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?

[Kooky Korky, BSN, RN]

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."

Libby, sadly, I have read lately how some nurses speak to laboring women. The nurses deserved to be horsewhipped.

I remember two of my wife's L&D nurses. One was fabulous - nice, kind, empathetic. Her relief was not. It's been 30 years and I still remember how each one treated us.

[mystcnurse, MSN, APRN, NP]

jadelpn said:

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.

Jadelpn, excellent responses. IM or IV Ketorolac can work wonders, as long as you can assure that the patient can tolerate it with regards to renal function. I am very careful using NSAIDs, as the OTC NSAIDs are often over used for pain before a patient comes to the ER. These are among many classes of drugs that can ruin a patient's kidneys, if other factors are present. However, if it is safe, they are an effective go to drug that can be very synergistic along with stronger pain medications.

I have rarely had a patient or family member that I could not at least temporarily turn around. Some of this might come from the bartending experience that put me through nursing school. I always try to find a common ground and try to determine what the motivation is, beyond the obvious need. Then I find a motivating statement. Like for example "wow, Mrs. XXX, you are so fortunate to have a man that cares about you so much! Where did you find him?" There are so many underlying issues that we are not aware of.... it could be that the husband feels guilty, or impotent in this case and needs to prove his "manhood".... just for example. I might say something like "you poor thing! I know how bad that hurts, it has happened to me! And I am going to do everything I can to help you. I have a request in for more pain medication and you will have it as just as soon as it is available, I will go check on it right now!" And then follow up every few minutes, even if I just stick my head in the door.

There are many pain control techniques that can be used and even taught to family members. I try and make that person a partner in the patient's care. Once, I had a woman completely freak out on me when her boyfriend was transferred to my unit without orders for pain medication. Her biggest issue, however, was the anal tube that was in place. I think it was grossing her out. She was very, very self absorbed. So I killed her with kindness... "you seem to be a very caring and compassionate person, I understand how uncomfortable you must feel seeing your loved one like in such pain and discomfort. It must be very hard for you", etc, etc. I let her walk with me to the desk where I began putting in orders and requests, and sort of explained what I was doing as she continued her tearful and emotional rant. I hugged her and suggested that she take a walk and get some air and she did. By the time she returned, her partner was resting quietly. It was truly all about her. She did call me some nice names in the beginning, but later apologized, and instead of spending my energy fighting with her, standing the ground that I KNOW I have, and ultimately having to call security, I focused on providing care for the actual patient.

I really don't think it is very helpful to try and explain the process to a patient who is in pain or upset or what was the word? "Deranged"? People generally are at that WORST when in the hospital, ER, etc. I have been there as a patient, and although I tried to be nice, I did witness a lot of incompetence and lack of compassion that frankly, really irritated me. This was especially true considering that I was in the worst pain of my life so far at that point AND I had no idea what was wrong, because there were no textbook answers. I had suffered for days before finally breaking down and going to the ER. There, and during my entire hospital stay, I watched and witnessed attitudes and lack of skill and compassion that frankly, I could have written a book about. I was actually in a hospital under which I practiced in an outpatient clinic as an advanced practice nurse, and all of the nurses were aware, which I found terrifying, not so much for myself, as much as for others who did NOT have the education that I do. Additionally, I didn't talk about it for years, which I later realized was due to being traumatized and utterly disempowered through the entire ordeal. In fact, once I came to terms with it, the experience prompted me to go back into bedside nursing so that I could teach.

I have also never made a big deal out of ranting and raving, even when it may be directed towards me. I simply don't take it personally. I have found that when nurses try and maintain their boundaries in situations such as the one presented, the patients and their family members are more likely to become escalated, which usually prompts security being called or some other more drastic measure. Of course, I am not talking about the threat of actual physical violence. I have refused to allow a patient's partner into the ICU due to inappropriate behavior, that I felt was causing the patient more harm than good. He was a very controlling man who actually grabbed my arm when I was attempting to explain what was happening with his partner, who was going through DTs secondary to a surgery and inaccurate history. I had asked about the patient's drug and ETOH use, and the man became angry and grabbed me, instead of answering my questions, he began demanding to be allowed into the ICU. I simply told him to go sit down and we would update him when information was available, as I pried his fingers from around my arm. I think the look on my face was enough to get the point across. After he approached several other staff members with the same demands, I did have our big, burly house supervisor explain the "rules" to him, and that was the end of that.

If pain control is a problem in your ER, maybe the nurses should get together, and involve the Pharm D, and the medical director and come up with some protocols to assist in safely achieving pain control for patients. A sleeping patient is a happy patient. As long as the breath rate is normal and O2 Sats are normal, and you aren't covering any unidentified problems such as a bleed.

I guess the point I am trying to make is that a human being, be it nurse or patient, only has so much energy, and for me, I would prefer to use mine to create the outcome I desire than promote and then deal with unneeded drama. I never approach a situation looking for the worst, and I usually find a way to keep a situation in check if it gets out of hand. I just really don't feel the need to demand respect, and that saves me a lot of time and energy. If a problem seems to present itself over and over, then to me, it is a systemic issue that should be addressed proactively. Finally, I simply will not work in an environment where I have no power to provide excellent nursing care, due to egos or policies that are sabotaging. Just my 25 cents

[Libby1987]

Libby, sadly, I have read lately how some nurses speak to laboring women. The nurses deserved to be horsewhipped.

I remember two of my wife's L&D nurses. One was fabulous - nice, kind, empathetic. Her relief was not. It's been 30 years and I still remember how each one treated us.

