When the Hospital Fires the Bullet

[Not_A_Hat_Person]

The NY Times ran an article about armed guards in hospitals. The patient profiled went to the hospital during a manic episode, seeking treatment for suspected bipolar disorder. He ended up shot in the chest.

When doctors and nurses arrived at Room 834 just after 11 a.m., a college student admitted to the hospital hours earlier lay motionless on the floor, breathing shallowly, a sheet draped over his body. A Houston police officer with a cut on his head was being helped onto a stretcher, while another hovered over the student.

Blood smeared the floor and walls. What happened?” asked Dr. Daniel Arango, a surgical resident at the hospital, St. Joseph Medical Center.

The student, 26-year-old Alan Pean (PAY-an), had come to the hospital for treatment of possible bipolar disorder, accidentally striking several cars while pulling into the parking lot. Kept overnight for monitoring of minor injuries, he never saw a psychiatrist and became increasingly delusional. He sang and danced naked in his room, occasionally drifting into the hall. When two nurses coaxed him into a gown, he refused to have it fastened. Following protocol, a nurse summoned security, even though he was not aggressive or threatening.

Soon, from inside the room, there was shouting, sounds of a scuffle and a loud pop. During an altercation, two off-duty Houston police officers, moonlighting as security guards, had shocked Mr. Pean with a Taser, fired a bullet into his chest, then handcuffed him.

I thought of the hospital as a beacon, a safe haven,” said Mr. Pean, who survived the wound just millimeters from his heart last Aug. 27. I can't quite believe that I ended up shot.”

[nutella, MSN, RN]

I would have to agree that there is a hospital leadership problem here. The biggest failure that I see after carefully reviewing the article is patient placement. Mr. Pean came in for a psychiatric emergency and got put on a surgical floor, which is unacceptable.

The hospital leadership should be ensuring that patients who come in with a psychiatric crisis end up receiving psychiatric treatment and have psych nurses taking care of them. Med/surg and ICU nurses are just not trained to handle potentially violent psychotic patients. I don't know about this hospital, but the only crisis intervention training I have ever had was in nursing school before I did my psych rotation, and that was a long time ago at this point. I would be willing to bet there are more non-psych nurses like me who have not had a crisis intervention class recently than there are ones who have. I have had active shooter training, of course, which is ridiculous because an active shooter is less likely to happen than a patient getting violent, but that's administration for you.

I doubt security would have even been called if the patient's escalation had happened on a psych floor, and really, I doubt he would have escalated in the first place if he had received appropriate psychiatric evaluation and treatments on arrival to the hospital.

The problem started long before security walked in the patient's room.

Reality is that not all patient who have behavioral /psych problems can be admitted to a psych facility or psych floor (for a variety of reasons from medically not cleared to no bed, financial..).

I worked on med/surg floors that took pat with MH problems and I worked on neuro floors, which seemed to be the designated place for "all things weird and crazy". Staff can be trained and need to know how to access resources. In one of the hospitals they had psych CNS nurses who were just a call away to come and help as well as a code for psych emergencies. The security officers did not carry weapons and were all trained in de-escalation. I worked on a non psych floor that had daily psych emergency codes and things did not get out of control because staff was trained and reacted early to get appropriate help. We needed security often but they were totally de-escalating and helpful! Once in a while somebody would end up in four point restraints (violent behavior) or seclusion (for spitting at staff) but this was last resort, carefully monitored and an intervention with the goal to get the pat out of restraints/seclusion as soon as safe.

[Asystole RN]

I would have to agree that there is a hospital leadership problem here. The biggest failure that I see after carefully reviewing the article is patient placement. Mr. Pean came in for a psychiatric emergency and got put on a surgical floor, which is unacceptable.

The hospital leadership should be ensuring that patients who come in with a psychiatric crisis end up receiving psychiatric treatment and have psych nurses taking care of them. Med/surg and ICU nurses are just not trained to handle potentially violent psychotic patients. I don't know about this hospital, but the only crisis intervention training I have ever had was in nursing school before I did my psych rotation, and that was a long time ago at this point. I would be willing to bet there are more non-psych nurses like me who have not had a crisis intervention class recently than there are ones who have. I have had active shooter training, of course, which is ridiculous because an active shooter is less likely to happen than a patient getting violent, but that's administration for you.

I doubt security would have even been called if the patient's escalation had happened on a psych floor, and really, I doubt he would have escalated in the first place if he had received appropriate psychiatric evaluation and treatments on arrival to the hospital.

The problem started long before security walked in the patient's room.

