One Liner to Diffuse Escalating Situation With Patient

[Lev, MSN, RN, NP]

I recently had a patient in the ED who did have a lot of pain from her 1mm kidney stone. Understandable. However, the drama and borderline traits exhibited by her and her husband were highly disruptive to the staff and surrounding patients in the ED especially as we had a crashing patient who went into septic shock with a BP in the 50s before our eyes. The patient and husband were highly disruptive because of the perception that we were ignoring the patient and not taking care of her needs. I called security and the police who escorted the husband and another visitor out of the ED. I did not approach the husband as he was making a scene. We were all afraid he would come back with a gun. I did go back to the patient to give her more pain medication. This didn't stop the high drama from the patient. Besides for yelling about the pain, the patient was yelling that we didn't check her labs or urine (we did). She was also upset that we did not offer her a tampon or pad after we did her pelvic exam because she was bleeding. We never offer pads and I have never heard such an angry outburst over a pad.

Is there a one liner that you have in your back pocket that will help the patient and or visitors recognize their childish behavior and that we will not help them if they continue with this behavior.

Would something like this work? (Of course have security officer with you)

To the husband: Mr So and So, I can see that you are very upset. However, nobody deserves to be spoken to the way you are speaking. The other patients are disturbed by your outburst. If you want to be helped, you need to calm down and stop yelling. Yelling will not get you help faster. The doctor is with a critical patient at this time. I cannot give your wife a third dose of pain medication until there is an order from the doctor. I will have the doctor come check on your wife as soon as she is available. Is there anything else I can help you with?

To the patient: I can see you are very upset and would like more pain medication. As soon as the doctor puts in an order for more medicine I will bring it to you. The doctor is with a very sick patient at this time. Would you like and ice pack or some warm blankets to help manage your pain until we get an order? I will ask the doctor for some more medicine as soon as she is available. Is there anything else I can help you with?

[nutella, MSN, RN]

You want to de-escalate. If they are upset because they think you are ignoring the patient, your attempt of trying to develop insight into needs versus another one's need is most likely not going to work.

While some people will understand that "emergencies" can be more urgent than pain medication, most may not be too receptive to that idea.

Personally, I try to emphasize and transmit verbal and non verbal that I am willing to help, that I will advocate and keep communicating. If things start to escalate, security needs to come and I let them manage that - for example remove somebody who is disruptive. It is important to see the writing on the wall so to speak. Realize early signs of upset and escalation, use de-escalating strategies and get help early on. There are classes like Crisis Prevention Intervention that can be helpful.

[Lev, MSN, RN, NP]

What non verbal messages do you use?

[Double-Helix, BSN, RN]

Trying to use a logical, rational explanation won't work for those who are already acting illogical or irrational. They don't care that you "can't", no matter what the reason. They don't want to hear that someone else is more important to them because they don't believe that.

"I'm listening to you and I want to help. What can I do to help you?"

Generally that question forces the person to pause and think about what they need. When they respond, you can go into more detail but avoid making excuses ("the doctor is not available" will be perceived as an excuse). Maybe the demand isn't practical at the time. Let's use the demand for pain medication when no order is available:

"I hear that you need more pain medicine. I want to get your pain under control. In order to access the medication, I have to get an order from the doctor. I am going to go try to get that order right now but it may take me a few minutes. Is there anything else I can do to help while you wait, like bring you an ice pack or help you get repositioned?"

[Lev, MSN, RN, NP]

@Ashley

That can work if the doctor is available but if the doctor really is busy, it is going to be more than a few minutes. Then I will hear a rant about how I said it would be a few minutes and it's been 10 minutes and nobody is helping me. Certain doctors are just unable to multitask like that especially when they are dealing with a sick patient.

