Scariest patient/situations you've encountered

[Merely]

What are the scariest situations you've been in as a psychiatrist/resident? It could be violent patients, managing a patient incorrectly, anything really!

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[notdeadyet]

Pre-auth for Abilify Maintenna.

 

[nitemagi]

QA nurse.

 

[F0nzie]

I have some unsettling stories that are not worth sharing because they were encounters with criminals who opted to harass/assault the clinic instead of serve their punishment in jail. Exploitation of mental health services by criminals is one aspect of our specialty that I can do without.


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[Shikima]

I have some unsettling stories that are not worth sharing because they were encounters with criminals who opted to harass/assault the clinic instead of serve their punishment in jail. Exploitation of mental health services by criminals is one aspect of our specialty that I can do without.


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Send them back, on suicide watch, with only paper gown, no underware, no blanket, and finger foods only.

 

[Merovinge]

Send them back, on suicide watch, with only paper gown, no underware, no blanket, and finger foods only.

No low salt diet? Getting generous in your old age Shikima.

 

[Shikima]

No low salt diet? Getting generous in your old age Shikima.

lulz

 

[SeniorWrangler]

I remember a patient tried to sucker punch me once. I grabbed his fist (he wasn't very big or strong) and we just looked at each other for a long moment, then simultaneously stepped away from each other. A profound experience.

 

[Shikima]

I remember a patient tried to sucker punch me once. I grabbed his fist (he wasn't very big or strong) and we just looked at each other for a long moment, then simultaneously stepped away from each other. A profound experience.

Ditto. Float like a butterfly, sting like a bee.

 

[Merely]

I remember a patient tried to sucker punch me once. I grabbed his fist (he wasn't very big or strong) and we just looked at each other for a long moment, then simultaneously stepped away from each other. A profound experience.

Thank you for your input!

 

[TexasPhysician]

Not really psychiatry related, but we do go to medical school for a reason.

Faculty arrived at clinic and began demonstrating some signs of cognitive impairment. Faculty sternly disagreed with resident concern. Faculty also did not approve of a resident prompting an unofficial consult by nearby IM faculty.

IM faculty subsequently admitted psych faculty for serious medical issues.

Psych faculty discharged from hospital and was quite appreciative.

Good rule of thumb: Do NOT point out faculty cognitive impairments without being positive that something is very wrong.

 

[Armadillos]

Not really psychiatry related, but we do go to medical school for a reason.

Faculty arrived at clinic and began demonstrating some signs of cognitive impairment. Faculty sternly disagreed with resident concern. Faculty also did not approve of a resident prompting an unofficial consult by nearby IM faculty.

IM faculty subsequently admitted psych faculty for serious medical issues.

Psych faculty discharged from hospital and was quite appreciative.

Good rule of thumb: Do NOT point out faculty cognitive impairments without being positive that something is very wrong.

Good rule of thumb: Do NOT come to work intoxicated if you work with psych residents

 

[TexasPhysician]

Good rule of thumb: Do NOT come to work intoxicated if you work with psych residents

If only it were that mild. Unlikely faculty survived the week without timely admission.

 

[Liquid8]

The most uncomfortable experience I had was with a patient I saw who claimed to have treatment resistant schizophrenia from the age of 5-6(!) and listed over a dozen antipsychotics that had been tried including clozapine. However, he’d never had ECT.

It didn’t take very long to work out he had anti-social PD written all over him. This patient talked about wanting to tie people up (including myself and my staff), put them in his car and cut them with power tools, which he attributed to the “voices.” Then he later admitted that he had actually done this in real life to threaten people who owed him money when he used to deal drugs as a teen, also felt that this was half due to voices, and half due to him. Other warning signs were a lengthy childhood forensic history that he played down due it being wiped after he turned 18, and a huge interest in hydroponics and growing his own strains of weed.

