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?

[twozer0, NP]

I've dealt with numerous stones in the ER over the years. One thing I have learned is that the nurse-patient relationship is a two way street and no one side should have the upper hand, its best to meet in the middle. I always try and explain to my patient that I will do the best in my power to meet them there, but at the same time, they need to make some effort to also get there as well. I'm here to help you, not be your servant. Nurses gonna nurse, and patients gonna.. well... complain...

In any event. Kidney stones hurt like a *****. Over 5 years of seeing them the single best med you can give is Toradol, it litterally destroys stone pain (at least for a while). It's hard being in a facility where pain meds are ordered sparingly, and this comes down to your rapport with the doctor to get the patient something else. I realize you have other patients but its always easier to ride the wave than paddle through it. I doubt your patient was borderline, just stressed from the pain and has a husband who is dealing with his screaming wife, also stressed and irrational. I've had numerous patients and families like that, its uncomfortable for you the nurse to deal with, best to approach with caution and an open mind. Do what you can but stress the meeting in the middle, its not like you arent doing anything. The pain meds are under ordered, try and get more, the effort looks good even if fruitless.

Its a daunting task working in the ER. Something I know too well. You dont have to answer to every whim of a patient but sometimes small things can put a person at ease (Theory of Comfort, freaking theory...). So be sure to have toradol for your patients, typically the renal function is fine in stone patients. Try and push the doc to the edge but not off the cliff when asking for more meds. finally get your patient to understand that they need to meet you half way and that you will give but they need to be willing to receive and accept as well!

[Lev, MSN, RN, NP]

Then why say it?

I never did say she had borderline personality disorder. I said that she was exhibiting borderline traits so people had a better idea of how she was acting. I was using it purely as a clinical term and not meant to stigmatize. I am not one who calls people "retarted" or "schizo" either. I will say that someone is acting psychotic or if they are paranoid. I had a patient the other day which schizophrenia and bipolar disease who was acutely ill and the tech was asking why her belongings were thrown all over the room and covering the floor (we were afraid she would trip but she wouldn't let us clean up her stuff) and I explained it is probably from her mental health issues.

[Lev, MSN, RN, NP]

I've dealt with numerous stones in the ER over the years. One thing I have learned is that the nurse-patient relationship is a two way street and no one side should have the upper hand, its best to meet in the middle. I always try and explain to my patient that I will do the best in my power to meet them there, but at the same time, they need to make some effort to also get there as well. I'm here to help you, not be your servant. Nurses gonna nurse, and patients gonna.. well... complain...

In any event. Kidney stones hurt like a *****. Over 5 years of seeing them the single best med you can give is Toradol, it litterally destroys stone pain (at least for a while). It's hard being in a facility where pain meds are ordered sparingly, and this comes down to your rapport with the doctor to get the patient something else. I realize you have other patients but its always easier to ride the wave than paddle through it. I doubt your patient was borderline, just stressed from the pain and has a husband who is dealing with his screaming wife, also stressed and irrational. I've had numerous patients and families like that, its uncomfortable for you the nurse to deal with, best to approach with caution and an open mind. Do what you can but stress the meeting in the middle, its not like you arent doing anything. The pain meds are under ordered, try and get more, the effort looks good even if fruitless.

Its a daunting task working in the ER. Something I know too well. You dont have to answer to every whim of a patient but sometimes small things can put a person at ease (Theory of Comfort, freaking theory...). So be sure to have toradol for your patients, typically the renal function is fine in stone patients. Try and push the doc to the edge but not off the cliff when asking for more meds. finally get your patient to understand that they need to meet you half way and that you will give but they need to be willing to receive and accept as well!

She got toradol as soon as her urine pregnancy came back negative.

[Libby1987]

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

Understandable, I probably would, too. I'd still say it and do whatever I could, including meeting with my manager and asking for solutions for such a predictable recurrent issue.

