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?

[APRN., DNP, RN, APRN, NP]

.....wait, what?!

Well.......this DID come from a guy, soooo.......

[Kooky Korky, BSN, RN]

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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.

There is no reason to not give a pad, towel, something to someone who is bleeding. I'd be leary of the tampon.

In addition to a scared, overly cautious doctor who has trouble calling out an order for a pt he's already seen, you have a patient who doesn't want to lie in a bloody bed and who is in excruciating, unmanaged, uncontrolled pain. Some procedural and policiy changes need to be instituted.

You have received lots of good advice here. I hope it helps. How's the pt? spouse? Did she pass the sone? Get lithotripsy?

[canigraduate]

After reading this thread, I understand why so many of my patients who come from the ED are angry and in pain.

Major failure of the system.

[Lev, MSN, RN, NP]

I totally disagree. Particularly in an ED setting; if this isnt 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.

If you read what I wrote carefully, you wouldnt have written this. I did not say she was Borderline. I was identifying some of the ways she was acting as borderline traits which does not mean she has borderline personality disorder. As I said before, lots of people exhibit borderline traits from time to time which does not mean they have a disorder. To get to the level of disorder means that your life is disrupted. I have a friend with a personality disorder and have read about personality disorders to learn more about them.

[Lev, MSN, RN, NP]

@canigraduate and everyone

Another thing Id like to point out is that these patients often come with zero pain meds in their systems. The cummulative effect of pain medication is not working in our favor yet which is why we can give so much pain medication in relatively high doses and it barely touches their pain. My ER also does not give dilaudid.

[Lev, MSN, RN, NP]

There is no reason to not give a pad, towel, something to someone who is bleeding. I'd be leary of the tampon.

In addition to a scared, overly cautious doctor who has trouble calling out an order for a pt he's already seen, you have a patient who doesn't want to lie in a bloody bed and who is in excruciating, unmanaged, uncontrolled pain. Some procedural and policiy changes need to be instituted.

You have received lots of good advice here. I hope it helps. How's the pt? spouse? Did she pass the sone? Get lithotripsy?

Unless there are large volumes of blood which there wasnt we usually dont offer a pad. Patients have their own. Of course if someone asks we will get them what they need. This patient didnt even ask.

I have no idea how the patient is. I work in the ED. After the fentanyl and toradol and a dose of ativan her pain went down to a 4 and she was discharged. The spouse was much more calm after being kicked out of the ED and when he called to ask his wife something I apologized for the impression that we were not meeting his wifes needs. We let him back in. FYI, this was not an elderly couple. They were in their 20s and acting in the stereotype of my generation (me me me). Contrast this to my other patient in severe pain with her husband also of my generation and there is a world of a difference and we were still busy with crashing patient.

[Farawyn]

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If you read what I wrote carefully you wouldnt have written this. I did not say she was Borderline. I was identifying some of the ways she was acting as borderline traits which does not mean she has borderline personality disorder. As I said before, lots of people exhibit borderline traits from time to time which does not mean they have a disorder. To get to the level of disorder means that your life is disrupted. I have a friend with a personality disorder and have read up a lot on the subject.

Oh, so she's not Borderline, she's just ACTING Borderline...

[Lev, MSN, RN, NP]

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."

The answer to your second liner probably would havr been "F*** breathing. GET HER SOME PAIN MEDICINE NOW. "

[Lev, MSN, RN, NP]

Oh, so she's not Borderline, she's just ACTING Borderline...

She is exhibiting some borderline traits. Having one or two borderline trait does not give you a diagnosis. Look at the DSM.

[elkpark]

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If you read what I wrote carefully you wouldnt have written this. I did not say she was Borderline. I was identifying some of the ways she was acting as borderline traits which does not mean she has borderline personality disorder.

Then, as Dogen suggested, just don't use "the B-word." It's entirely possible and appropriate to describe behaviors without connecting them to a highly stigmatizing psychiatric disorder when you have no idea whether or not that is a legitimate connection, or, for that matter, attributing a motivation (seeking attention from the husband) that you can't really know, either. "Borderline traits" is a diagnosis, not a description of behavior.

[Farawyn]

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."

No no no no no. In so many ways, no.

[Farawyn]

She is exhibiting some borderline traits. Having one or two borderline trait does not give you a diagnosis. Look at the DSM.

Then why say it?