SPIT AT....AGAIN!

Specialties Emergency

Published

I am so tired of being spit on by patients! We all know the aggressive, out of control patients that spit. You're attempting four point restraints, they're growling snarling, someone holds their head so you won't get bit as 10 people try to restrain the maniac then comes the sound.....hawk! That I-am-collecting-a-large-loogey-in-the-back-of-my-throat-to-hit-you-in-the-face-with-sound. Anybody have a solution. Clearly regular masks don't work because they thrash around, get them dislodged, plus you risk being bitten while placing it. I was thinking bipap but it's pretty hard to get an order for bipap because someone is violent. Anyone come up with a solution for spitters? They're pretty hard to control. Our psych population has been unusually high lately for the summer and my fuse is wearing short.

Specializes in Critical Care.

If a surgical mask isn't working, then try the spit net or a non-rebreather mask. The NRB works well since it has the elastic strap. And if they say no to that because its high flow O2 without an order, just pull off the valve covers so they don't need to be hooked up to the O2 at all.

Specializes in Med/Surg.

I HATE being spit at. Usually when someone holds them down I put a surgical mask on them. This way, when they spit, it's going to get on them and NOT me! Then (if ordered of course) I give them Ativan with a Geodon chaser. Haldol too!!!

Specializes in Nephrology, Cardiology, ER, ICU.

In IL, they get a police report, restraints, B-52 (haldol 5mg and ativan 2mg IM) and I press charges.

They end up in jail.

Specializes in ER, NICU.

Being spit at ranks right up there with fishing wayward silverware out of my garbage disposal as my least favorite things in life.

If a surgical mask isn't working, then try the spit net or a non-rebreather mask. The NRB works well since it has the elastic strap. And if they say no to that because its high flow O2 without an order, just pull off the valve covers so they don't need to be hooked up to the O2 at all.

Just pulling off the covers will not prevent CO2 retention. Putting a patients face into a piece of plastic with oxygen is a big no no. I would never encourage that practice at risk of being negligent and even getting a criminal charge if something happened to the patient. With the O2 running you are also at risk of spray. Hopefully your hospital covered the use and precautions of oxygen masks and BiPAP during the H1N1 season. At least the nets and the surgical masks absorbs most of the spray.

Specializes in ED.

Towel over the face with a strong tech, worked for me a couple of nights ago!

Specializes in Emergency.

I think many of you don't have a good mental image of the pt I am trying paint an image of. I am talking about young, healthy men. They're large and strong on any given day. Add ETOH and some cocaine, plus noncompliance with psych meds and add a heavy dose of ****** off. I am talking about a pt that can have 6 or so staff members, all men, including a cop laying on him and he can still throw people off. There is no putting a surgical mask on these people. Plus he is now biting and I don't want to put my little fingers that close to his mouth. It's almost impossible to hold the head still, but even if you can get the mask on, the pt will either literally eat it, or shake his head and move his mouth hard enough to dislodge the mask. Those things are a joke for most pts. I really did like the idea of the spit bag thing, but I don't think I'd be able to get our hospital to buy those for us. So the idea of the OB panties is awesome! We always have those handy and they'd be far easier to throw on someone who is uncooperative than trying to loop the elastic of a mask over the ears. We have had several pts wind up getting tazed in our ED but unfortunately sometimes these things are going down before our on duty cops shows up, or the cop on may not carry a tazer, etc. I may preemptively just put panties on everyone's head while putting on the restraints. Of course when I am no longer in spitting range, I'd take it off. Also, strangely we have had pt's who were this violent and aggressive but we were unable to give our usual B52's due to contrandications. One was straight out of surgery believe it or not. Also, even if I am giving IMs, I am still in spit range plus no medication is immediate acting unless given IV. The one pt I am referring to here actually had an IV that he ripped out with his mouth while in restraints. He then tried to eat the catheter and attatched tubing. Anyway, panties, great idea!

On a side note I don't see why you can't have someone restrained with bipap on. I have had unrestrained pts not remove the bipap while they actively vomited into the mask. Plus, if I did use it for a non respiratory purpose, couldn't I just turn down the rate and amt of forced air. I think ours have controls for all that. Just because it is on doesn't mean it's blowing. You could attatch O2 for blow by purposes, right?

Specializes in Emergency & Trauma/Adult ICU.

I do indeed get the kind of patient you're talking about ... the ones that still aren't knocked down after multiple IV doses of Ativan & Haldol, and maybe even some Versed thrown in there.

Those ... get tubed.

Specializes in CVICU, Obs/Gyn, Derm, NICU.

Go in there with at least 4 guards with your PPE on ....face mask with visor attached. With security holding the guy down, throw in an IV (fit young men have great veins) .... give the Haloperidol and Lorazepam ...stand back and wait.

This approach works best if you have fit, big, young muscled guards ....not small, older ones :lol2:

Specializes in Emergency.

Hmmm...not all, fit young men have great veins. The one that ate his IV?....it was a 24 in the wrist. Secondly, most of my pts buck unexpectedly, otherwise I would be dressed in PPD rendering spit irrelevent. I don't think my microphone is working. Wish everyone could take a turn in my ED.

Specializes in CVICU, Obs/Gyn, Derm, NICU.
Hmmm...not all, fit young men have great veins. The one that ate his IV?....it was a 24 in the wrist. Secondly, most of my pts buck unexpectedly, otherwise I would be dressed in PPD rendering spit irrelevent. I don't think my microphone is working. Wish everyone could take a turn in my ED.

Our guards are mostly all at least 6' 2'' and are huge. Several of these can hold someone down well. We sometimes have to give Haloperidol IM first and then wait. Obviously we are not giving these p'ts a measly dose.

If we happen to have police in the ED ....they get cuffed too.

I wouldn't feel safe approaching a p't and placing an IV until he has five Samoan big boys on him

On a side note I don't see why you can't have someone restrained with bipap on. I have had unrestrained pts not remove the bipap while they actively vomited into the mask. Plus, if I did use it for a non respiratory purpose, couldn't I just turn down the rate and amt of forced air. I think ours have controls for all that. Just because it is on doesn't mean it's blowing. You could attatch O2 for blow by purposes, right?

That's not the way BiPAP works unless you are using one of the cheap prehospital models. For home care and the hospital models, the IPAP and EPAP along with the rate control flow as does the rise and flow termination settings, determine the amount of flow. For an aggitated patient with increased MV and a closed circuit, you would need no less than 15 liter and probably more like 25 liters minimum.

You also take an hospital expensive machine out of service for someone who really needs it. You may have a difficult time explaining its use for billing purposes since the setup can be quite expensive and some cost center's will take a hit. Even if the patient doesn't pay, the cost can be counted on paper. But, if you bill for a large expensive item, you had better be able to account for it and justify its use. That includes machine, ciruit and head gear. That is also a very expensive machine to have broken and removed from service when there may be patients with medical emergencies who could use it for its intended purpose. If you alter the intended purposes, you would have a very difficult time explaining yourself in a sentinel investigation. If a patient vomits while on BiPAP and you have followed protocol, it is considered an acceptable risk.

Intubating a patient for purposes of just control but have no other medical indication can also be a problem. If a spit net works for a spitting patient, why take an ICU bed away from someone who needs it who then gets stuck in holding or faces the risks of an IFT transfer? Intubation is just a temporary solution and they will have to wake up sooner. It is better to give whatever chemical restraint for the short term to get them cleared medically and sent to the appropriate unit or facility and one that is equipped to deal with these patients.

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