Violent patients on inpatient

[Wardles888]

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Hi everyone,
How do you approach violent patients on the inpatient unit who are particularly angry with you because you are the evil doctor that won’t give them what they want (discharge, ect). I have a patient on the unit who has extensive violence hx, is aggressive to all staff but seems to hate me in particular. I find that every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me. Currently I have a low threshold for walking away from our conversations when I see him getting worked up, which is every time, but I wonder if me doing so makes me a poor team leader (he gets worked up with others too). Would you keep trying to engage or just keep it short/ avoid? Situation is also complicated by the fact that I’m pregnant which has made me extra cautious/ skittish around patients in general.

 

[OldLeech]

Are you sure you are the particular doctor or does it feel that way? What is your exact role—you mentioned being a team leader. Are you a chief resident or attending?

I would ask yourself what you are trying to realistically accomplish in each interaction. For whatever reason this patient wants ect and if you've already decided it's not appropriate, don't engage on that subject. As far as discharge, recognize that the patient's feelings are probably very much in the realm of normal. As you said yourself, you have a low threshold for being in a situation in which you feel threatened and you leave. That is what it sounds like your patient is asking for, as well.

You have your answer right here: "every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me"

Why are you trying to talk to him if you know it makes things worse? Medicine isn't about making chit chat for the sake of it. He either has a medical condition you can help with or he doesn't. It doesn't sound like you, or maybe anyone, can.

The other tact would be to consider his requests as rational. You mentioned discharge and ect. What are the issues with these? What is his rationale for each?

 

[Crayola227]

Always look out for your own safety #1. Period. And you might have a lower threshold than others, that's OK. Also trust your gut on that.

 

[Wardles888]

Are you sure you are the particular doctor or does it feel that way? What is your exact role—you mentioned being a team leader. Are you a chief resident or attending?

I would ask yourself what you are trying to realistically accomplish in each interaction. For whatever reason this patient wants ect and if you've already decided it's not appropriate, don't engage on that subject. As far as discharge, recognize that the patient's feelings are probably very much in the realm of normal. As you said yourself, you have a low threshold for being in a situation in which you feel threatened and you leave. That is what it sounds like your patient is asking for, as well.

You have your answer right here: "every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me"

Why are you trying to talk to him if you know it makes things worse? Medicine isn't about making chit chat for the sake of it. He either has a medical condition you can help with or he doesn't. It doesn't sound like you, or maybe anyone, can.

The other tact would be to consider his requests as rational. You mentioned discharge and ect. What are the issues with these? What is his

Are you sure you are the particular doctor or does it feel that way? What is your exact role—you mentioned being a team leader. Are you a chief resident or attending?

I would ask yourself what you are trying to realistically accomplish in each interaction. For whatever reason this patient wants ect and if you've already decided it's not appropriate, don't engage on that subject. As far as discharge, recognize that the patient's feelings are probably very much in the realm of normal. As you said yourself, you have a low threshold for being in a situation in which you feel threatened and you leave. That is what it sounds like your patient is asking for, as well.

You have your answer right here: "every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me"

Why are you trying to talk to him if you know it makes things worse? Medicine isn't about making chit chat for the sake of it. He either has a medical condition you can help with or he doesn't. It doesn't sound like you, or maybe anyone, can.

The other tact would be to consider his requests as rational. You mentioned discharge and ect. What are the issues with these? What is his rationale for each?

thanks for your response!! To answer some of your questions, I am a first year attending. I don’t feel he “has a condition I can help with”. He is too delusional and paranoid for a rapport. However, nursing is calling me multiple times a day that he demands to speak with me. I don’t want to leave them hanging and yet every conversation results in him accusing me of giving him poison (his meds) and throwing a tantrum over discharge. Today we discussed giving him a behavioral plan, but everyone on the unit is too scared to actually implement it. He’s had multiple episodes of significantly attacking both staff and random people on the street out of paranoia.

