One Liner to Diffuse Escalating Situation With Patient

[Lev]

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?

[MunoRN, RN]

You're certainly not going to see people at their best in the ED, so if they are a jerk on their best day... I try to keep in mind that they are in pain, or that they're having to watch their loved one in pain, and getting inadequate treatment. I usually will explain that the fewer things on my list that I have to do, the quicker I can get to getting them pain medication, and having to deal with a disruptive patient and husband isn't making my list any shorter.

What sticks out to me though is that the doc is only giving one time pain med orders for a patient with a known kidney stone, I've never known an ED doc to do that and is pretty much guaranteed to inadequately treat the pain. I'd tell the Doc that the patient in bay 12 wants to talk to them about their poor prescribing habits.

[KatieMI, BSN, MSN, RN]

Non-verbal: just stay there, quietly, listening to their every word. Pay attention to what they say/do (or at least make the strong impression of it). Then CALMLY ask "I am here to help you, what can I do?" Listen to outburst, let them vent it all out. Do not interrupt. Then in the same calm, polite tone state the facts of life, one by one. Use simple sentences, no rationalizations, avoid excuses if possible. Offer them a reasonable timeline and STICK TO IT. They are already not trusting anyone, so if you say that doctor will be with them in 15 min., he better be there in 14 min 55 sec. If something cannot be done as promised, do not promise it, say that you try to expedite things. Apologize often, offer them any comfort you can. Do not use any medical jargon, like "coding", they may have no idea what does it mean and feel tricked and intimidated. Do not mention other people, these kind of folks are pretty sure that the universe is revolving right around them.

" I am sorry that everyone is so busy that you feel ignored. I cannot give you any more drugs till the doctor is free to see you, I am sorry. I need an order to give you more drugs. I hope it will not be long, but I do not know for sure. Would you like warm blanket? It can make you more comfortable. We do not have pads or tampons, would you like a towel? I now need to go, I will check on you in 15 min. Now is 4:15, I will see you at 4:30".

If necessary and possible, get them (or hubby alone) to see computer screen and explain that, for example,no green mark means no order available. Sometimes it convinces them that you are telling them the truth.

Otherwise, they very well can make the drama and all that, but small kidney stone can easily be "pain emergency". They are usually safe to pass otherwise but 100/10 pain they cause can kill a human being.

[Lev, MSN, RN, NP]

You're certainly not going to see people at their best in the ED, so if they are a jerk on their best day... I try to keep in mind that they are in pain, or that they're having to watch their loved one in pain, and getting inadequate treatment. I usually will explain that the fewer things on my list that I have to do, the quicker I can get to getting them pain medication, and having to deal with a disruptive patient and husband isn't making my list any shorter.

What sticks out to me though is that the doc is only giving one time pain med orders for a patient with a known kidney stone, I've never known an ED doc to do that and is pretty much guaranteed to inadequately treat the pain. I'd tell the Doc that the patient in bay 12 wants to talk to them about their poor prescribing habits.

We have a couple doctors who will order morphine 4mg IV q15 PRN. And then we have doctors who are super safe to the extreme that they want to be in control of every dose. This is the same doctor who we had to ask at every move if we could titrate up the norepi (on the crashing patient).

[jadelpn, LPN, EMT-B]

You could always ask for longer acting (ie: toradol, for instance) and then morphine X 3 or 4 doses--that way you have a bit of a leeway in timing.

The husband: "You are an amazing advocate for your wife and I hear you. However, yelling in the hall is frowned upon. I will be in as soon as I can."

As far as the patient. I get it. Pain can make people act out. Sometimes the loss of control makes people act out. Some people are criers, some people will laugh inappropriately, some scream, some whip around on the bed as if possessed. Sometimes due to past experience and labelled as a "drug seeker", they will come in defensive and escalate from there. Husbands/partners/s.o.'s don't like feeling out of control either. So they get allll up in arms about their perceptions based on the patient's behaviors. They "have" to fix it stuff.

So instead of one liners, I would be firm with the company,("do not yell in the hall, I am aware of your concerns and are addressing them with the MD.")

As soon as the patient starts upping the hysterics, be clear with the MD before he rushes off--"patient in room 3 is escalating. Can you give me a few doses of PRN pain med so that I can try and at least get her to a manageable level, perhaps Ativan as well?" The magic combo may be anti-inflammatory, pain, and anxiety med.....

[0.adamantite]

"You need to speak respectfully to me." Has worked surprisingly well for me. The has startled a few patients in the their tracks and then they try to back pedal. I had one lady say, "I guess you're right about that." Then if they comply I do my best to resolve their issue in a reasonable manner. If they don't comply, I leave.

