opinion, what your intentions are. It's how it is perceived by the person, and the lasting impression it will leave them with. I still do not agree that it is necessary but, I also understand that this seems a systemic approach.
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.
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.
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.
Anna Flaxis,
Thank you. Your post has done much to explain some misconceptions I had. Are you familiar with a training program called "Living Works?" Also known as "ASSIST." It is, in essence a suicide prevention and intervention training program open for anyone willing to pay to get it. I do not know if it is available in the United States, but I am sure there must be something equivalent. I have received this training and have used it in a few occasions. I will not claim I deal with many suicidal persons (I don't think I would be able to handle it), but I have. Most of my comments, especially with risks assessment are, derived from this training.
Part of that training taught me how to assess those risks (in order to make a decision as to how to best help a suicidal person). It's not that hard, really. You just have to be committed to ask the right questions. The issue is that I don't think that every suicidal person is best treated at the hospital. The more severe cases, with high risks? Sure. But low risks? No. I wouldn't and I haven't, except in one occasion.
Thank you for taking the time to provide your thoughts. I wonder at what point during the procedure your "runners" decided to take off (if that information is available). Also, I wonder if these are the statistical minority. I cannot imagine this happening on a regular basis.
What happens if a patient refuse to undress? Again, let's stick with a low risk case, someone who's coherent, non-violent and cooperative. Well, right up until they are told to undress. What then? Does the ED staff escalate?
It doesn't matter, in my opinion, what your intentions are. It's how it is perceived by the person, and the lasting impression it will leave them with. I still do not agree that it is necessary but, I also understand that this seems a systemic approach.
Dany
So, we're usually pretty good in getting people to undress - the key is in how one approaches the patient. My tricks include pinning the blame on my bosses - "hospital rules. Yeah, it sucks. But I'm going to put your stuff right out at my desk with your name on it, and I can have our security guy lock [whatever] up in our safe if you'd like." Our next level is pulling somebody in and playing a "good cop, bad cop" routine. If I think that there is a religious reason that they won't undress, I'll offer two gowns and a pair of scrub pants. Gender differences? I'll get a male in the room.
We don't jump on people and rip off their clothing. If nothing I do can get them out of their clothes, the doctor will go in and pull even more rank.
Patients are very good about giving me their shoes, though. And in situations like that, when they won't undress, I put them in a room within my eyesight and call security down to sit with them. (And chart it all very, very well.)
The few times I yelled at a patient, they were teens/pre-teens who didn't quite get that they weren't the ones calling the shots. And even then that wasn't yelling in the classical sense, it was just getting extremely firm, being very blunt about the situation, and telling them that what goes at home Does Not Happen in my ED. That they may have [legal, responsible adult] wrapped around their little finger, but I'm a much tougher nut to crack...and that was also in front of their parents/guardians. Shock for everybody not expecting it.
And yes, runners are very much the minority. But that's also because we do have a locked unit and much training has been performed in the idea that non-clinical staff just can't open doors for patients. There is no real way to predict when they'll take off, because it can happen at any stage of the process.
Really, the bigger part in making the patients feel comfortable is acknowledging that the situation is awkward for them, being empathetic, and most importantly non-judgmental. Many of our psych patients come in saying that they're suicidal, look, I cut my wrist (less than a papercut, no bleeding, doesn't even need a bandage), and all they really want is somebody to listen to them and make them feel important. That they can get some attention that isn't negative in relationship to their illness(es) and lives in general. Sometimes all that is needed is a hot meal and a warm (safe) bed...then life suddenly picks up. One patient in particular does that on a regular basis, in fact. This patient knows me well enough that when they arrive, they're always making a comment about how "look what I did this time, I didn't do X like that one time that you got really upset with me and oooh, you dyed your hair! Pretty!" Low risk, coherent, cooperative, non-violent...but they still get the same treatment of gown, removing personal belongings, draw blood, ask for a urine sample, and a beverage of their choice. It's not up to me to change hospital protocols, but I can certainly work within them.
And something that I didn't mention earlier. We do end up straight cathing psych patients sometimes. Because if they're geriatric and usually wear a brief...but if somebody can at least hit a hat in a bedside commode? (Or use a urinal even with somebody holding, well, everything) I'm happy.
So, we're usually pretty good in getting people to undress - the key is in how one approaches the patient. My tricks include pinning the blame on my bosses - "hospital rules. Yeah, it sucks. But I'm going to put your stuff right out at my desk with your name on it, and I can have our security guy lock [whatever] up in our safe if you'd like." Our next level is pulling somebody in and playing a "good cop, bad cop" routine. If I think that there is a religious reason that they won't undress, I'll offer two gowns and a pair of scrub pants. Gender differences? I'll get a male in the room.
We don't jump on people and rip off their clothing. If nothing I do can get them out of their clothes, the doctor will go in and pull even more rank.
Patients are very good about giving me their shoes, though. And in situations like that, when they won't undress, I put them in a room within my eyesight and call security down to sit with them. (And chart it all very, very well.)
