Hostile, aggressive patients

[TerraceHouse]

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Hello, PGY-1 here. Since I'm fairly new in training, I had a question that hopefully some of you can help with.

On adult inpatient, when one of your patients are violent, aggressive, with only basic English skills and has had to require emergency medications multiple times while still remaining violent, how do you guys treat such a patient?

I've been reluctant to drag in a digital interpreter for fear of patients using the pole that the iPad is hung on as a weapon so interactions have been minimal. I'm also jumpy as a new trainee so when these types of patients start inching toward me at all, I start to get out of there. It feels very rookie-like on my part. In the past, it was just consecutive days of minimal interactions such as this until emergency medications kind of did their part in calming down the patient enough to have better interactions after a week or so and slowly would turn around. Other times, patient would be sent off to a long-term facility.

Would love any advice/tips/input.

 

[adaptation1]

Just basic ideas.

1) Always sit next to the door and keep the door open. Don't be in a position where the patient can corner you.
2) Bringing in a MH tech to accompany you can be helpful. Or at least let them know to keep an eye out while you're interviewing.
3) An aborted interview is not a failed one. If they are show alarming and aggressive behavior at the outset of the interview, never feel compelled to continue the interview. Don't push. The patient is probably still fulfilling legal hold criteria. Document what you observed in the session and on the unit, , and safety first. That the patient required multiple PRNs during the day is already highly indicative of the patient's behavior.
4) Sometimes it's better to interview the patient after they got their scheduled medications in, as long as they aren't too sedated.

 

[deleted480308]

Bring security if they are that bad.

Anyone who is threatening gets backup , gets medicated, gets arrested or gets tied down. It’s not your job to get punched

The question of the translator is nonnegotiable. If they linguistically require it, it doesn’t matter if they are violent. They get one. All the above options can be done with a translator

 

[pediatric_psydoc]

When I worked in inpatient psych units, if a patient was aggressive they would typically be placed on a one-to-one (i.e., having a tech with them at all times) and/or be restricted to the unit. These restrictions were per the orders of the attending. If there was no unit restriction precaution in place, patients would be taken off the units for meals, for recreation, for art therapy, and to meet with their therapist or psychiatrist (the latter was per the discretion of the individual clinician and I typically did not take adults off the unit at all, only children when I worked that unit). I also followed the safety precautions outlined above as far as leaving the door open, letting someone know where I was, being the one closest to the door. One hospital I worked at had emergency buttons under the desk but others I worked did not.

The patient needs to have access to an interpreter. If you’re concerned about the pole, have a tech with you and keep the patient on the unit (if you already don’t). The lack of an interpreter may actually be worsening this patient’s aggression, in that the patient is frustrated that they have minimal understanding of what’s going on due to language barriers.

 

[Ironspy]

I agree with Sabine that the language barrier may be a source of frustration. If language is an issue and the virtual interpreter is a safety risk, consider asking for an in-person interpreter which is often a better experience for all. At my last hospital, I would call the patient rep and they connected me to someone at interpreter services.

Safety first of course for you and staff in all patient encounters. This means keeping distance, not being alone with certain patients, having an escape etc. Your seniors attendings should be providing supervision.

 

[FatherPsychiatry]

I'm also jumpy as a new trainee so when these types of patients start inching toward me at all, I start to get out of there. It feels very rookie-like on my part.

Not rookie at all. Safety is your #1 priority and you should never feel ashamed for doing what you need to for maintaining your safety. This is true whether you are a PGY1 or a PGY50. Many good suggestions in the replies above (have a tech with you, appropriate positioning etc). But honestly, too many variables here for us to make anything but generic recommendations. Is he truly psychotic, manic and acting out on this? Is this personality disorder? Is it TBI? His formulation matters in terms of how you approach him. Positioning isn't gonna help much if your patient is a sociopath malingering to stay in the hospital for 3 hots and a cot, but it might if they are paranoid. Hopefully your attending is giving you good guidance on how to work with this particular patient.

 

[TerraceHouse]

So many great replies. I honestly have gotten a lot of good feedback from SDN over the years.

1. I will absolutely bring in the interpreter whether live or digital from now on for all encounters.
2. Will def notify someone or bring in a tech.
3. Context: it's looking more and more like this particular patient may have some developmental delay with history of psychosis. But will keep in mind that context matters as I'm sure to encounter many more aggressive patients throughout my career.

While on this topic... what are the legal ramifications of psychiatrists when it comes to self-defense? I've heard mixed things. Some senior residents told me all I can legally do is run and even if they're on the brink of beating you to a pulp, you cannot ever strike back. Others said if it really gets that bad, you do what you do and worry about legal later.

 

[Armadillos]

So many great replies. I honestly have gotten a lot of good feedback from SDN over the years.