[Tenebrae, BSN, RN]

Use of therapeutic silence can be helpful, allowing the patient to have a rant and acknowledging that its ok to feel sad/angry/scared etc.

Consistency also works really well, eg if you say you will do something, make sure you do it.

Failing that, 'dont speak to me like that" works well for me. Fortunately its well reinforced here if a patient is being violent or acting out in the ED, they will be escorted out in hand cuffs.

[Karou]

If they are upset over something legitimate, I try to be patient/calm and listen to their complaints. I'll validate their feelings- "I am so sorry that you are hurting, kidney stones are extremely painful, and I thank you for being patient with us". I will remind a patient/family member that, "the doctor has to prioritize, he/she is seeing the most critical patient right now. He/she will be in with you as soon as possible." And say, "I have talked to the doctor, they are aware of what is going on, they will be here as soon as they can. In the meantime can I get you a cool washcloth/ice pack/heating pad, ect?"

Mostly just listening to their complaints. When I can't calm the situation well enough or the patient/family member escalates (especially to the point of cursing, threatening, I feel unsafe), I don't hesitate to say, "sir/mam, I know you are frustrated, and I am sorry for that. However, this is a hospital and there are other sick patients here for help. This must remain a SAFE environment for everyone. You need to remain calm and stop any threats, yelling, or foul language, or security will be called". One warning only, then security is called.

I've also left a room and said, "I will return when you calm down and can speak to me without yelling or cursing".

[FranEMTnurse, CNA, LPN, EMT-I]

I would say to the husband; "Right now my mind and skills are in overdrive helping the patient in a life threatening experience."

To the patient, I would say; "If you don't calm down, I'm going to switch into low gear and you will be waiting even longer. I already gave you a double dose of pain medication, and the ER is not a store where we hand out things like that freely."

[Libby1987]

Some of the responses here validate some of the complaints.

I'm all about being constructive but this woman is passing a kidney stone. Is this how you would speak to a woman in labor? Or any other legitimate severe pain? Evidently.

Here's a one liner.. "I'm tackling the Dr as soon as he finishes CPR, it's a top priority of mine."

Here's my 2nd liner.. "Let me show you how to help your wife with breathing that can help her get through until I can get her more pain med."

[Axgrinder]

There are some people whom literally cannot see beyond their own needs, therefore will have no concern regarding sharing ER staff time with a crashing pt. Their needs being meet are the ONLY thing that matters, and the his type of pt will tell you so. Often these pt's will have partners and/or family members whom feed this delusion, and will provide fuel for the fire. The best you can do is not the react to the childish antics, and remain professional at all times (how you respond in your own mind is without censor - so smile blandly and say what you want in you head). Escort out disruptive visitors PRN. I've found commiserating with an upset pt helps diffuse many an angry outburst.

[Kooky Korky, BSN, RN]

@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.

It was an emergency. Sounds like you have never had a kidney stone. And the answer you think might help is too long and too logical because the patient is in agony and not fully rational because of that. Her husband is horrified seeing the woman he loves in agony and not being able to do anything to alleviate her agony. So what if she had a stent placed? Don't those collapse or otherwise often fail?

You did not convey competence, caring, or caring. Why did the doctor deny a PRN order???? Did you tell the couple that? If the blame is the doc, definitely tell them.

It shows you are trying. You could have told them you were going to ask again or find a different doctor. Even if you weren't or had already tried. It would have shown your caring. Or just get somebody to switch with you.

Never mind crying vs demanding. It's easier of course, to feel sorry for the one quietly weeping, but perhaps her pain wasn't as bad or she was shedding tears for another reason.

Take a deep breath, put yourself in the shoes of a patient you have trouble dealing with, and keep on truckin'. Be nice. Pretend you are a patient, not a nurse, not ER staff. That should help you see the matter through their eyes.

[Kooky Korky, BSN, RN]

I would say to the husband; "Right now my mind and skills are in overdrive helping the patient in a life threatening experience."

To the patient, I would say; "If you don't calm down, I'm going to switch into low gear and you will be waiting even longer. I already gave you a double dose of pain medication, and the ER is not a store where we hand out things like that freely."

Sorry, this is completely wrong. If I were your boss, I'd do a write-up.

Leave out the comedy, leave out the threat, leave out the lecture. Just say "You've had a double dose of pain med (which she has not - she had two separate doses) and it's starting to kick in. Meantime, do some guided imagery - butterflies in a lush meadow, rainbows over a waterfall, hold her hand for a moment, do some breathing with her. Teach the husband to help with these things. If he can't be engaged, you might have to have him escorted out. Do it not in anger or a holier-than-thou way. Lower the lights, give a warm blanket, try other comfort measures. Don't be a smart aleck. You have to realize these folks are terrified.