The few times I yelled at a patient, they were teens/pre-teens who didn't quite get that they weren't the ones calling the shots. And even then that wasn't yelling in the classical sense, it was just getting extremely firm, being very blunt about the situation, and telling them that what goes at home Does Not Happen in my ED. That they may have [legal, responsible adult] wrapped around their little finger, but I'm a much tougher nut to crack...and that was also in front of their parents/guardians. Shock for everybody not expecting it.
And yes, runners are very much the minority. But that's also because we do have a locked unit and much training has been performed in the idea that non-clinical staff just can't open doors for patients. There is no real way to predict when they'll take off, because it can happen at any stage of the process.
Really, the bigger part in making the patients feel comfortable is acknowledging that the situation is awkward for them, being empathetic, and most importantly non-judgmental. Many of our psych patients come in saying that they're suicidal, look, I cut my wrist (less than a papercut, no bleeding, doesn't even need a bandage), and all they really want is somebody to listen to them and make them feel important. That they can get some attention that isn't negative in relationship to their illness(es) and lives in general. Sometimes all that is needed is a hot meal and a warm (safe) bed...then life suddenly picks up. One patient in particular does that on a regular basis, in fact. This patient knows me well enough that when they arrive, they're always making a comment about how "look what I did this time, I didn't do X like that one time that you got really upset with me and oooh, you dyed your hair! Pretty!" Low risk, coherent, cooperative, non-violent...but they still get the same treatment of gown, removing personal belongings, draw blood, ask for a urine sample, and a beverage of their choice. It's not up to me to change hospital protocols, but I can certainly work within them.
And something that I didn't mention earlier. We do end up straight cathing psych patients sometimes. Because if they're geriatric and usually wear a brief...but if somebody can at least hit a hat in a bedside commode? (Or use a urinal even with somebody holding, well, everything) I'm happy.
So... In other words, bullying... Hmmm... That's straddling a fine line between seeking consent and enforcing it.
I still don't get the impetus in cathing someone... Eventually everyone has to go, no matter what. It seems to me if it's outside of strict medical necessity, then it comes down to a mere matter of inconvenience for the facility. As in they can't be bothered to wait. Also wrong, in my opinion; too many risks associated with that.
But thanks for your comments. I do appreciate you taking the time to engage me on this.
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.
Dany
A suicidal patient on a non-psych ward was not properly attended to and she tried to strangle herself with some cord or tubing (IV? O2? Call light? I don't remember; wasn't my unit) in her hospital room room. Would it help you, if a patient harms themselves, to know that when they told you they were suicidal, you thought they weren't really *REALLY* suicidal?
How suicidal is suicidal enough to warrant protection from themselves?
You've also mentioned ambivalence, but I'd bet many people are ambivalent right up until they are dead.
Thank you for taking the time to provide your thoughts. I wonder at what point during the procedure your "runners" decided to take off (if that information is available). Also, I wonder if these are the statistical minority. I cannot imagine this happening on a regular basis.
What happens if a patient refuse to undress? Again, let's stick with a low risk case, someone who's coherent, non-violent and cooperative. Well, right up until they are told to undress. What then? Does the ED staff escalate?
It doesn't matter, in my opinion, what your intentions are. It's how it is perceived by the person, and the lasting impression it will leave them with. I still do not agree that it is necessary but, I also understand that this seems a systemic approach.
Dany
How often is a dead patient an acceptable outcome?
A suicidal patient on a non-psych ward was not properly attended to and she tried to strangle herself with some cord or tubing (IV? O2? Call light? I don't remember; wasn't my unit) in her hospital room room. Would it help you, if a patient harms themselves, to know that when they told you they were suicidal, you thought they weren't really *REALLY* suicidal?
How suicidal is suicidal enough to warrant protection from themselves?
You've also mentioned ambivalence, but I'd bet many people are ambivalent right up until they are dead.
Once you have assess the risk, the key is understanding the reason why a person wants to end their life. You look for triggering events (what precipitated their decision) . Connecting a person with the right resources to help them cope with their situation is part of helping them. It could be psychological help (through their PCP), or social workers, or financial adviser, or even a minister (priest).
Again, if the risks are high, I'm not against having the ED handle it. Sometimes it is the only way. But not always. Again, someone recognizing he or she needs help, is enough of a motivator that, when provided with avenues of solution, they will actually realize that killing themselves is not the way to solve their problem
Ambivalence is what you build your intervention on. I am not going to explain the whole process, you can go read about it yourself by following the link I provided to the ASSIST program. It works.
Thank you. Your post has done much to explain some misconceptions I had. Are you familiar with a training program called "Living Works?" Also known as "ASSIST." It is, in essence a suicide prevention and intervention training program open for anyone willing to pay to get it. I do not know if it is available in the United States, but I am sure there must be something equivalent. I have received this training and have used it in a few occasions. I will not claim I deal with many suicidal persons (I don't think I would be able to handle it), but I have. Most of my comments, especially with risks assessment are, derived from this training.