1. I will absolutely bring in the interpreter whether live or digital from now on for all encounters.
2. Will def notify someone or bring in a tech.
3. Context: it's looking more and more like this particular patient may have some developmental delay with history of psychosis. But will keep in mind that context matters as I'm sure to encounter many more aggressive patients throughout my career.

While on this topic... what are the legal ramifications of psychiatrists when it comes to self-defense? I've heard mixed things. Some senior residents told me all I can legally do is run and even if they're on the brink of beating you to a pulp, you cannot ever strike back. Others said if it really gets that bad, you do what you do and worry about legal later.

My understanding is from a liability standpoint you definitely can be held liable for injuring a patient even in clear self defense almost no matter what the patient is doing because ostensibly you “should” have been able use a “less restrictive” way to assure patient safety.

However if your dead, your not going to care if your in the clear legally....

 

[dl2dp2]

Nothing really to do. If patient isn't cooperative with interview and shows any sign of aggressiveness, leave the room and document.

It's actually a much more rookie move to try to engage with an uncooperative patient. Senior attendings spend 2 sec with these patients and move on. You would still bill for a full consult. Most of the relevant info for real problems in terms of diff dx (i.e. ? drugs vs. not) comes from history/collateral anyway.

The same can often be said about people who are wildly psychotic/manic. Junior people are often sucked into spending hours interviewing these people, which is fine, since when you are in training it's kind of fun and interesting to dissect out the pathology. But if you are experienced, you spend 5 min and move to your next consult for efficiency. This is how you clear a list of 20 people in 12 hour ER shifts.

 

[Armadillos]

Nothing really to do. If patient isn't cooperative with interview and shows any sign of aggressiveness, leave the room and document.

It's actually a much more rookie move to try to engage with an uncooperative patient. Senior attendings spend 2 sec with these patients and move on. You would still bill for a full consult. Most of the relevant info for real problems in terms of diff dx (i.e. ? drugs vs. not) comes from history/collateral anyway.

The same can often be said about people who are wildly psychotic/manic. Junior people are often sucked into spending hours interviewing these people, which is fine, since when you are in training it's kind of fun and interesting to dissect out the pathology. But if you are experienced, you spend 5 min and move to your next consult for efficiency. This is how you clear a list of 20 people in 12 hour ER shifts.

Nothing better (or worse) than watching the MS4 eager to match try to talk some sense into a floridly manic patient.

 

[TerraceHouse]

Nothing better (or worse) than watching the MS4 eager to match try to talk some sense into a floridly manic patient.

 

[Mass Effect]

Hello, PGY-1 here. Since I'm fairly new in training, I had a question that hopefully some of you can help with.

On adult inpatient, when one of your patients are violent, aggressive, with only basic English skills and has had to require emergency medications multiple times while still remaining violent, how do you guys treat such a patient?

I've been reluctant to drag in a digital interpreter for fear of patients using the pole that the iPad is hung on as a weapon so interactions have been minimal. I'm also jumpy as a new trainee so when these types of patients start inching toward me at all, I start to get out of there. It feels very rookie-like on my part. In the past, it was just consecutive days of minimal interactions such as this until emergency medications kind of did their part in calming down the patient enough to have better interactions after a week or so and slowly would turn around. Other times, patient would be sent off to a long-term facility.

Would love any advice/tips/input.

Safety, safety, safety.

But...

Interpreter, interpreter, interpreter. What is the diagnosis? Is it mental illness that's making him lash out like this? There's really no excuse to not have an interpreter, either by phone or digital. Bring security up with you if you have to, but the man has a right to an interpreter in a medical setting. It's not cool to have minimal interactions with him when you don't even have an interpreter to tell him why.

 

[Mass Effect]

.

 

[FlowRate]

The question of the translator is nonnegotiable. If they linguistically require it, it doesn’t matter if they are violent. They get one. All the above options can be done with a translator

If a patient is getting frequently violently agitated, I'm not sure that I'd wheel in a talking head on a baseball bat for the patient. Agree that they have a right to an interpreter which in this case would probably have to be a real person.

 

[Mass Effect]

If a patient is getting frequently violently agitated, I'm not sure that I'd wheel in a talking head on a baseball bat for the patient. Agree that they have a right to an interpreter which in this case would probably have to be a real person.

Sure, if an in-person interpreter is available, snatch that person up. But frequently, we'd get patients speaking a language for which we didn't have an in-person interpreter. In these cases, you take in the digital interpreter AND security. You keep the machine away from the patient and you keep the door open, again with security. You need to understand the agitation in order to help this patient and there's no way to truly do that until you can get someone on scene who speaks the same language.

 

[hallowmann]

Sure, if an in-person interpreter is available, snatch that person up. But frequently, we'd get patients speaking a language for which we didn't have an in-person interpreter. In these cases, you take in the digital interpreter AND security. You keep the machine away from the patient and you keep the door open, again with security. You need to understand the agitation in order to help this patient and there's no way to truly do that until you can get someone on scene who speaks the same language.

