Saving Frank!

[spotangel, DNP, RN, NP]

This article was written and initially submitted in December 2017 and at that time I asked for it not to be published yet. With what just happened in the last few weeks, I feel now is the time. Ironically enough my initial title was, “I can’t breathe!” I had changed the title as I did not want to evoke or trigger emotions. Now that same title is a hashtag! It is out there now. Trevor Noah called it and gave us all a perspective of how the shoe feels on the other foot.

Frank

In the last two weeks, we have seen blatant discrimination captured on camera in NYC and Minneapolis. As a human being, it was extremely hard to watch George Floyd die. As a professional, my mind was screaming to let up on the knee pressure, start CPR on the field and right a wrong. I imagined the other end of it as the ER staff now received a patient who was clearly dead and desperately tried to save him. It took me back to 2008 when my ED team and I were in a similar situation. Frank was brought into my ED when a Group Home staff's good intentions backfired. Here is what happened.

Saving Frank in Today’s World

“Not again lord!” my brain screamed as my hand reached for the red phone calling with an emergency.

This was our 5th code in the space of 2 hours that EMS was bringing in on a Saturday.

A 25-year-old black male without a pulse and CPR in progress. ETA (Estimated Time of Arrival) 5 minutes.

I marshalled my weary troops again and set up for the code. We had plenty of time as they took around 20 minutes to arrive. We took over once they rolled in. Behind the ambulance around 6 squad cars pulled up. As I went in and out of the resuscitation room, my eyes lingered around 20 police officers by the entrance of the ED.

“Something is cooking!” I thought to myself.

The Story of What Happened

The patient, Frank, was DOA (Dead on Arrival) and had been coded in the field for over 40 minutes. We worked on him for over an hour without a rhythm. He was finally pronounced. The EMS gave us the story. Frank was a schizophrenic and lived in a group home. He had no family. He was agitated and pacing and so one of the staff got worried. They asked him to go to the ER and he refused. They called 911 after consulting their manager and EMS arrived as so did the cops.

When Frank refused again, the cops called for reinforcements and struggled to contain him. He struggled violently. They then put him in an Emotionally Disturbed Person (EDP) body bag also known as a "burrito". Every time he raised his head up and screamed, they held him down. Soon he stopped struggling. The EMS team got him on the stretcher to put him in the ambulance. One of the EMS workers noticed that he was not breathing and had no pulse. They called for reinforcement and started CPR.

The ALS team arrived to help and intubated him on the scene, continued CPR, and brought him to our ER. I saw the ED Tech take his belongings and clothes after the code, label the bag with his name, date of birth, Medical Record number and the date, then put it in our utility room. The weary staff moved on to the next emergency disheartened that we could not save him.

Police Arrive

I saw two more unmarked police black SUVs park at the ambulance bay and a few suits come in. They wanted to speak to the ED attending that ran the code. I pointed him out to them and they thanked me. They were from the police IID (Internal Investigation Division) as a call had gone out to them. They were also directed to Medical Records as they wanted copies of the ED course and copy of the medical chart as part of their investigation. Medical Records would direct them on our hospital protocol to obtain records.

Frank's Group Home Contacted

A phone call was made to the group home and the phone number obtained for the manager. She was not informed of his death but asked to come to the ED. She came with the assistant manager and the doctor and I took them to our family room. Sitting around a small table we informed them gently of his death. Rose, the manager, began shaking and crying. “I should not have asked them to send him to the ER. I should have come in and calmed him down. He would have been alive!”

Sara, the assistant manager, raised a trembling hand and put it on Rose’s shoulder to comfort her. “I can’t believe it! Poor Frank. Dear God! What did we do! We only wanted to help him.”

Both women sat crying. The doctor walked out after hearing an overhead page for him leaving me with both of them.

Swallowing my tears, I asked them if they wanted to view Frank’s body. Hesitantly, still in shock, they agreed. I walked them into the resuscitation room and pulled 2 chairs for them to sit by Frank. They sat silently, tears rolling down and dripping, shoulders shaking, Sara covering her face while Rose stared at Frank’s face, her eyes anguished. I silently offered them a box of tissues and murmured that I would be back in a few minutes.

