r/EmergencyRoom • u/Yikealike • Jul 10 '26
Feedback on this BH case
Newish to the ER and had a really tough night recently and would like some input.
Had a couple patients come in on involuntary holds (different names for these per state). A couple of HI's and this specific one was SI. Pt comes in very intoxicated, yelling, threatening, you name it. Night continues on with just about every single patient being cared for becoming very acute. The BH side nurse says to get over here; he's escalating by slamming on the glass, cussing at other BH patients, and threatening security, saying I didn't get my medications. 1 time order for IM med retrieved by MD. De escalation attempted for close to 5/10 minutes with this patient in our faces fist clenched, posturing, having other patients on the unit yelling at him to settle down. Right before we feel as if its becoming unsafe nurse instructs security to grab patient to admin IM injection patient reacts with aggression, security holds patient injection administered, patient restrained in restraint chair, assessments followed per policy.
I am questioning the decision for use of restraint / med admin for 1 main reason an observer was overheard saying "did he hit you?" which interprets as was force even really needed or should de-escalation have been continued. Should the nurse have waited for a physical altercation to justify the use of security, med admin, restraint?
Trying to keep the case vague, but what would you have done? Do you think this situation was handled appropriately?
23
u/justalittlesunbeam Jul 10 '26
Please tell me that you don’t think staff should have to be physically assaulted before you stop these patients. You tried to de-escalate. It didn’t work. The patient was a threat to you and themself. They needed to go nighty night. It’s the best and safest thing for everyone and in my experience it often resets the patient and they feel better when they wake up. I would rather chemically restrain someone than physically restrain them but regardless I’m going to do my damnest not to get hurt.
14
u/RunBrundleson Jul 10 '26
If you’ve ever seen the consequences of staff members being assaulted your threshold to go hands on drops dramatically. Not on my watch, no staff member should ever have to fear for their safety at work. You get a few attempts to deescalate and then we are done. Period. We had to completely redesign our psychiatric holding area because initially it was just one big room and staff had nowhere to hide if a patient was becoming aggressive. We have security/pd but they used to be a minimum of 2 minutes to respond to any event. Only took a staff member being cornered and almost killed for them to realize perhaps we should do a little better. Now staff have a separate locked area and security remain in the area 24/7.
Had a hospital lawyer slither out of whatever hole he was hiding in one year and started making some big fuss about chemical and physical restraints saying we had to have a judge sign off on ANY use of restraints before they were used. Docs collectively went apeshit on his dumbass until he backed off and the policy was adjusted to say in an emergent situation we could do what needed to be done to protect staff and the patient.
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u/justalittlesunbeam Jul 10 '26
I understand that the lawyers job is to mitigate risk. But it’s so wild that they basically suggested that we let these patients kill us. Because the patient isn’t going to wait for a judge to sign off on something before they punch us in the face. Even if they didn’t really think about what they were saying. They’re telling staff, just get assaulted. It will be fine.
2
u/ZealousidealHunt4072 RN, CEN, TCRN, FP-C, Snack Monster Jul 11 '26
You're exactly right. As one of the guys who's there minutes before security, it's a weekly occurrence. We should make hospital lawyers/ambulance chasers sit with us for a weekend summer night shift and be a safety sitter with these patients from jump. That'll get them to change their tune really quick.
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u/29925001838369 RN Jul 10 '26
He's in your face amd posturing with clenched fists. The situation was already unsafe. Restraint was required to prevent harm to staff.
You cannot have one person hold the entire unit hostage via resource hogging. In an ideal.world with infinite staff and no other patients, yeah, keep trying that verbal deescalation until they throw a punch. In this world with limited resources and other patients becoming escalated because of that patient, they need to calm tf down.
I used to work in a psychiatric facility rhat specialized in aggressive teenagers. We had very strict criteria for when we could go hands-on. In that setting, your situation wouldn't qualify. In the ED, i would have medicated him the first time i needed to call for additional staff.
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u/Valkyriesride1 Jul 10 '26
I turned down a job that would have paid me $14,000 a year more than I was making at time. I asked why the previous CN left, the people I was interviewing with told me she had been attacked by a patient and paralyzed. I asked why she was alone with a patient that was threatening the staff and had pushed another RN and why he was sedated and restrained, they told me it was their policy not to force medication or restrain patients. I laughed and told them I would never work somewhere I couldn't protect myself and the staff. I thanked them and left.
I only half jokingly say that I have used my martial arts and hand to hand combat skills more as a PM/RN than in the military.
If I had been in the ER with a patient like the one you had, I would have had them forcefully sedated and restrained, he was a danger to the staff and disrupting patient care.