The other option is to simply remove the iPad from the stand. Worst case scenario, the iPad is broken. We use interpreter iPhones regularly (plenty of patients from African communities with very limited availability of in-house interpreters in those languages), so that would be an even better option. I hate wheeling those iPads on a stand into patient rooms.

 

[birchswing]

Enjoy this post while it's up as I will likely delete it in 24 hours...

As a brand new MS-3, I encountered a psychotic patient in the medical floor who swore that God had impregnated her, she had delivered the baby, and these doctors had taken the baby from her and wouldn't allow her to contact the media.

I tried to reason with her insisting she was mistaken.

IIRC, you don't validate or invalidate the delusion, correct?

I also kind of remember hysterical pregnancy being its own thing. I can't remember what they said they do for it.

Have you seen the movie Lars and The Real Girl? Sort of a similar situation.

 

[lyla]

What did your attending advise

Hello, PGY-1 here. Since I'm fairly new in training, I had a question that hopefully some of you can help with.

On adult inpatient, when one of your patients are violent, aggressive, with only basic English skills and has had to require emergency medications multiple times while still remaining violent, how do you guys treat such a patient?

I've been reluctant to drag in a digital interpreter for fear of patients using the pole that the iPad is hung on as a weapon so interactions have been minimal. I'm also jumpy as a new trainee so when these types of patients start inching toward me at all, I start to get out of there. It feels very rookie-like on my part. In the past, it was just consecutive days of minimal interactions such as this until emergency medications kind of did their part in calming down the patient enough to have better interactions after a week or so and slowly would turn around. Other times, patient would be sent off to a long-term facility.

Would love any advice/tips/input.

What did your attending advise you to do?

 

[calvnandhobbs68]

The other option is to simply remove the iPad from the stand. Worst case scenario, the iPad is broken. We use interpreter iPhones regularly (plenty of patients from African communities with very limited availability of in-house interpreters in those languages), so that would be an even better option. I hate wheeling those iPads on a stand into patient rooms.

Yeah the ipads are fancy but at every hospital I've been in there's always the option of the trusty old school interpreter phone. Dial them up and put them on speakerphone on a hospital phone. Usually through the same company that's doing the ipad stuff anyway.

 

[NickNaylor]

I personally hate using interpreters that aren't in-person (whether they be over the phone or video-based), and in this case I agree that having an in-person interpreter would be ideal. We've had patients that speak very uncommon languages, and our interpreting department while find an interpreter and have them be available on the unit for set periods of time each day (usually 4-8 hours). Obviously this is expensive to the hospital, but I also wouldn't be interested in getting assaulted with some kind of equipment to facilitate lower costs/convenience, so if you're really that concerned ask your unit manager to figure out how to get an in-person interpreter. I also think that in-person interpreters just offer a better experience and are more "patient-centered" (god I hate that term), but that probably is a great way to sell the need.

 

[TerraceHouse]

What did your attending advise

What did your attending advise you to do?

He told me to just keep it minimal and let the meds take effect and mostly gain collateral

 

[spaceydaisy]

Senior attendings spend 2 sec with these patients and move on. You would still bill for a full consult. Most of the relevant info for real problems in terms of diff dx (i.e. ? drugs vs. not) comes from history/collateral anyway.

How do you bill for a full consult for that?

 

[psychapp121]

How do you bill for a full consult for that?

“pt not cooperative with assesment, refuses to answer questions and acting aggressively towards myself and staff” boom done

 

[Mass Effect]

IIRC, you don't validate or invalidate the delusion, correct?

This was acute psychosis in a hospitalized patient on a medicine service. You don't validate or invalidate. You observe, formulate, and come up with a recommendation/treatment plan.

“pt not cooperative with assesment, refuses to answer questions and acting aggressively towards myself and staff” boom done

Um, no. You don't bill for a full consult if that's all your note says.

How you bill for a full consult if the patient is too ill to speak to you is that you document clearly what happened on your meeting with the patient, then report ED/EMT report (how and why did the patient get there?), nursing report, family report if they're around, your observations, etc. You collect collateral for history from previous records and/or family since you still need to gather some type of hx about psych, substance abuse, social. You still need a formulation, diagnosis, and treatment plan.

 

[whopper]

Repeating what was said above-make sure your inpatient has the appropriate infrastructure for safety.

E.g. while I worked in a state hospital in Ohio we all wore safety buttons connected to a necklace, that is pulled hard would snap so you wouldn't get choked. You pressed that button an alarm went off and security was on-the-spot within about 1 minute if not sooner. Everyone had safety training.

My last job in a hospital it took security about 30 minutes to show up. I left that job. It was a tragedy of errors that whenever I tried to fix one of them someone higher than me would try to stop me from fixing it. I stayed at that last job for about a year and gave up. Only reason why I didn't leave sooner was cause my original long-term plan was academia, and cause I had real respect for the head of the department (and no he wasn't the guy blocking me).