The patient had only been admitted HOURS prior, not really enough time to do much other than admit. Before all of his psych issues can be addressed his medical condition had to be assessed and stabilized. Not to mention that not all hospitals have the luxury or benefit to have dedicated psych units with psych nurses and psychiatrists standing by 24/7. There is the fantasy world where every facility has an unlimited amount of space and resources and then the real world.

Reasonable and prudent care is all that is asked of nurses and that is all we should ask and expect from hospitals. We all do the best we can with the resources we have.

Again though, this was a police issue not a entirely a hospital issue. A police officer shot the patient, not a nurse.

[elkpark]

The patient had only been admitted HOURS prior, not really enough time to do much other than admit. Before all of his psych issues can be addressed his medical condition had to be assessed and stabilized. Not to mention that not all hospitals have the luxury or benefit to have dedicated psych units with psych nurses and psychiatrists standing by 24/7. There is the fantasy world where every facility has an unlimited amount of space and resources and then the real world.

Reasonable and prudent care is all that is asked of nurses and that is all we should ask and expect from hospitals. We all do the best we can with the resources we have.

Again though, this was a police issue not a entirely a hospital issue. A police officer shot the patient, not a nurse.

The article notes that this hospital does have an inpatient psychiatric unit, so it's perfectly reasonable to expect that there is a psychiatrist available for emergencies 24/7 (not necessarily physically on site, but at least available). Even if they didn't, CMS and JCAHO require that hospitals have some means of providing psychiatric evaluations when indicated. And he had already been admitted to an observation unit, so his acute injuries presumably had been "assessed and stabilized."

In my reading of the coverage, everyone involved in this case "dropped the ball" several times. Bad enough, IMO, to have cops moonlighting as hospital security playing Wild West in the hospital, but I cannot imagine a scenario in which it would be considered acceptable for them to go into a client's room and shut the door, without any healthcare personnel present to at least witness what ensued. The shooting probably could have been avoided entirely if they hadn't chosen to go into his room and shut the door.

Since the police officers involved were employed as hospital security at the time, this is clearly a hospital issue. And just one more of many examples of why guns in hospitals, even when they are being carried by supposed "good guys" are a really, really bad idea.

I cannot believe that it's possible that anyone considers it reasonable or acceptable that a mentally ill individual who came to the hospital seeking help ends up getting shot in the hospital. I do not see the "care" provided in this instance as "reasonable" or "prudent."

[MunoRN, RN]

This is how the article read to me.

Patient was admitted just hours prior.Two POLICE OFFICERS who happened to be working as security shot the patient as he fought the POLICE OFFICERS. There is a surprising lack of detail of the fight but we do know one of the police officers was wounded.

I am not sure what this has to do with "bean counters" but this does have to do with POLICE OFFICERS defending themselves with lethal force. Whether or not they were justified in that defense the article did not even try to comment on. The article does not expand upon this particular situation and whether or not the patient received reasonable and prudent care up to the fight. Considering he was just admitted hours earlier, I doubt there was enough time to conduct a full psych eval...let alone completely rule out any other medical causes.

This is a police issue, not a nurse, doctor, or hospital issue IMHO.

I'm not sure where you're getting that this was a "police issue" since the police were not called until after the shooting. The HOSPITAL SECURITY GUARDS that shot the patient also worked as police officers but were not acting as police officers at the time. Many hospital security guards have also been in the military, but that doesn't mean when something happens while they are working as security guards that it's a "military" issues.

According to reports he was admitted quite a few hours before since this occurred the next day after he was admitted, although that doesn't really change that his care at the hospital was completely bungled; he drove himself to the hospital over mental health concerns, in the process he hit a couple of cars in the parking lot, only some minor injuries from the parking lot were addressed and his altered mental state was identified as drug use, even though he was negative for all the drugs that explained his behavior, to make matters worse they gave him flexaril which likely exacerbated his actual chief complaint which was AMS.

Apparently security was called because he did not want his gown snapped up, although was not combative, there's no reason that should immediately escalate to a gunshot to the chest/abdomen when dealt with by properly trained healthcare staff. If that was a normally accepted outcome of similar situations then half the patients in my ICU would end up shot everyday.

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

I think nurses should have access to Xanax/Haldol coated blow darts for the out-of-control patients.......

[calivianya, BSN, RN]

Reality is that not all patient who have behavioral /psych problems can be admitted to a psych facility or psych floor (for a variety of reasons from medically not cleared to no bed, financial..).