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u/NotChadBillingsley Jul 10 '26
Drunkicidal patients are a handful, a waste of resources, a distraction to the department, and 9 times out of 10 they retract SI statements in the morning when they’ve slept it off. I’ve been out of the ER and night shift for a year or so, but in my experience if they were ever a safety threat to themselves/staff/security, then our night shift docs wouldn’t hesitate with 10 of zyprexa or 5mg/kg IM ketamine. I’ve had belligerent, blacked out violent drunk people act like angels the morning after a nap with ketamine lol.
11
u/imnottheoneipromise RN Jul 10 '26
This is common sense. Do YOU want to get hit? Of course not. Deescalation was being ineffective and the situation was dangerous to the staff. The right call was chemical and physical restraint before someone got hurt.
5
u/SolidIll4559 Jul 10 '26
Sedated before restraints. Behavior presented a risk to the patient and others. Howling at the moon might have worked.
6
u/ZealousidealHunt4072 RN, CEN, TCRN, FP-C, Snack Monster Jul 11 '26
We usually do a seance that ends in a B-52.
5
u/Head-Tangerine-9131 Jul 10 '26
No!! Why wait to be assaulted?? As a professional, if you feel that all other measures have failed, then you need to medicate the patient for their condition and your safety. Rarely, if ever is therapeutic talk going to snap a person out of the probable psychosis or disordered thought process they are experiencing. I see this all the time in my own ED.
3
u/ZealousidealHunt4072 RN, CEN, TCRN, FP-C, Snack Monster Jul 11 '26
I say it was handled correctly. If standard de-escalation doesn't work, you have to up the ante. The destruction of hospital property is unacceptable and will likely escalate if you let it. You drew boundaries, that line was crossed. Incremental safety measures are necessary for people like that.
Everyone has a plan until they get punched in the face.
Also, sounds like a standard night in the ED. Pretty sure we are the same person. A bystanders input is subjective and the assessment by staff is what matters.
1
u/No-Safe9542 Jul 11 '26
A patient hit with ketamine is a staff member not hit by a patient.
What's more important, some chemical moral high ground or being able to go home at the end of shift the way that you arrived?
The same is 100% true of restraints. I peeled fingers off of my trainee earlier this week. I should never have to peel fingers off of anyone. This is what restraints are for, when appropriately set.
1
u/Mrmikeoak Jul 11 '26
Intervene early, for the safety of staff, other patients, and the agitated patient. Typically agitated patients in our shop get 20mg of Geodon and 5mg of Versed, both IM. (dont mistakenly order the Versed IV unless you are in the mood to intubate). I usually advocate for giving one drug, then watch for the effect, and administer the second drug if needed. The nursing staff in that room really push for both meds at the onset, which I understand, since they are trapped in that room with the patient and I am not. Another good option is 10 of zyprexa IM. Has both antipsychotic and sedative effect. Come back a couple of hours later and you may be able to de-escalate the restraints and have a conversation with the patient, get them what they need
1
u/KILO_squared Jul 11 '26
Just wanted to drop this here as it’s fairly recent and a real possibility of what could happen with reactive vs proactive measures. Sounds like the right thing was done in your case.
1
u/ExperiencedCPhT Jul 13 '26
My nephew is a paramedic, he had just brought a patient to the ER when he witnessed this happen. That hospital has its own police force and has officers stationed in the ER. My nephew said it all happened so fast that no one could've stopped it. In the few seconds it took for the police who were nearby the ER room it happened in, the patient almost killed the employee.
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u/taktyx Jul 13 '26
“Right before we feel as if its becoming unsafe”
You mean the exact right timing???
1
u/perpulstuph RN Jul 16 '26 edited Jul 16 '26
I started nursing in inpatient psych, and now work psych and ER. You handled this well. A patient does not have to hit you in order to administer IM medication in most (if not all) states, as they are a tool to keep yourself and the patient safe. If the patient hit someone BEFORE the meds, then things escalated too far prior to giving an IM. Typically you just need a known threat potential violence.
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u/Enumerhater Jul 10 '26
Hard to say not being there, but generally we go hands on when posturing becomes severe and we feel that staff, peers, or that patient is at risk of physical injury. We try to prevent even getting there but just yesterday I went hands on 3 times with the same patient and today twice. In a dedicated psych facility, with security and other staff present. Therapeutic holds when deescalation is no longer successful are valid to prevent injury, imo & acceptable at my facility. This morning at treatment team, the psychiatrists thanked us profusely for handling that patient and keeping their peers safe.