Part of that training taught me how to assess those risks (in order to make a decision as to how to best help a suicidal person). It's not that hard, really. You just have to be committed to ask the right questions. The issue is that I don't think that every suicidal person is best treated at the hospital. The more severe cases, with high risks? Sure. But low risks? No. I wouldn't and I haven't, except in one occasion.
Dany
I agree with the bolded sentiment above.
But please keep in mind, that it is not the role of the ER RN to determine this. The role of the ER RN is to provide for patient safety while they are under our care. It is the qualified mental health professional who interviews the patient, and based upon their professional assessment, makes recommendations for further intervention, whether it is discharging the patient home with a safety plan in place or inpatient admission to a behavioral health facility. This is not the role of the ER Nurse. Again, the ER nurse's role is to keep the person - a person that we do not know, who has expressed a desire to take their own life -safe while they are in the Emergency Department.
Also keep in mind that the ED did not go to the patient. The patient came to the ED. Contextually, this is much different from intervening as a private citizen out in the community. You are attempting to apply this to the ED context, and it just doesn't work. It's apples and oranges.
And, we cannot turn anyone away if we receive any federal money, due to EMTALA. We take all comers. And if we do discharge someone who ends up going out and killing themselves, then we can be held liable. I personally know of situations like this, where the family is now suing the hospital.
That's great that you're trained and have provided assistance to individuals in your community. But it's important to understand that this is not the function of the ED in this situation. We do not provide intervention and treatment beyond immediate, acute needs. We are only the conduit to the next phase as determined by the qualified mental health professional.
Do I think this is the way it should be? Absolutely not. We have a mental health crisis in the USA. Behavioral health services are terribly underfunded so as to be nonexistent for all intents and purposes in some locales, and people come to the ED because there is no other way for them to get help. Inpatient behavioral health beds are at such a premium that people who really need this service spend days, weeks, and even months in the Emergency Department - not receiving therapeutic treatment, but just being housed. You may think I am exaggerating, but I'm not.
It is messed up. Nobody is more aware of this than the ED RNs who are on the front lines. You are trying to apply your own experiences and ideals to a context where it just doesn't work. We are just as frustrated by the situation as anyone, if not more so because we see it day in and day out. It's frustrating as hell, because we know we're not providing for the patient therapeutically, we're just meeting basic needs.
The solution, in my opinion, is to undo what Ronald Reagan did in the 1980s, and federally fund mental health services, taking away the block grants and imposing rules and structure for what the states have to do, and, most importantly, to fund those things appropriately.
But please keep in mind, that it not the role of the ER RN to determine this. The role of the ER RN is to provide for patient safety while they are under our care. It is the qualified mental health professional who interviews the patient, and based upon their professional assessment, makes recommendations for further intervention, whether it is discharging the patient home with a safety plan in place or inpatient admission to a behavioral health facility. This is not the role of the ER Nurse. Again, the ER nurse's role is to keep the person - a person that we do not know, who has expressed a desire to take their own life -safe while they are in the Emergency Department.
Also keep in mind that the ED did not go to the patient. The patient came to the ED. Contextually, this is much different from intervening as a private citizen out in the community. You are attempting to apply this to the ED context, and it just doesn't work. It's apples and oranges.
That's great that you're trained and have provided assistance to individuals in your community. But it's important to understand that this is not the function of the ED in this situation. We do not provide intervention and treatment beyond immediate, acute needs. We are only the conduit to the next phase as determined by the qualified mental health professional.
Do I think this is the way it should be? Absolutely not. We have a mental health crisis in the USA. Behavioral health services are terribly underfunded so as to be nonexistent for all intents and purposes in some locales, and people come to the ED because there is no other way for them to get help. Inpatient behavioral health beds are at such a premium that people who really need this service spend days, weeks, and even months in the Emergency Department - not receiving therapeutic treatment, but just being housed. You may think I am exaggerating, but I'm not.
It is messed up. Nobody is more aware of this than the ED RNs who are on the front lines. You are trying to apply your own experiences and ideals to a context where it just doesn't work.
The solution, in my opinion, is to undo what Ronald Reagan did in the 1980s, and federally fund mental health services, taking away the block grants and imposing rules and structure for what the states have to do, and fund those things appropriately.
I said I was not going to respond in this thread again, but I have to say that this is a great post. :)
Ronda89
6 Posts
Ok, I just want to clarify a few things... The patient was given a straight cath. Why anyone would assume otherwise confuses me. Nothing in my op insinuated that the patient "left with a cath." So, whatever... The patient was not handcuffed until they came to transport him. I clarified that in one of my follow-up posts, by there it is again. More than one (three, I think) persons to reply has questioned why the patient wasn't given socks... The reason he wasn't, was the same reason his clothes were taken in the first place... I would think that would be obvious, too. Someone suggested that it was because I was still "admiring" his feet. True, they were nice, but my later mention (focus at the time) of his bare feet was in relation to his vulnerability.