[elkpark]

I never did say she had borderline personality disorder. I said that she was exhibiting borderline traits so people had a better idea of how she was acting. I was using it purely as a clinical term and not meant to stigmatize. I am not one who calls people "retarted" or "schizo" either. I will say that someone is acting psychotic or if they are paranoid. I had a patient the other day which schizophrenia and bipolar disease who was acutely ill and the tech was asking why her belongings were thrown all over the room and covering the floor (we were afraid she would trip but she wouldn't let us clean up her stuff) and I explained it is probably from her mental health issues.

Saying someone is "exhibiting borderline traits" isn't describing how the person is acting. It's much more effective communication to simply describe the behaviors. If you have someone with a rash, do you describe the rash, or say that the individual is "exhibiting measles traits"?

[Lev, MSN, RN, NP]

Understandable, I probably would, too. I'd still say it and do whatever I could, including meeting with my manager and asking for solutions for such a predictable recurrent issue.

It's not a predictable recurrent issue. Most people actually do not behave like these two. Calling police and security is not a usual reaction to someone being upset over pain medication. 98% of the time I can redirect them.

[Lev, MSN, RN, NP]

Saying someone is "exhibiting borderline traits" isn't describing how the person is acting. It's much more effective communication to simply describe the behaviors. If you have someone with a rash, do you describe the rash, or say that the individual is "exhibiting measles traits"?

Describing a personality disorder is a lot more complex that describing a physical syndrome such as measles. Similarly, someone can be described as depressed without being diagnosed with major depressive disorder. I used "borderline traits" as an umbrella term.

[elkpark]

Quote

Describing a personality disorder is a lot more complex that describing a physical syndrome such as measles. Similarly someone can be depressed without being diagnosed with major depressive disorder.

Exactly, which is why we are suggesting that you not throw around diagnostic terms like "borderline traits" (or, for that matter, "depressed"). Just describe the behaviors you observe without attributing diagnoses or motivations that you can't possibly know.

[Libby1987]

It's not a predictable recurrent issue. Most people actually do not behave like these two. Calling police and security is not a usual reaction to someone being upset over pain medication. 98% of the time I can redirect them.

Oh my goodness. The issue is the lack of adequate pain management for a common condition resulting in this patient coming undone and affecting the husband who is advocating for his wife in the unsophisticated way he knows.

Yes, they are not as emotionally mature as your older couple next door. Irrelevant.

You seem to just want them to deal better and are looking for a simple statement to shut them up.

[Lev, MSN, RN, NP]

There was a critical patient who I went to tend to with the MD after giving the patient another 4mg of morphine. If the critical patient wasnt there this patient would have been the doctors priority. Unfortunately for all of us, pain management was not the number one priority for about 20 minutes that the scene errupted. I asked for and was given many good answers for how to deescillate the situation.

[Dogen]

Quote

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.

Right. You're using a mental illness as a way to stigmatize someone. "That lady is so annoying, she's a lot like someone with a mental illness!" You don't say people who are having trouble expressing themselves are exhibiting "retarded traits," do you? Because that would be inappropriate. Labeling people who are demanding as having "borderline traits" is inappropriate. "Borderline traits" is the pseudopsychiatry label du jour applied to anyone a healthcare worker wants to demean. Again, diagnoses don't exist to help you better insult your patients.

I don't care if you want to insult your patient, but perpetuating the stigma of mental illness by using it as an insult is unprofessional. We do use the term "borderline traits" in psychiatry, but the goal of using it is to identify areas for further evaluation or where there may be a need for work to be done. By using clinical terms as insults you stigmatize our clinical language, which makes my job harder, and I'm not cool with that either.

So please stop using the term borderline traits.

[Dogen]

Exactly, which is why we are suggesting that you not throw around diagnostic terms like "borderline traits" (or, for that matter, "depressed"). Just describe the behaviors you observe without attributing diagnoses or motivations that you can't possibly know.

For God's sake, yes.