Frank's Belongings

I walked into the utility room and put on gloves and took out the bag of Frank’s belongings and the belongings list clipped to it. Silently, I opened the bag and checked all the items against the list. A watch with a cracked dial, shoes and socks, a tee-shirt still wet with his sweat and sweat pants and underwear soaked in urine, a wallet with a $2 Lotto ticket, and a train monthly pass.

Eyes smarting, I put all the belongings back imagining his last struggle at life as with every ounce of his strength he struggled to live.

I Wish ...

I wish he had got a second chance in life. I wish he had been with staff that knew how to handle his pacing and increased agitation. I wish it had been a weekday with full access to a psychologist and other trained personal that could have handled his issue in a safe manner. I wished that the EMS and cops that had come in contact with him had dealt with him differently given a second chance. None of the wishing would change the outcome. Wiping my tears away, sick to my stomach, I walked slowly back into the room and gave them his belongings. They left and Frank was sent to the morgue as he had no family. The police group and the IID also left.

De-escalation

I went home feeling drained, wondering what we as nurses can do to educate others in handling psych patients. Many times as situations can quickly change, chances of violence and harm are high, triggering the choice to use force to subdue a patient. De-escalation is a learned art.

• How much training and mock practices on de-escalation are our first responders getting?
• What kind of training should health teams get to help patients, keeping ourselves safe at the same time?
• What is the aftermath of the ones left behind and the ones that worsened the situation while meaning to help?
• Which professional schools teach these techniques in mainstream classes as anyone at any time can be affected as one goes about their daily life?

I have seen videos of how to deal with an active shooter scenario but very few on psych outbursts and de-escalation techniques.

How Can We Help Save the Franks of the World?

For starters, the focus should be on primary care. Many times, these situations escalate during off-hours and weekends when there is minimum help available. Primary care health providers including Nurses, Home Health Aides, Med Techs, Community Health Workers, and all who touch the patient in clinic or at home (family members) should be taught mental health awareness, de-escalation techniques and how to recognize early signs of agitation and mental health changes.

The training should include:

• Scenarios
• Role-playing
• Drills on a yearly basis

Safety for both staff members and patients is critical.

• Always be near a door
• Be fully aware of your escape route
• Have a backup plan in your head
• Watch for nonverbal cues of increased agitation from the patient
• Always listen to your instincts as they will guide you to be safe

This could be done as a public health funded program where training is offered in a primary care setting.

The next group that could potentially touch the patient are EMS, police, and firefighters. There should be yearly mandatory training. The response team should preferably include those who excel at de-escalation especially when responding to an Emotionally Disturbed Person (EDP). Once they arrive, they should collaborate with someone who works well with the patient as much as possible. NYC police (NYPD) presently have a dozen crisis de-escalation teams that collaborate with Health professionals and are on call for street calls.

The Receiving Emergency Department

The ER that the patient is brought to should preferably be a psych ER. Since this is not always feasible, the ER should follow the protocol for EDP to keep both staff and patient safe. It is amazing is to see how certain doctors and nurses excel in dealing with these patients, so they would be your first resource when available for a smooth transition.

I was heartened to read a recent article about a collaboration of a healthcare system with emergency services to provide ongoing training for first responders in New Mexico. The University of New Mexico’s Department of Psychiatry and Behavioral Sciences has an ongoing collaboration with Albuquerque Police Department to improve patient outcomes, including 24/7 contact with officers and continued education for both police officers and physicians. This would be a model of care of collaboration within a community and would be more proactive than reactive in nature and help save lives. Yet another article talked about mentoring youth that are touched by violence (Youth Alive, a California based nonprofit organization that work with hospitals to instill leadership traits in adolescents and prevent further violence).