 

[splik]

Your approach is correct. There is no therapeutic alliance and it’s not possible to have when pt is in this state. Keep interactions brief and once a day. They should not keep paging you about it. You should make it clear and everyone else he only gets to see the doctor once a day barring some emergent situation. Don’t get into circular conversationork with the nurse manager to make sure behavioral plan is implemented. Also make sure he is liberally medicated.

Pregnancy is not a complicating factor. I would argue it makes it easier as it is a no brainer to keep you and your baby safe and disengage at first sign of any escalation.

as an aside also do a search and make sure your personal information is not easily found online. If it is, take steps to remove it. Prevention is better than cure.

 

[Fan_of_Meehl]

thanks for your response!! To answer some of your questions, I am a first year attending. I don’t feel he “has a condition I can help with”. He is too delusional and paranoid for a rapport. However, nursing is calling me multiple times a day that he demands to speak with me. I don’t want to leave them hanging and yet every conversation results in him accusing me of giving him poison (his meds) and throwing a tantrum over discharge. Today we discussed giving him a behavioral plan, but everyone on the unit is too scared to actually implement it. He’s had multiple episodes of significantly attacking both staff and random people on the street out of paranoia.

I'd only chime in to say (a) like others have said, trust your gut when it comes to feeling a sense of danger around potentially violent patients...there are likely neurological circuits that have evolved over aeons to detect incipient interpersonal violence and listening to them may save your life, and (b) also be aware of contingencies of reinforcement in this situation; this patient is likely to have a history of getting what he wants by engaging in or threatening violence, I'd be careful about responding by giving him what he wants (e.g., access to you) contingent upon engaging in threatening behavior...maybe at least put in a delay in responding or meet with him on a regular (non-contingent) basis or even respond when he exhibits either the absence of threatening behavior or even pro-social behavior

 

[Old&InTheWay]

I don’t feel he “has a condition I can help with”.

If this is true, why not just discharge him? Call the police to be present in case he becomes violent and escort him off the hospital grounds.

 

[Bartelby]

We are also living in the age of COVID and telehealth. Is a video-based assessment possible? That has been common even on inpatient units this year.

 

[Attending1985]

Hi everyone,
How do you approach violent patients on the inpatient unit who are particularly angry with you because you are the evil doctor that won’t give them what they want (discharge, ect). I have a patient on the unit who has extensive violence hx, is aggressive to all staff but seems to hate me in particular. I find that every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me. Currently I have a low threshold for walking away from our conversations when I see him getting worked up, which is every time, but I wonder if me doing so makes me a poor team leader (he gets worked up with others too). Would you keep trying to engage or just keep it short/ avoid? Situation is also complicated by the fact that I’m pregnant which has made me extra cautious/ skittish around patients in general.

Is there someone else you can transfer the patients to? If so please do. The health of your baby needs to be number one.

 

[psychacad]

Yeah, second what everyone is saying. Make sure you don't see him more than once a day and I'd make it clear for him and the staff. You aren't supposed to talk to him per his whims and I think that's reinforcing the dynamic. If he is this paranoid and agitated that he can't tolerate a conversation the best thing is indeed to walk out at the first sign. In a way, that is the 'behavioral plan'.

I'm also wondering what is your sense behind the violence? Is it just paranoia, or is there a some underlying character stuff where he's used to obtain what he wants by making people around him scared? If it's the latter, I'd consider making it clear to him that his behavior makes people around him nervous. Sometimes this sort of openness and feedback can improve alliance. Otherwise your best hope is to wait it out for the meds to start kicking in.

 

[Wardles888]

If this is true, why not just discharge him? Call the police to be present in case he becomes violent and escort him off the hospital grounds.

I don’t feel he has a condition I can help with by going to speak with him further. He’s extremely paranoid and psychotic and definitely needs to be in the hospital

 

[clausewitz2]

I'm also wondering what is your sense behind the violence? Is it just paranoia, or is there a some underlying character stuff where he's used to obtain what he wants by making people around him scared? If it's the latter, I'd consider making it clear to him that his behavior makes people around him nervous. Sometimes this sort of openness and feedback can improve alliance.

