Armed with a fresh degree, good intentions and the latest and greatest PMAB (preventative management of disruptive behaviors), I was ready to start helping people.
My first official shift was on an adolescent inpatient psychiatric unit in some city at some hospital, which for privacy reasons we can call “City Hospital.” I had three patients, one of whom was an 11-year-old boy with a history of the following:
- Self harm
- Aggressive behaviors
Let’s call him “Jack” (which is not his real name of course).
The shift went pretty well for the first few hours. Jack and I built a rapport over a mean game of battleship. We even talked about anger management. I was feeling great about the connection we were making and how well he was doing. But still, his continued physical escalations were a concern and I found out that he’d be going to a secure facility for further treatment rather than his home.
I had to break the news to him.
I sat down with Jack and let him know that he would not be going home. He immediately grabbed for the first thing he could reach (a telephone hand set) and winged it at me.
PMAB rule number 14 “deflect” only works when you are expecting something to be thrown at you. Don’t let the plastic fool you, it hurts!
Jack ran out of the room. I followed closely while giving him enough space to not feel threatened in hopes that he would slow down. He went into his room and slammed the door so hard it shook the halls. I thought this was an ok turn of events being that he was in his room within a secure facility where he had no access to anything dangerous.
Following protocol, I immediately got more staff and had a nurse wait outside his door in case he escalated again while I went to the video surveillance monitor to see what he was up to.
He seemed to be shredding a stuffed animal he had received on the unit. While it didn’t seem dangerous, it was suspicious, so I grabbed the charge nurse and we went down to see what he was up to. As soon as we opened the door we found him holding a shard of a broken CD he had hidden inside the stuffed animal. He had started cutting his arm with it while I was walking to his room from the monitor.
I started with the command “STOP!” hoping it might register with him.
Being that he was cutting we had no choice but to immediately go hands on. Again following protocol I did a loud “STAFF!” call to get help and the two of us went in to stop him from doing any serious damage to himself.
PMAB falls apart as soon as everything goes exactly not the way you were thinking it would. First we had to stop the cutting so we both swarmed in on the boy. After prying the shard out of his hands (suffering a small cut along the way), he lunged at me. The ideal would have been a “two person sitting wall hold,” but I swear there were limbs flying everywhere. It felt chaotic. The boy was escalating and he had been here before.
More staff showed up as he continued to fight us as hard as he could. No matter how we held him he cried out that we were hurting his arms, legs and even his spleen. He called me names and spit on me but the worst part was how heartbreaking it felt to see him in so much emotional pain. The whole ordeal went on for about 30 minutes until the order came for 4pt restraints. From there it was 1:1 watch and he took his PRN Ativan. He finally calmed down and even fell asleep.
I wasn’t sure if I was up for this. I felt exhausted physically and emotionally. I felt horrible for the boy who had so much history that brought him here. More than anything I felt like I had failed. What could I have done differently? How could I have better given him the news about his transition? And how could we have avoided having to restrain him?
Somehow I went back to work. I have now participated in probably over 50 restraints. They still suck and I still don’t always have a better alternative when the patient is being dangerous, but every now and again I can talk someone down or find an alternative and that feels like a win. Sometimes that small victory is a breakthrough. It’s all relative I guess but I sure wish there were more alternatives.