Monday, September 14, 2009

Shall I call in sick and stay home? / Lloyd

[Note: a previous posting, “Do I go to work, or not?” was erroneously erased. This is a second, expanded attempt to share that story.]

He brought down both fists on the table and shouted, “Why are you here? Get away from me. I want to kill myself and I want to kill you!” The first moments with Mr. Lopez (name changed) weren’t great, and he was very convincing, but then again he hadn’t immediately hit me.

Just moments before, we had been frantically scratching out the last of 32 shift notes on our patients and extensive behavior summaries for the 11 highest acuities—Lopez was one of those. The night shift soon would be in and expected everything tidied up and us out the door after a quick shift change. I serve as shift lead on a maximum security, hospital intake unit for psychiatric referrals from the state’s prisons.

There had been loud pounding outside the secured nursing station and in popped a head announcing, “Lopez is at it again—better get out here.”

A year ago staff would simply have pulled their alarms, and a thundering herd of folks from other units and hospital police would have arrived to take Mr. Lopez down to the floor, or contain him against the wall, and then wrestle him into five-point restraints.

Now, if at all possible, we attempt to walk patients through their rough moments. It takes longer and appears riskier for staff; but whenever we take away a patient’s agency, his fragile sense of personal control, he regresses for days--sometimes for weeks, the unit's therapeutic milieu is shattered, and general safety of both patients and staff is jeopardized.

As a volunteer facilitator for AVP (The Alternatives to Violence Project) in Maryland and California state prisons, I have taught non-violent resolution of conflict to inmates. And the principles are applicable when working with psychiatric patients. Essentially, avoid responding to violence with violence; work with people to help them deescalate themselves and ratchet down their acute behaviors—help them to reestablish personal control.

Mr. Lopez did more pounding and yelling and jumped up and turned off the TV for everyone watching in the dayroom. Normally, that would have caused a firestorm of protest, but all the patients were measuring how we would handle things, waiting to see if we were more than just talk, but could walk the walk. Eventually, Mr. Lopez said he would be able to get control of himself without staff intervention, and he stalked off to his room.

We returned to our notes and shift cleanup, and a few minutes later Mr. Lopez knocked at the office door wanting to talk. He said, “Someone’s going to kill my son—I just know it.” Like many patients, Mr Lopez responds to intense internal stimuli (voices, which are never kind). And he recounted his night terrors—horrible images and imaginations. He agreed to take a PRN medication for his agitation and anxiety and hopefully for sleep, and we agreed to always be there to walk with him through these terrors, that he needn’t do it alone. He and I shook hands.

The previous week an out-of-control patient assaulted staff on our unit. Two were sent home hurt, and the patient was placed in restraints. He had been dangerous to both staff and patients, and his time overnight in restraints with emergency medications gave him time to sleep and reset. Many of his peers expressed relief.

Many mornings, when I’m at home safe with Judy and away from the danger and frequent surges of adrenalin at work, I question whether to call in sick and just stay home. But I can’t do that everyday.

Besides, I have a mandate from Heavenly Father to provide for my family and to serve. This hospital is my venue for both service and to earn a living. I was prompted to take psychiatric technician training and apply for my current position, and I received a blessing that I would be kept safe from serious harm. Every night that I return safely to Judy confirms that promise, but there are moments.

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