Sometimes with someone like this being very direct about this point ends up being very helpful. "I'm curious as to what you expect will happen when you yell at me like this. I'm aware of being less inclined to agree to what you're asking for." In the moment this might lead to more of an explosion but after the encounter they might have time to mull this over. this has historically been effective for me in getting people with strong antisocial traits to be less aggro in interactions (with me, anyway). Some combination of recognizing their own self-interest and that you won't be an easy mark, if nothing else.

Otherwise echo everyone else, there is nothing therapeutic for the patient in punching you in the face.

 

[comp1]

Concur with most of the above. If you find that you interacting with this patient is definitely harmful to him and potentially harmful to you, then don't. Observe from a distance and collect collateral from the rest of his care team for documentation purposes. That's actually demonstrating good leadership by involving everyone in his care. The beauty of inpatient is that you should never feel that you are making decisions alone. Nurses should feel free to update you on his status, but there should be an understanding that you having repeated daily interactions are harmful towards him and ultimately putting everyone at risk. That may change as medications have time to take effect, of course.

 

[PsyDr]

What you are describing is instrumental aggression, not emotional aggression. Conceptually, this is like a little kid throwing a fit because they didn't get what they want. You ignore it. Outline the expectations and refuse to discuss further. Watch the extinction burst, because it will get worse. Then wait. The supernanny shows cover this pretty well. The fact that the aggression is organized and goal directed is positive. That is VERY different than a disorganized delusional person who keeps referring to "what I know", but can't explain the thought content.

 

[LimpSpatula]

Hi everyone,
How do you approach violent patients on the inpatient unit who are particularly angry with you because you are the evil doctor that won’t give them what they want (discharge, ect). I have a patient on the unit who has extensive violence hx, is aggressive to all staff but seems to hate me in particular. I find that every time I try to talk to him, he gets even more agitated bc he can’t tolerate that he isn’t getting what he wants from me. Currently I have a low threshold for walking away from our conversations when I see him getting worked up, which is every time, but I wonder if me doing so makes me a poor team leader (he gets worked up with others too). Would you keep trying to engage or just keep it short/ avoid? Situation is also complicated by the fact that I’m pregnant which has made me extra cautious/ skittish around patients in general.

Medicate them or discharge them. Some of these responses, lol.

 

[Candidate2017]

Is there someone else you can transfer the patients to? If so please do. The health of your baby needs to be number one.

Safety first, but I disagree with transferring the patient. It's sort of an a-hole thing to do to your colleagues. Having a fetus is not a disqualifying factor unless you are physically impaired to the point you need maternity leave.

This is merely the average agitated/psychotic patient who is riling up the average subpar staff, who runs to the doctor because they don't want to do their job. This is staff management and patient management 101. Run of the mill stuff. This is what we all signed up for as part of the job.

 

[Attending1985]

Safety first, but I disagree with transferring the patient. It's sort of an a-hole thing to do to your colleagues. Having a fetus is not a disqualifying factor unless you are physically impaired to the point you need maternity leave.

This is merely the average agitated/psychotic patient who is riling up the average subpar staff, who runs to the doctor because they don't want to do their job. This is staff management and patient management 101. Run of the mill stuff. This is what we all signed up for as part of the job.

Absolutely disagree. If I was her colleague I would insist on taking the patient. I would say a colleague complaining about this is an a-hole thing to do. If it’s so average as you say there should be no issue with transfer.

 

[Candidate2017]

Absolutely disagree. If I was her colleague I would insist on taking the patient. I would say a colleague complaining about this is an a-hole thing to do. If it’s so average as you say there should be no issue with transfer.

We roll the dice. These types of patients are not risk free. OP could be beaten to a pulp. But her having a fetus doesn't warrant shirking the risk on to someone else, Everyone is valuable. Who's to say the Dr taking this patient off her can also be beaten to a disabled pulp, while having 5 mouths to feed?