[Lev, MSN, RN, NP]

I also need general advice on how to maintain my composure. One of my coworkers told me that if I start feeling like I can't handle the patient and that my patience has run out I should have another nurse take over the care of the patient. The patient ended up firing me which I was happy about. When I went in to give her pain medication after the outburst by the husband, the tech was in her trying to calm her down and she was ranting on and on, I don't remember everything she said but at one point she said the nurse was ignorant. So I responded: "So do you want your ignorant nurse to give you more pain medicine or not." Then she started ranting about how the nurse was a "smart @ss." That was probably the only thing she said that was true the entire night. I went back in there to give her ativan and then she demanded that I leave her room and not come back. :)

[Double-Helix, BSN, RN]

Also, a little empathy goes a long way. Some people are just jerks, plain and simple. Most people who are angry or belligerent, however, are acting out another emotion. Fear, frustration, pain. Maybe the patient has has multiple hospital admissions (kidney stones are often chronic) where her pain went unmanaged due to delays in medication administration.

On another note, minimizing delays in pain medication administration and effectively managing pain are both Joint Commission standards and huge indicators of patient satisfaction. As medical reimbursement is becoming satisfaction-driven, your facility should look at ways to prevent the situation you just described. If the one doctor on service is the only one who can order pain medication, and the only doctor who manages codes and recussitations, perhaps your ER needs to rethink their policy. Having the doctor order a few doses of PRN pain medication rather than a single one time dose would prevent the nurse from needing a new order with each administration. Allowing the nurse to enter an order after verbally confirming with the physician may help expedite situations in which the doctor cannot enter the order themselves due to care of other patients.

[nutella, MSN, RN]

Quote

I also need general advice on how to maintain my composure. One of my coworkers told me that if I start feeling like I can't handle the patient and that my patience has run out I should have another nurse take over the care of the patient. The patient ended up firing me which I was happy about. When I went in to give her pain medication after the outburst by the husband the tech was in her trying to calm her down and she was ranting on and on, I don't remember everything she said but at one point she said the nurse was ignorant. So I responded: "So do you want your ignorant nurse to give your more pain medicine or not." Then she started ranting about how the nurse was a "smart @ss." That was probably the only thing she said that was true the entire night. I went back in there to give her ativan and then she demanded that I leave her room and not come back. ?

It is good advice to realize when somebody is pushing your buttons and to take a step back or swap patients if possible. But it is good not to respond to provoking comments because that will usually just fuel whatever is going on. When somebody is confrontational they keep on going if you respond.

Try not to take things personal. People who come to the ER are stressed, in pain, mentally deranged and what not.

[Lev, MSN, RN, NP]

@Ashley

I think in this case it was the former. They were just jerks. I am not denying that she was having pain, but compared to my other patient I got later on who was also in severe pain and crying, her behavior and that of her husband was highly inappropriate. I did ask for a prn order which was denied. The patient with the kidney stones had been hospitalized in the past couple months for kidneys stones and had a stent placed then. We do not have a specific resuscitation room or code doctor. The critical patients can go anywhere in the main ED and for another doctor to put in an order for a patient they have to evaluate the patient and do an assessment. That is their personal policy. They are not going to take the time to eval another patient who can't wait 1/2 an hour when they have their own patients to see. At any given time there are usually 4-5 doctors at time in the adult side. 1 in each part of the main ED and sometimes one in the fast track area. There was no PA working with the patient at that time. We do not take verbal orders unless it's an emergency. Against hospital policy.

[Lev, MSN, RN, NP]

People who come to the ER are...mentally deranged

Oh this absolutely.

[nutella, MSN, RN]

Pain can be an emergency - just saying.

You assume and expect certain behavior based on general norms. There is nothing "normal" in an ER. People are just not themselves in that environment, it can bring out the worst in people.

Trying to understand the other person instead of judging can help you because your attitude will be less judging and more understanding. That itself often de-escalates.

If the system is failing the patients perhaps the way they do business is not that good,

I am not saying that it is ok to behave inappropriately but often there is a reason for it and compassion for the person's situation will go a long way...

[Libby1987]

My kidney stone made me irrational. And I suppose deranged if I got a lecture. Much worse than any of my childbirths where I at least got a break.

They're not a rare occurance, I question why you don't have better protocols in place so that you don't have to predictably wait on the physician to become available.