I worked on med/surg floors that took pat with MH problems and I worked on neuro floors, which seemed to be the designated place for "all things weird and crazy". Staff can be trained and need to know how to access resources. In one of the hospitals they had psych CNS nurses who were just a call away to come and help as well as a code for psych emergencies. The security officers did not carry weapons and were all trained in de-escalation. I worked on a non psych floor that had daily psych emergency codes and things did not get out of control because staff was trained and reacted early to get appropriate help. We needed security often but they were totally de-escalating and helpful! Once in a while somebody would end up in four point restraints (violent behavior) or seclusion (for spitting at staff) but this was last resort, carefully monitored and an intervention with the goal to get the pat out of restraints/seclusion as soon as safe.

I have never worked somewhere that gave me that kind of extensive psych training and everywhere I have worked as had a violent things happening code, but it's the same regardless if it's a visitor or patient and if the patient is fully alert and oriented with no problems or has some sort of psychiatric emergency, which is a problem in and of itself. There's a lot of difference between a visitor getting POed and shoving someone, an alert patient deciding to hit a nurse because he doesn't like her, and psych patients thinking we are trying to kill them, and they need to be handled differently with different staff, but they're not. Every single one of those situations is going to have the same code and be responded to with a handful of burly guys in security uniforms, which helps a lot with the alert and oriented patients but often make the psychiatric patients worse.

Every hospital should be more like yours - no exceptions. i would say it would cost less to give everyone crisis intervention training than to deal with the fallout of a situation like this guy getting shot, but what do I know. I'm not a bean counter.

My hospital is a 900+ bed regional referral center for reference. In theory, if anyone should have the resources to handle psych situations it's us, but we don't.

I think nurses should have access to Xanax/Haldol coated blow darts for the out-of-control patients.......

I like this idea a lot. Or a Ativan diffuser for real... it's dangerous to get close enough to some of these people to hit them with an IM.

[dream'n, BSN, RN]

Laws have made the use of restraints so difficult, that many times when they are indicated the staff is unable to get them due to policy, etc. I'm sure this patient would have rather have been restrained for a bit, than shot. I understand that restraints are a last resort, but they should be used prior to shooting a patient.

[nutella, MSN, RN]

I have never worked somewhere that gave me that kind of extensive psych training and everywhere I have worked as had a violent things happening code, but it's the same regardless if it's a visitor or patient and if the patient is fully alert and oriented with no problems or has some sort of psychiatric emergency, which is a problem in and of itself. There's a lot of difference between a visitor getting POed and shoving someone, an alert patient deciding to hit a nurse because he doesn't like her, and psych patients thinking we are trying to kill them, and they need to be handled differently with different staff, but they're not. Every single one of those situations is going to have the same code and be responded to with a handful of burly guys in security uniforms, which helps a lot with the alert and oriented patients but often make the psychiatric patients worse.

Every hospital should be more like yours - no exceptions. i would say it would cost less to give everyone crisis intervention training than to deal with the fallout of a situation like this guy getting shot, but what do I know. I'm not a bean counter.

My hospital is a 900+ bed regional referral center for reference. In theory, if anyone should have the resources to handle psych situations it's us, but we don't.

I like this idea a lot. Or a Ativan diffuser for real... it's dangerous to get close enough to some of these people to hit them with an IM.

This is a major teaching hospital.

I worked at other major hospitals that did not offer that training or support and the result was less ability to cope with behavioral challenging patients.

Now I work for a hospital that does not offer much training or support for nurses and it shows. As part of my job I address also behavioral problems and when I point out that certain behavior is based on illness nurses and aids are not always understanding. Those pat can be very time intense or emotionally draining. Sometimes intervention includes medication but not for everybody - sometimes it is something like "distraction and reassurance".

Although there were of course also things that were not so great at the major teaching hospital, the care of behavioral challenging patients was very good and the psych CNS were very accessible and teach.

[ProgressiveActivist, BSN, RN]

Every violent and unarmed ED pt that I have ever seen will get themselves together immediately when faced with a growling barking K-9 dog.

This is in my opinion the safest way to deal with an unarmed person who poses a serious threat.

These people were well behaved if there were any subsequent visits.

[dream'n, BSN, RN]

Oh our K-9 dog is so cute. I have to check myself every time he rounds the hospital so I don't pet or bother him

[nursej22, MSN, RN]

I listened to the "This American Life" podcast, and it includes an interview with the patient, his physician father, and his brothers. Their concerns included the fact that even though the client identified himself as being manic, it was never addressed. The father requested a psychiatric evaluation that never happened. The hospital gave the client flexaril, which mostly likely exacerbated his mania and delusions.

I would hope that this should have never reached the point where 2 armed, off-duty police officers felt it necessary to go into a room, and shut the door, without any other staff present. I don't think its hard to imagine how a manic, delusional person is going to react. The plan was to discharge the patient to his parents, who had left to get a rental car, and drive him to a psychiatric facility. Dad was gone for about 40 minutes.

[TheCommuter, BSN, RN]

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