I think some of the approaches suggested on this thread and others on this site contribute to the squeaky wheel myth, which probably has also insidiously helped perpetuate the customer service entitlement phenomen seen everywhere. I don't think though that some could ever be persuaded to believe it.

[KatieMI, BSN, MSN, RN]

I think some of the approaches suggested on this thread and others on this site contribute to the squeaky wheel myth, which probably has also insidiously helped perpetuate the customer service entitlement phenomen seen everywhere. I don't think though that some could ever be persuaded to believe it.

I have rather opposing observation. Yes, folks of this type can get more attention at first (and more drugs as well) but that is working just as long as they make noise. After that, everybody avoids them as a plague and staff enters their rooms only when it is absolutely necessary. These are precisely the patients who do coding for seemingly no apparent reason or found dead in their beds. They did have changes and signs and symptoms, of course, and these changes would be noted if their antics would not alienate every single staff member they encounter to the point of avoidance.

If they name it "customer service", that's fine. But I wish someone would explain to general public that causing a person who literally holding your life in his or her hands to avoid you is not a smart idea at all.

[Libby1987]

I have rather opposing observation. Yes, folks of this type can get more attention at first (and more drugs as well) but that is working just as long as they make noise. After that, everybody avoids them as a plague and staff enters their rooms only when it is absolutely necessary. These are precisely the patients who do coding for seemingly no apparent reason or found dead in their beds. They did have changes and signs and symptoms, of course, and these changes would be noted if their antics would not alienate every single staff member they encounter to the point of avoidance.

If they name it "customer service", that's fine. But I wish someone would explain to general public that causing a person who literally holding your life in his or her hands to avoid you is not a smart idea at all.

I don't think that's an opposing observation. I agree with you and think they all go hand in hand, but it also may be a chicken and egg question. And perhaps the answer varies.

[Dogen]

Please don't refer to people as having borderline traits. That's like saying "the guy in bed 2 is totally schizo," or "that lady is retarded." Mental health diagnoses don't exist to help you better denigrate your patients. If the patient is needy, say that. If they're demanding, say that. You don't need to propagate the stigma of mental health to explain annoying behavior.

Thanks.

[Lev, MSN, RN, NP]

Please don't refer to people as having borderline traits. That's like saying "the guy in bed 2 is totally schizo," or "that lady is retarded." Mental health diagnoses don't exist to help you better denigrate your patients. If the patient is needy, say that. If they're demanding, say that. You don't need to propagate the stigma of mental health to explain annoying behavior.

Thanks.

Yelling that we didnt even draw labs or check urine to get attention from husband when we clearly did is exhibiting a borderline trait. Making a hissy fit over the fact that we didnt offer a tampon or pad - I have never heard such an outburst. Many people exhibit borderline traits from time to time, doesnt mean they have borderline personality disorder.

[TriciaJ, 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.

I had a patient admitted to the floor with a kidney stone with orders for Dilaudid IV Q1h. Doesn't matter what dose; it wears off in 15 mins and then he had to writhe in pain for another 45 mins. The urologist wasn't going to be coming up for a couple more hours. I called the ED doc back and asked for a PCA. He hadn't thought of it because they're not commonly used in the ED. Made the patient much happier till he could see the urologist.

This is a bit off-topic but worthwhile to consider for kidney stones.

As far as disarming one-liners? There aren't any. Empathy works best. "I know kidney stones really hurt. So I'm going to do what I can to chase down the doctor and get this pain under control. It's not your fault that there are emergencies going on and I have to take care of them, too. But I won't forget you and it is my mission in life to control your pain. What can I do right now while I'm here to make it a tiny bit better?"

[NuGuyNurse2b]

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."

That might fall under the category of assault.

I'd like to point out (since no one has picked it up yet) that when you fart, it diffuses. If you want to de-escalate a situation, you are defusing the situation, like defusing a bomb.

[NickiLaughs, ADN, BSN, 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.

I unfortunately work at an ER and see this commonly. None of the docs will order prn pain meds for any patients....I've had pts with broken bones where the docs also wont give anything if they're going to consciously sedate them eventually to do a reduction. Absolutely stupid...but even with all my advocating they remain idiotic.

I can relate to OP...its very much culture dependent. Some places their goal is to give them a couple doses of IV and then switch to POs and send them home. This doesn't work for everybody..and its super frustrating for those of us (as well as the pt) who are stuck constantly harassing the doctor.

[Julius Seizure]

Quote

Yelling that we didn't even draw labs or check urine to get attention from husband when we clearly did is exhibiting a borderline trait. Making a hissy fit over the fact that we didn't offer a tampon or pad - I have never heard such an outburst. Many people exhibit borderline traits from time to time doesnt mean they have borderline personality disorder.

I totally disagree. Particularly in an ED setting; if this isn't a preexisting diagnosis, personality disorders are not something that is likely going to be diagnosed in the short time that they are in the ER.

As far as the "trait"...more likely their outbursts are just rude and poor behavior, NOT an actual mental health issue. To jump to the conclusion prematurely is like assuming that a demanding and overbearing pt. mother in pediatrics has munchausens by proxy. Sure, you might be right on the rare occasion, but more often you end up doing more harm than good by putting that label on them. It is incorrect to identify all outbursts and inappropriate behavior as being a trait of a mental health issue.

Not to mention adding to the stigma that mental health already has, like Dogen said. If nothing else, its not PC.

[Julius Seizure]

) when you fart, it diffuses. If you want to de-escalate a situation, you are defusing the situation, like defusing a bomb.

.....wait, what?!