Thursday, July 26, 2007

Restraint

"Second unit in, for a psych??"

My partner was incredulous. What a ridiculous call. This facility always has a ton of psychs in it, it's like a nest where they are all kept. They are always fighting with eachother, halfway trying to kill themselves, or looking for attention. To tie up two ambulances on a call like this seemed like such a waste, and we both thought about all of the better things we could have been doing on our lights + sirens response to the address. Surely someone, somewhere in the city was having a heart attack (or something!) and would be denied our help because of this.

We followed the other crew up the stairs and down the hallways, alternating between grumbles and jokes. Directed down another hallway by staff members, we could begin to hear the chaotic scene. A man lay on the floor, prone, with a knee of a police officer square in his back. Two staff members were sitting on his legs, while another tried in vain to hold the patient's head as he thrashed from side to side, screaming, crying, and spitting.

He has a history of outbursts, a staff member tells me. The paperwork read MR, and "Intermittent Explosive Disorder." He got in an altercation with another resident over the amount of cheese that was added to their midday meal, and things have been downhill since. They gave 5 of Haldol and 2 of Ativan about 40 minutes ago and it hasn't made a bit of difference.

I'll say. The room was destroyed. The pile of bodies lay in the center of the room, surrounded by a ring of chairs, tables, and lunch trays that look as if they were ejected circumferentially from some sort of uncontrolled explosion. Everyone looked a bit exhausted, and the cops, sweaty, looked at me with a hint of a pleading expression on their faces. Salvation, in the form of a paramedic. They have come to take this one away!

We pulled the stretcher up beside the patient, and tried to devise a plan to get him onto it. We would all lift at once, each person responsible for a limb. We'll get him up and over, then bring the sheet across his torso and over his arms. The staff warns us: watch out for spitting, kicking, biting, pinching... the works. The patient is looking a little calmer now, though, so we are sure it can be done. Up and over he goes, one swift and smooth motion. He lands on the stretcher with a little bounce and smiles.

...And then he frowns. He jerks his arms suddenly and thrashes about on the stretcher, which sways dangerously from left to right. He is able to get one arm free, and starts clawing at one of the other staff members who pulls back in fear of getting hurt. Another leg free. One of the police officers grabs his shoulders and pins him down, while another attempts to regain control of the free arm. I am too close and he reaches towards me, talons out. He scratches my forehead once before I can get him back under control, drawing a bit of blood. God dammit.

We tie him down, limb by limb, but he continues to fight. He keeps finding one way or another wriggle and cause trouble: first banging his head against the metal stretcher frame, then scratching at his own skin wherever he can reach. He strains and stresses against the bounds, arching his body upward and screaming. The staff look at us with sympathy. They've been through this before, they say.

I decide to chemically restrain him. We cant transport him like this, we all agree, and he is going to hurt himself if he finds a way to manage it. I kneel down and open up my pack. Our protocols allow for 5 milligrams of Haldol combined with 2 milligrams Ativan, mixed in the same syringe and administered IM. It takes me a few minutes to draw the drugs up, and the gelatinous Ativan is giving me a little bit of trouble.

In walks the patient's doctor. He demands to know what is going on, asking for the whole story and expecting us all to stop and explain it to him. I have the staff members explain to him while I finish drawing up the drugs, but he stops me before I am able to administer them. He wants to know exactly what I am giving him, where I am giving it, and if I have called a doctor for orders. He had heard from the other nurses that the patient already got sedatives about an hour ago, and seems shocked that I would consider giving the patient another round.

"How about you just do one of Ativan," he says. "We don't want him to stop breathing, do we?"

His voice is as condescending as it is demanding, and I am a little taken aback as I sit there holding the uncapped syringe. I explain to him that I have Haldol and Ativan in the same syringe, and that this is standard procedure. I express doubt that 4 milligrams of benzodiazepine, administered IM over the course of an hour will really cause anyone of this size to stop breathing. I relent, though. How about I just give him half of the syringe. About 2.5 Haldol, 1 Ativan. The doc agrees and, in a bit of a huff, leaves the room. I feel a bit embarrassed. Taken down a notch.