 

[Attending1985]

We roll the dice. These types of patients are not risk free. OP could be beaten to a pulp. But her having a fetus doesn't warrant shirking the risk on to someone else, Everyone is valuable. Who's to say the Dr taking this patient off her can also be beaten to a disabled pulp, while having 5 mouths to feed?

I’m not sure what you gender is or if you’ve ever been pregnant but I’m a female who has. The profound vulnerability and physical limitation I felt allows me to empathize in a way you may not be able to. I think we will just have to agree to disagree.

 

[thepoopologist]

thanks for your response!! To answer some of your questions, I am a first year attending. I don’t feel he “has a condition I can help with”. He is too delusional and paranoid for a rapport. However, nursing is calling me multiple times a day that he demands to speak with me. I don’t want to leave them hanging and yet every conversation results in him accusing me of giving him poison (his meds) and throwing a tantrum over discharge. Today we discussed giving him a behavioral plan, but everyone on the unit is too scared to actually implement it. He’s had multiple episodes of significantly attacking both staff and random people on the street out of paranoia.

Either staff is appropriately scared of him because he isn't medicated enough or they are overly scared of him based off his history/behavior. I don't know what it is but based on your description it sounds like they are calling you to do their job for them. You need to discuss what you'll respond to and what you won't and make sure to cc/email the appropriate supervisors in case nursing tries to turn it back on you saying you won't submit to their requests to see the patient. If they continue to call you multiple times a day because they don't know how to deal with psych patients you have a bigger problem on your hands than this one guy. Don't make it about your pregnancy when you talk to staff or your supervisors about this patient, but also make sure to mention on a separate day perhaps how your pregnancy is advancing. Any admin who isn't dumb as rocks will get the message

<---Government employee


Also, either he is well medicated and its a matter of time before he gets better, or he isn't medicated enough but you don't have the justification to push it higher based on his current presentation and then he needs to get worse before you can make him better.

 

[Liquid8]

With overly hostile patients I find it best to keep interactions brief. You can assess, perform a mental state examination and make treatment decisions from a distance without endangering yourself.

If the behaviour is being driven by an illness, then treat it aggressively. In extreme cases I’d be considering injectables, with either security guard and/or physical restraints to assist if needed. If such patients are under medicated, you’re only placing yourself and others at risk.

However, if you think it’s primarily personality that is driving this, then set appropriate boundaries, get together with staff to work out a specific behavioural management plan to ensure you’re all on the same page and plan for discharge. If possible, I’d also think about getting a forensic opinion to back you up if you’re unsure.

 

[erg923]

We roll the dice. But her having a fetus doesn't warrant shirking the risk on to someone else,

Good Lord, son. Want your wife to "roll the dice," be my guest. But don't tell others such careless nonsense about their children.....and probably start lookin for a divorce attorney as well.

 

[robellis]

Good Lord, son. Want your wife to "roll the dice," be my guest. But don't tell others such careless nonsense about their children.....and probably start lookin for a divorce attorney as well.

What he’s saying is spot on..if your wife is pregnant she can choose to not work but I’m not seeing her violent patients because she’s pregnant..

 

[birchswing]

I have a lot of opinions I would truly love to engage in discussion with about regarding gender and pregnancy, but it would probably get me banned.

So I'll skip to my much more boring question. People keep talking about waiting until the meds kick in. Aren't the medications that could make a person docile nearly immediately effective?

Also to the OP, that the patient knows you are the ticket out of the building seems to suggest he isn't that far gone. Just a very lay perspective.

 

[robellis]

I have a lot of opinions I would truly love to engage in discussion with about regarding gender and pregnancy, but it would probably get me banned.

So I'll skip to my much more boring question. People keep talking about waiting until the meds kick in. Aren't the medications that could make a person docile nearly immediately effective?

Also to the OP, that the patient knows you are the ticket out of the building seems to suggest he isn't that far gone. Just a very lay perspective.

No they are not immediately effective they take couple days to weeks in some cases

 

[LimpSpatula]

No they are not immediately effective they take couple days to weeks in some cases

This is just plain wrong. If a patient is on the inpatient unit and are violent, immediate action is taken.