The only thing that had worked for his symptoms was Xanax (of course) which he’d been getting from local dealers, and when I told him I wouldn’t prescribe it, he then wanted to prove to me he could be trusted. He only mentioned late in the consult that he was also managed by a public community team who he referred to as “idiots” because they wouldn’t prescribe him benzos, and he’d gone off and seen a GP on his own bat who without knowing his history stuck him on a crap load of clonazepam. For some reason he was very keen to continue seeing me. I’d challenged him on one point where he’d said I was a great doctor by questioning him if he was only saying this because he thought I would prescribe what he wanted – but this lead him to say how he respected my honesty, and agreeing to let me contact his treating team. Obviously, I didn’t think I had anything to offer but he was insistent on coming back and paying. However, during the interview the counter transference was so strong that I got the strong sense that if I didn’t give him what he wanted I might find him waiting for me in the carpark so working out an exit strategy was imperative.

Between appointments I spoke to his case manager who confirmed antisocial behaviour, as well fillling me in on his current forensic history which included assault and drug dealing charges. They also felt that a lot of his “psychosis” was learned behaviour, and due to showing no response to very high doses of medications they felt he probably sold whatever he was prescribed. In the end, he didn’t attend the next scheduled appointment which gave me a reason to quickly discharge him back to his clinic and GP.

 

[Shikima]

The most uncomfortable experience I had was with a patient I saw who claimed to have treatment resistant schizophrenia from the age of 5-6(!) and listed over a dozen antipsychotics that had been tried including clozapine. However, he’d never had ECT.

It didn’t take very long to work out he had anti-social PD written all over him. This patient talked about wanting to tie people up (including myself and my staff), put them in his car and cut them with power tools, which he attributed to the “voices.” Then he later admitted that he had actually done this in real life to threaten people who owed him money when he used to deal drugs as a teen, also felt that this was half due to voices, and half due to him. Other warning signs were a lengthy childhood forensic history that he played down due it being wiped after he turned 18, and a huge interest in hydroponics and growing his own strains of weed.

The only thing that had worked for his symptoms was Xanax (of course) which he’d been getting from local dealers, and when I told him I wouldn’t prescribe it, he then wanted to prove to me he could be trusted. He only mentioned late in the consult that he was also managed by a public community team who he referred to as “idiots” because they wouldn’t prescribe him benzos, and he’d gone off and seen a GP on his own bat who without knowing his history stuck him on a crap load of clonazepam. For some reason he was very keen to continue seeing me. I’d challenged him on one point where he’d said I was a great doctor by questioning him if he was only saying this because he thought I would prescribe what he wanted – but this lead him to say how he respected my honesty, and agreeing to let me contact his treating team. Obviously, I didn’t think I had anything to offer but he was insistent on coming back and paying. However, during the interview the counter transference was so strong that I got the strong sense that if I didn’t give him what he wanted I might find him waiting for me in the carpark so working out an exit strategy was imperative.

Between appointments I spoke to his case manager who confirmed antisocial behaviour, as well fillling me in on his current forensic history which included assault and drug dealing charges. They also felt that a lot of his “psychosis” was learned behaviour, and due to showing no response to very high doses of medications they felt he probably sold whatever he was prescribed. In the end, he didn’t attend the next scheduled appointment which gave me a reason to quickly discharge him back to his clinic and GP.

You say counter-transference, I say spidey-sense.

 

[Merely]

The most uncomfortable experience I had was with a patient I saw who claimed to have treatment resistant schizophrenia from the age of 5-6(!) and listed over a dozen antipsychotics that had been tried including clozapine. However, he’d never had ECT.

It didn’t take very long to work out he had anti-social PD written all over him. This patient talked about wanting to tie people up (including myself and my staff), put them in his car and cut them with power tools, which he attributed to the “voices.” Then he later admitted that he had actually done this in real life to threaten people who owed him money when he used to deal drugs as a teen, also felt that this was half due to voices, and half due to him. Other warning signs were a lengthy childhood forensic history that he played down due it being wiped after he turned 18, and a huge interest in hydroponics and growing his own strains of weed.

The only thing that had worked for his symptoms was Xanax (of course) which he’d been getting from local dealers, and when I told him I wouldn’t prescribe it, he then wanted to prove to me he could be trusted. He only mentioned late in the consult that he was also managed by a public community team who he referred to as “idiots” because they wouldn’t prescribe him benzos, and he’d gone off and seen a GP on his own bat who without knowing his history stuck him on a crap load of clonazepam. For some reason he was very keen to continue seeing me. I’d challenged him on one point where he’d said I was a great doctor by questioning him if he was only saying this because he thought I would prescribe what he wanted – but this lead him to say how he respected my honesty, and agreeing to let me contact his treating team. Obviously, I didn’t think I had anything to offer but he was insistent on coming back and paying. However, during the interview the counter transference was so strong that I got the strong sense that if I didn’t give him what he wanted I might find him waiting for me in the carpark so working out an exit strategy was imperative.