Increased Mental Health Issues During the Pandemic

The reality of our lives is that these cases are becoming more the norm than the exception. The COVID-19 pandemic has increased mental health issues among Frontline Workers along with the general public! It is important for us nurses as frontline staff to be aware of how to deal with volatile situations and have a few plans in place both as individuals and as teams. Staff at a supervisory level should have safety as a top agenda and mandate trainings and drills. In primary care, people coming in for doctor’s appointments should get screening questionnaires that trigger referrals to appropriate services that support their mental health and teach caretakers how to deal with exacerbations or flare ups of a patient’s mental state.

Another collaboration would be a group home supervisor reaching out to the local police precinct and building a relationship with their clients and the cops so that there is a connection when the call comes in. Our call to action as nurses is to get in touch with our local government and be their resource and expert when needed. This requires time and commitment but think of the lives you can save with your actions! The ripple effect can go far and wide!

I have worked in a group home setting in the past and learned to build a trust base with all clients. What I learned to foster de-escalation was to use activities that calmed the patient at the beginning stages of agitation and not to ignore the behavior. For one, it was walking to the store and getting a cup of coffee (fresh air therapy as I call it). For another, it was putting on his favorite show or music in a quiet space. For yet another, it was tearing down white paper methodically and piling them up (sorry trees).

Each of these activities helped the individual get to a safe space within themselves and made the situation more manageable. An approach that worked with Frank might have kept him alive instead of being in a body bag at the Medical Examiner’s office. It is easier for us to point and blame than recognize the underlying problem and come up with ways to fix it and thus save the Franks of the world.

This Year, Let Us Mark Mental Health As One of Our Priorities

Let us not forget our mental health and the mental health of others entrusted in our care. Be kind to one another! Use your professional expertise to advocate for others that cannot advocate for themselves! I do not know if Frank ever got justice and what was the outcome of the investigation.

In the case of George Floyd there was no known mental issue but a suggestion of “awfully drunk” on the initial 911 call that needs to be verified by toxicology report. It still does not justify in any shape or form the overuse of restraint techniques used by the policemen. I hope and pray for swift justice for George Floyd, his family, an end to innocent people being harmed and for us to heal as a community. Every life is precious and every day is a chance to be a better person! As we cry out against injustice, let us persist for justice to prevail and be there for one another.

In this time of unrest, I pray that let there be peace on earth and let it begin with me!

[smoup]

I know you said you wrote this in 2017, but this is so eerily similar to this case that happened in 2016 and was covered up for years. They even lied to his mother about what happened.

Dallas police body cam footage shows officers mocking a man who later died

EVERYONE deserves care and compassion regardless of skin color, mental status, physical limitations, etc. EVERYONE

[Chi-Keeta Sookbirsingh]

I want to say, as reading this article it has touch me, in so many ways as a health care worker, working hands on with psych patients and actually taking me time, to view how some techniques as such as de-escalation does work! But most importantly is not having fear, understanding that your tone and your demeanor is important but most vital to communicating with EDP patients is the willing to show you care, you have the spirit of love and patience and my favorite word of all is transparency.

Yours truly,

Chi-keeta Sookbirsingh Masters in Health Psychology

[spotangel, DNP, RN, NP]

9 hours ago, smoup said:

I know you said you wrote this in 2017, but this is so eerily similar to this case that happened in 2016 and was covered up for years. They even lied to his mother about what happened.

https://www.cnn.com/2019/08/02/us/dallas-police-body-cam-footage-captures-death/index.html

EVERYONE deserves care and compassion regardless of skin color, mental status, physical limitations, etc. EVERYONE

Just to clarify.Frank was brought in to our ED in 2008. I wrote this article in 2017 but did not publish it.

[FolksBtrippin, BSN, RN]

I had to Google emotionally disturbed person body bag. I can't believe they actually call it a body bag.

Of course people die in those.

There is never a reason to use one of those, ever.

[spotangel, DNP, RN, NP]

I agree 100%. De-escalation should start early and not at the point when the person is extremely agitated. In Frank's case they had him inside the EDP bag, face down and 6 cops sat on him till he "stopped struggling". By then he was probably in cardiac arrest.The cops didn't recognize the fact till EMS arrived ,found him pulseless and started CPR. This was a preventable death. Mental health is a priority and prevention and early de-escalation is key to saving lives.