 

[Mad Jack]

Actual violence on my unit is met with handcuffs. We don't have physical restraints and safety is number one for myself and the rest of the staff. Aggression is met with a firm statement that violence is completely unacceptable on the unit and will result in police intervention and likely criminal charges, and furthermore that assaulting a health care provider is a felony in my particular state.

 

[birchswing]

This is just plain wrong. If a patient is on the inpatient unit and are violent, immediate action is taken.

That's what I was wondering. I am not a medical provider, but on TV shows you see people being injected with what I assume is supposed to be a first-generation antipsychotic and benzo and within 20 minutes or so being sedated. I am curious which drugs take weeks.

 

[Stagg737]

The level of incompetence and ignorance demonstrated on this thread is astounding. Psychiatry is an extremely safe job and it is disgusting that people would make this a social issue about pregnant women in the workplace. The people talking about how violent an inpatient unit is to a psychiatrist fall into two groups:

1: People living in a bubble their entire life, falsely believing what they do is dangerous with no sensibility as to what danger is, and having no damn respect for the security and psych techs who actually are subject to violence

And

2: People who are so dumb that they are actually rolling the dice and putting themselves in unnecessary, dangerous positions.

Either way, youre wrong.

I wouldn't have a problem covering this patient for a pregnant colleague (or anyone really as these patients really interest me), but assuming your statement is true then why would a pregnant physician need coverage? If the situation is so safe this entire conversation is irrelevant.

That's what I was wondering. I am not a medical provider, but on TV shows you see people being injected with what I assume is supposed to be a first-generation antipsychotic and benzo and within 20 minutes or so being sedated. I am curious which drugs take weeks.

You can snow chemically sedate someone with high doses of antipsychotics, benzos, and benadryl, but sedating someone is not the same as treating them. It can take weeks for antipsychotics to actually improve their psychotic state if that is the underlying cause of their aggression. You can constantly chemically sedate them until their psychosis resolves, though this would pretty much be against standard of care in almost all situations.

 

[LimpSpatula]

I wouldn't have a problem covering this patient for a pregnant colleague (or anyone really as these patients really interest me), but assuming your statement is true then why would a pregnant physician need coverage? If the situation is so safe this entire conversation is irrelevant.



You can snow chemically sedate someone with high doses of antipsychotics, benzos, and benadryl, but sedating someone is not the same as treating them. It can take weeks for antipsychotics to actually improve their psychotic state if that is the underlying cause of their aggression. You can constantly chemically sedate them until their psychosis resolves, though this would pretty much be against standard of care in almost all situations.

To your first point, she shouldnt. To your second point I’ve never seen psychosis driven violence last weeks. Have you? Ive actually never seen it last more than 24 hours.

 

[hallowmann]

I have a lot of opinions I would truly love to engage in discussion with about regarding gender and pregnancy, but it would probably get me banned.

So I'll skip to my much more boring question. People keep talking about waiting until the meds kick in. Aren't the medications that could make a person docile nearly immediately effective?

Also to the OP, that the patient knows you are the ticket out of the building seems to suggest he isn't that far gone. Just a very lay perspective.

The medications you are describing are for sedating purposes. Unless the patient is truly actively harming themselves or others, the use of medications purely with the intention to sedate should not be used. Usually you can find a balance whether it be in a quiet room or restraints with some agitation medications (not enough to truly "put them to sleep" or compromise breathing, which would be dangerous for the patient).

What we are talking about with waiting for medications to "kick in", are antipsychotics and/or mood stabilizers to actually treat the patient's underlying condition (e.g. psychosis, mania, etc.). They take many days to have the intended effect.

To give you an idea, one patient I had seen in intern year took high doses and >2 wks (both of which were consistent with prior episodes) to reach the point of actually having a meaningful conversation with him. This was also my first peer-to-peer with insurance to explain why the patient having behavioral codes almost nightly needed to remain in the hospital and at the same time was improving because its no longer multiple times a day.