Between appointments I spoke to his case manager who confirmed antisocial behaviour, as well fillling me in on his current forensic history which included assault and drug dealing charges. They also felt that a lot of his “psychosis” was learned behaviour, and due to showing no response to very high doses of medications they felt he probably sold whatever he was prescribed. In the end, he didn’t attend the next scheduled appointment which gave me a reason to quickly discharge him back to his clinic and GP.

Thanks for this! This is one of those things I think some people are scared of, getting assaulted (or killed) after hours by revengeful patients when you're only trying to do a good job and help them.

 

[birchswing]

Thanks for this! This is one of those things I think some people are scared of, getting assaulted (or killed) after hours by revengeful patients when you're only trying to do a good job and help them.

You could have the exact same situation working at a hair salon or a 7-11 or a late-night diner. All sorts of people can come in late at night with only one person working demanding strange things. It's not like mentally ill or drug-addicted people only exist in a doctor's office. They live 99.9% of their lives outside that setting.

Yes, there is a unique dynamic between psychiatrists and patients, especially if the care is involuntary. But in that situation the predictable factor is of the population that feels it's being antagonized, and so the variables that could favor a positive outcome have to do with the practitioner.

If I were a psychiatrist, I might be more concerned about cowboy doctors who admit to carrying guns with them against their place of employment's policy (search function . . .) than I would be patients whose frustrations are more predictable and whose psychological profiles are right in front of you and with whom you are attempting to ally yourself. You have more information and safe-guard protocols at your disposal than someone at Supercuts who has no idea what sort of person is entering right before close.

Also, Nidal Hassan . . .

 

[northernpsy]

Doctors of any specialty that has patient contact can be threatened or assaulted by patients. Personally, I actually feel safer on my inpatient psych unit than I would if I saw outpatients. I know my inpatients have been checked for weapons and the nurses can also give me a heads up since they spend more time with the patients than I do. However, this is a well run and decently funded psych unit. I have worked at other places that didn't seem as safe.

Even if you do pediatrics, you could be shot by an irate parent. At least in psych, the risk of violence is usually not far from our thoughts so we can take steps to try to reduce the risk. You definitely never want to become complacent or cocky. Nobody has ever tried to take a swing at me yet but it could always happen. I do try to stay aware of my surroundings and make sure I don't put myself in a situation where I can't bail out if I feel uneasy.

 

[medicool]

Have a few to share but almost all of them were outside the US.

1) Bodybuilder with auditory hallucinations brought in for eval by cops. The cop was friends with him and hence not cuffed, great. This guy was clearly psychotic but insists on going home and starts pacing and I feel my body shaking and sweating. I excused myself on the pretext of discussing with my attending, call the cop and ask him to get back up. So eventually there were 9 cops and 4 security guards along with 2 big nurses and a nurse aide that directed him to the inpatient unit without using force. Sometimes demonstration of force is good enough without actually having to use it. The good part was this guy called his lawyer and my attending told the lawyer off.

2) Another boxer in inpatient unit admitted voluntarily and I was on call. Informed he was getting agitated (likely coming off something) and I went to check on him and he wants to leave and of all things challenges me to a boxing duel, no thanks. So security gets called in and we are ready for a showdown when his nurse gently approaches him and lets him put his hands on her shoulders and guides him to the secure unit with no incident. He was making some inappropriate remarks to the nurse but she let them slide. Dude doesn't even remember the stuff next day. I looked him up and he was a legit boxer, thank god for the 30-second delay he allowed me for the fight prep.

3) My forensic attending told me to always offer oral meds to agitated/psychotic people initially and to be around when they are being injected emergent IM meds as it helps rapport. I got cussed when they get shots but I keep talking to them and apologize that I had no other option. I generally feel my knees shake but had better outcomes than bad. Also had a bunch of dinguses on deaddiction inpatient who wanted more Suboxone for detox and would get angry and yell but since no psychosis or safety issues were present in the majority it was more like stay or leave.