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?

[Lev, MSN, RN, NP]

I dont think I have ever said a patient had borderline traits until this instance. You had to be there to see where I am coming from. I understand what you are saying about not labeling patients. And I apologize if any of you were offended by this.

[canigraduate]

I honestly get the sense that you just want a quick quip to make the patient and family shut up. Unfortunately, it doesn't work like that. This situation was allowed to progress too far.

Young people act stupid because they don't know any better. Older people have experience and know how to act. Usually. You get your outliers from time to time. I had a perfectly pleasant 26 year old male who was in excruciating pain a few days ago and a 52 year old woman who was nucking futz.

In this case, the situation would best be managed by outlining the expectations for the patient-nurse interaction from the beginning.

There's no easy way to clean up a mess of that magnitude.

[OCNRN63, RN]

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.

Thanks. I'm surprised at how many people confuse diffuse with defuse.

[ProgressiveActivist, BSN, RN]

If the patient can have a meltdown about not being offered a peri pad then I would surmise the pain management was adequate.

"If you want my help you need to stop screaming"

" If you want my help don't insult me."

Said in a calm assertive and non threatening manner, this has worked for me.

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.[/quote']

[Hollybobs]

If you could empathise with your patient rather than judge her, that would go a long way. You found her reaction to her pain disproportional and judged her as exhibiting extreme behaviour and compared her to another patient. You also had your own stresses to deal with and were annoyed with her. I would find it surprising if that did not come across when you were speaking with her and her husband and inflamed the situation rather than calming it.

I feel really preachy saying this and I apologise but if you could bear in mind you don't know her back story and are not experiencing her level of pain it would help you feel, and be, more patient and calming. It is a difficult thing to do when busy and we are naturally inclined to make judgements, we all do. But she sounds like she was in a lot of pain but also very frightened by it and we all can react in an extreme manner when we are panicked and scared. Watching someone you love in that situation is also extremely frightening and upsetting. They both had no control in that situation and were vulnerable. Many people will go into meltdown in that set of circumstances. And we really don't know what led up to that. Maybe they were sleep deprived. Maybe they had had a recent bereavement. Sheer pain can produce a reaction like that but maybe they were at the end of their tether for other reasons. I'm rambling a little but I'm trying to say the old adage about walking a mile in someone's shoes before judging them is a good idea, especially as a nurse.

From a conflict resolution point of view, tone and body language go a long way, especially as another poster had said, she wasn't entirely rational at that point- who is, when in severe pain? Keeping your tone and movements a few notches quieter and lower than theirs etc. But seriously, if you nail the empathy thing (and some days you are so busy and stressed it is a challenge) you can manage a situation like this much more easily as they can see in your eyes and your face and your tone that you REALLY care about their suffering and you REALLY want their pain to stop. This will work in 99 out of 100 cases. They then know it is true when you tell them you will get the pain relief as fast as it is possible to do so and you are awaiting the Doctor who is in another emergency and you are really sorry for that delay. Then come back and update them before they have to shout you, even only for 60 secs.

[bellabellabijou]

There is a point that talk and reasoning will not work. So it is very, very important to diffuse the situation as soon as it is noticed. The most important part is to LISTEN. Let people vent their concerns and frustrations, then for you to ACKNOWLEDGE their concern. Then ACT to reconcile the situation. Offering other options when the one they want to not readily available. Instead of saying, "I'll give you the medicine when the doctor orders it" try, "The doctor is putting in those orders as soon as he can. In the mean time I DO have _______. And we can also try _______" Just letting them vent and then showing them that you understand and are trying to do something is usually enough to calm them down. It is very important to follow through with anything you say you are going to do.

[CristyGerald]

To the husband and the patient: We are your nurses. We do our best to deal with you with utmost, love, patience and care. Please bear in mind that we are not your slaves. We have personal things also to dealt with but we put that on one side as we put your needs in our priority list. However, there are more sicker patients that require attention than you do and this is called triage especially if we are under staff and the doctor is attending also to some patients. Please wait for your turn to be attended, however please be assured that it is in our best judgment and discretion to give you the first aid and offer you comfort measures while we wait for the proper medical attention.

We are not your slaves, we are with you in looking after the best of your health.

[Dogen]

I dont think I have ever said a patient had borderline traits until this instance. You had to be there to see where I am coming from. I understand what you are saying about not labeling patients. And I apologize if any of you were offended by this.

I'm not offended. I'm advocating for my mental health patients who suffer worse outcomes when they're admitted to the hospital, in part because of associations like the one you drew between your annoying patient and borderline personality disorder. I think the practice of using mental illness labels as a way to describe difficult patients is unprofessional for that reason. I don't need to be there to know that it isn't okay. Even if I were this patients PMHNP, and had just finished describing them in a note as having borderline traits, I would still find it unprofessional to describe them that way on AN or in casual conversation. Just describe the behavior, and leave the diagnostic labels in the chart.

[Lev, MSN, RN, NP]

Same patient back tonight. I heard her yelling, just as agitated as the other night. The police officer was just shaking his head saying he was tired of dealing with her. I think the oxycodone script she got last week is just running out. Clearly you had to be there to have clear judge of the situation.

[Lev, MSN, RN, NP]

I'm not offended. I'm advocating for my mental health patients who suffer worse outcomes when they're admitted to the hospital, in part because of associations like the one you drew between your annoying patient and borderline personality disorder. I think the practice of using mental illness labels as a way to describe difficult patients is unprofessional for that reason. I don't need to be there to know that it isn't okay. Even if I were this patients PMHNP, and had just finished describing them in a note as having borderline traits, I would still find it unprofessional to describe them that way on AN or in casual conversation. Just describe the behavior, and leave the diagnostic labels in the chart.

For the umpteenth time I never said she had borderline personality disorder. She was however manipulative, attention seeking, staff splitting, lying, and guilt tripping.

[ProgressiveActivist, BSN, RN]

Ten years ago people like this - just the extreme cases - would be charged and fined for disorderly conduct. When the fines accumulated the judge would sentence them to thirty days in the county jail along with a stern lecture about abusing EMS and ER services.

They stopped frequenting our ER.

[hppygr8ful, ASN, RN, EMT-I]

If a person is just being a donkey's behind you can sometimes use one-liner's or reasoning - but with a truly borderline personality you won't talk them down from their perch. I would imagine in ED setting - just medicate as often as possible and turf them out as fast as you can unless they have a real medical emergency - then you just have to deal with it.