The strong and scary patients
Most of the people you come across as patients in the hospital won’t try to hurt you. Of the ones who do, some do it on purpose or on accident because of their medical condition. Both are no fun to deal with, the first one pisses me off more.
Awhile ago I had a patient, lets call him Mr. O. He was old, weak in his legs and got confused at night, sundowning as they call it. This occurred pretty quickly. The orientation questions we ask patients: Do you know where you are? What year is it? Is it daytime or nighttime? Who is the president? What is your name? Etc. The answers to these questions can change rapidly and quite drastically. The answers can go from semi normal to out of this world, literally. That’s a story for another time.
So this man, Mr. O, he was a very nice man normally, loved to chat and always kept himself busy with crosswords or coloring for fun. He also enjoyed a good documentary during the daytime when things got slow for his care. This sundowning that he did occurred without much warning, although I knew it would, just not when, it would happen. He first seemed to forget it was sleeping time. He began to think we were in his home. Then he thought it was a prison, which is a common confusion among patients who sundown. When someone looks frail and old, don’t underestimate their abilities to take you down during this confused state. The man didn’t feel pain from his massive surgery, didn’t even flinch when he tried to escape from the unit, eloping we call it.
He stayed in the hallway and wouldn’t leave. Screaming and disrupting our other confused patients, we tried to de-escalate the situation. The way that sounds makes it seem we chat and calm him and get things back to normal. If only this were true. He began to try to hit us, kick us and he even put a curse on us. Spitting usually comes with the territory. The easiest part of this, he had no drains attached or anything that would cause bleeding or limbs to fall off or break.
We had to call something that is basically a code for when a patient becomes uncontrollable in a situation where more people are needed and more specialists are needed, like psychology, to assess the situation. After we called this code, you could hear it overhead in the hospital speaker system. While other units probably could see a young person causing a disruption or a middle aged person becoming upset at their care, this was a very old person, who at first sight looked like he could fall with a simple push of your pinky. Let that be a lesson, don’t underestimate the strength in someone who doesn’t understand even the slightest bit of reality.
Multiple hospital officers came, along with the psych department, the patients surgical team as well as some people from the unit and head of nursing for the hospital staff. He began to try to throw punches that barely made the officers flinch, although I could see the surprise in their face when this happened. The staff that responded were calm, not shouting, nothing in their hands and kept their faces in a neutral look. Eventually the officers took a “walk” with the patient which led back to his room. Some medications, restraints and call to the family awhile later, solved the current problem at hand. However this was one night. For the rest of the stay, the patient had moments like this. Scary for the family, staff and patient as well.
During the following day, the patient was told why he had restraints on, he didn’t believe his ears. He had this sad face on, concerned about us and wanted to make sure nobody was hurt in this incident. It truly is sad when our minds are no longer under our control.
The next patient that I had with the same code announced was Mrs. Y. She wasn’t old, wasn’t young either, but strong in her arms and legs, not something you want in a confused patient. Her diagnosis wasn’t tricky or rare, seemed like a simple case of medications, physical therapy and rest. Despite the simple sounding diagnosis and treatment, it was far from it. She would become upset at the simplest little change in light or darkness in the room, staff members in the room and even when a medication was mentioned. The unpredictability became her biggest trigger. Ironically that part became predictable.
One day I was going to give her a medication, nothing extreme, it was one pill, not large and something she had taken before. I didn’t see it as something huge for her, but was cautioned just the same. As I walked in the room she became almost manic. She was rambling on about nothing, upset at my lack of response or understanding and seemed to be fed off of the simple reactions I had, even the non verbal ones. She had this look in her face, something I had seen in patients who attack their nurses or want to. I stayed by the door for a quick escape just in case. I left the room shortly thereafter and the room stayed calm for a bit. While cleaning up an incontinent patient I got a call. My gloves covered in poop, wipes all over the bed and not even close to finishing up with the patient. My PCT then got the phone from my pocket and I could hear a loud noise and words like “bed”, “sheets”, “tearing”, “belligerent”. None of the words sounded to get better as I listened to the conversation. I didn’t have to hear more to know what I was getting myself into, going back into that room.
I walked back to the room and found Mrs. Y on the top of the bed, sitting like a monkey with her knees to her chest, arms around her legs and food stuffed all around her. She had crumbs everywhere, medical supplies on the floor and this pacing look on her face. Pacing, closed fist and not talking are big non verbal cues of anger and a possible outburst. She showed all of the signs. She was in the perfect spot to fall, hit her head, end up with a TBI or worse, death. All nurses fear the day their patient falls and it’s not a simple day of paperwork or further education with the patient and their family members.
This patient, Mrs. Y, started to try to move from the bed, to the chair, to the doorway. She was becoming more manic by the second. I called in another nurse for backup and more manpower if needed. I then made the call I didn’t want to make. This usually opens a can of worms for some, however, she was well-known in the officer community at this hospital. Lots of these code strongs had been called for her. It normally required some medication, IM or IV depending on the incident in front of us, a psych consult and a report about what led you to call the code strong.
You would think a sedating medication would help with this, but no, it didn’t not. If anything it calmed the manic behavior, but continued her appetite for no sleep and more talking. Mrs. Y is a classic example of this code strong we call in hospitals. Luckily nobody was hurt and the patient was safe without any incident.
Saving the best one for last, of course.
Where would we be without the challenge that tests our abilities with language, bodily fluids and insults.
I had a shift once where I was talking with a patient about general medical concerns, nothing drastic. I could hear a loud noise, someone’s voice, but nothing specific. I opened the patient’s door and heard a language I couldn’t speak and loads of English where words like “calm down”, “don’t hit”, “my arm!” And more were said. I could tell the situation wasn’t getting any calmer so I decided to go assist the nurse with this patient. My language abilities aren’t vast and the ones I do know, besides English, I can survive shopping, asking about how people are and going to the bathroom. Nothing exciting or helpful in this setting.
I walk into the room and see an older lady, let’s call her Mrs. S, screaming at staff, trying to hit people, calling the nurses whores in her language and more that I am glad I didn’t understand. She didn’t have her dentures in, but despite this fact, she still attempted to bite the staff preventing her from falling off of the bed. Even with all of the effort put into this incident, we still had to make the call for a code strong. Officers came, psych came etc. It was a fiasco in two languages. It was as chaotic as it sounds, probably more. She continued to curse us, try to bite us, scratch us and more. It was more amusing than scary luckily.
It seems insensitive to call it amusing, however in the nursing world, if you can’t laugh at what stresses you out, you will go mad.
Code strongs are sometimes, but not always predictable. When they happen you need a good team of nurses, security, psychologists and more to assist with the patient and what is causing them to get aggressive or just in general, act out of character.