In goes the drug and we wheel the patient to the ambulance. He fights and claws the whole time, screaming like a teradoctyl and searching for ways to hurt himself or others. The elevator is small, and we all press our bodies against the walls so to add the necessary free space.

In the back of the ambulance I get the patient on the monitor as best I can. The patient is tied down but he bucks and fights each of our attempts. If a wire is near his hand, he will grab and pull. I get a set of vital signs, and put the patient on end tidal capinography along with a face mask to prevent spitting. He is sinus tachy at 120 or so, pressure 130/70 and all looks well. I look at my partner, exasperated. Let's just go.

5 minutes into the transport I notice that the ETCO2 is no longer reading. The apnea alarm goes off, but a quick glance at the patient and he is obviously breathing. Must be the sensor is displaced. I lift off the face mask to readjust, and find that the patient is attempting to eat the sensor. He has it, a lot of it, in his mouth, and is pulling in more each second like a long strand of spaghetti. He is chomping and chewing, staring at me vindictively with each motion of his jaw. I grab one end of the tubing and give a tug. "Give that back! Let go!" He vehemently shakes his head, refusing with clenched teeth. He will NOT give it up. I try a little more, but I don't want to pull too hard on the tubing and break it, losing it entirely to the patient's gaping maw.

I sit back for a second, tired and sweaty as I watch him chew. The apnea alarm goes off again. Fuck this, I think. I reach into my breast pocket where I still have the drawn up meds. In go the rest. The patient lets out a yep as I sink the needle into his muscle, and at the same time I yank the mangled tubing from his mouth. Win-win.

He fights more on the rest of the trip. I sit back at the end of the bench, watching him and the monitor. I try to straighten my uniform out but it is no use. His aggressive activity wanes slowly, and by the time we arrive at the hospital he is resting comfortably, half asleep on the stretcher. He asks me for a pillow for his head and I give it to him.

We roll into the ED triage looking like we're returning from battle. Our uniforms are disheveled and sweaty, hair mussed and composure wrecked. The patient naps pleasantly on the stretcher, as comfortable and content as could be. The nurse looks at us, smirking a little. She heard our patch asking for security at the door.

"All that, for this little guy? He's sleeping like an angel!"

4 comments:

Brendan said...

That's when you slap your empty med vials on the desk and say "Yeah, NO SH!T."

Shane said...

Don't let a doc on scene push you around. Unless he's going to assume responsibility and ride the call to the hospital, he doesn't get to dictate how the call is handled. You were right in the thinking that 4 mg Ativan wouldn't cause the patient to stop breathing. Especially when you consider we can give 8 mg to a seizure patient. So ativan is not a stranger to us in it's uses and doses. Also, if the patient were to stop breathing, what's the worst case scenario? You bag them? Stand your ground. You're the paramedic and the one that was called to handle the situation. If they could have handled it, you wouldn't be there. Do what you know needs to be done.

Shane

New Medic said...

I agree with Shane. If the doctor on scene wants to dictate care, then he can assume responsibility for the patient and sign a refusal. I have had physicians attempt to do the same thing and I tell them they have two options:

1-I take the patient and treat him the way that I see fit.

2-The patient remains here and he treats him.

If he disagrees with this, then it is in our protocols that we call our medical director. 99 times out of 100, our Medical Director will say the exact same thing to the doctor.

Your call has an added twist though. This isn't a strictly a disagreement over medical treatment, it is one of patient and provider safety. The doctor on scene is not going to be in a cramped space with the patient all the way to the hospital. YOU have a vested interest in keeping yourself, and the patient, safe during transport.

Those calls can be the most trying for new providers who don't want to step on toes. I think you learned a lot here. Good job.

Anonymous said...

I agree with all of the above....but am I the only one who was ROFL at the patient EATING the wire?