To your first point, she shouldnt. To your second point I’ve never seen psychosis driven violence last weeks. Have you? Ive actually never seen it last more than 24 hours.

The guy above had violent outbursts that lasted about 2 weeks, but he was suffering from mania with pretty severe psychotic features.

 

[LimpSpatula]

The medications you are describing are for sedating purposes. Unless the patient is truly actively harming themselves or others, the use of medications purely with the intention to sedate should not be used. Usually you can find a balance whether it be in a quiet room or restraints with some agitation medications (not enough to truly "put them to sleep" or compromise breathing, which would be dangerous for the patient).

What we are talking about with waiting for medications to "kick in", are antipsychotics and/or mood stabilizers to actually treat the patient's underlying condition (e.g. psychosis, mania, etc.). They take many days to have the intended effect.

To give you an idea, one patient I had seen in intern year took high doses and >2 wks (both of which were consistent with prior episodes) to reach the point of actually having a meaningful conversation with him. This was also my first peer-to-peer with insurance to explain why the patient having behavioral codes almost nightly needed to remain in the hospital and at the same time was improving because its no longer multiple times a day.



The guy above had violent outbursts that lasted about 2 weeks, but he was suffering from mania with pretty severe psychotic features.

Ya I dont buy violence 2 weeks later driven by mania. Sorry. I could see it in a “Bipolar” patient who was acting out though. But the point is irrelevant. If for some reason this patient is under your care theres no reason you should ever be in a position to be “beaten to a pulp”. The 2 week history makes this patient safer than john doephetamine walking through the door. Give me a break.

 

[hallowmann]

Ya I dont buy violence 2 weeks later driven by mania. Sorry.

Believe what you want, by week 3 the guy was back to being normal (no hallucinations or hyperreligiosity), sleeping 8-9 hrs, and talking about getting back to work as an accountant and visiting his mom in the hospital. He spent so much time in the quiet room that we had to have multiple meetings about use because it had such a big impact on our "average use" time and restraint time, something that we went out of our way to minimize. He needed it, and it was ultimately found to be justified.

I will say, I haven't seen another case quite like that since.

 

[LimpSpatula]

Believe what you want, by week 3 the guy was back to being normal (no hallucinations or hyperreligiosity), sleeping 8-9 hrs, and talking about getting back to work as an accountant and visiting his mom in the hospital. He spent so much time in the quiet room that we had to have multiple meetings about use because it had such a big impact on our "average use" time and restraint time, something that we went out of our way to minimize. He needed it, and it was ultimately found to be justified.

I will say, I haven't seen another case quite like that since.

Ok fair enough if its a one off thing. Id also be curious as to what you define as violence. We’re talking assault right?

 

[hallowmann]

Ok fair enough if its a one off thing. Id also be curious as to what you define as violence. We’re talking assault right?

Assault or attempts at it, but we knew how to handle him (i.e. distance and lots of bodies) and he was obviously not the most organized (or quickest) person, often swinging out at hallucinations (broke a few doors and fell a few times while swinging). I think maybe he actually connected (in a negative way) with one staff member, but honestly that almost never happens. Our staff are very good at taking precautions and we have a very tight and well-staffed behavioral code team that are within a minute of the units.

 

[psychacad]

I've seen my share of manic patients who needed weeks to stabilize, and yes, they were violent and threatening and the whole story.

Violence with psychosis tends to be a little more different as it is usually more confined. Most often there is a character component if it's a recurring pattern.

 

[robellis]

Ya I dont buy violence 2 weeks later driven by mania. Sorry. I could see it in a “Bipolar” patient who was acting out though. But the point is irrelevant. If for some reason this patient is under your care theres no reason you should ever be in a position to be “beaten to a pulp”. The 2 week history makes this patient safer than john doephetamine walking through the door. Give me a break.

You’re so arrogant and sure of yourself yet you have several psychiatrists who work inpatient disagreeing with you..I would take a step back and think about things before continuing rather than telling us we’re plain wrong or delusional

 

[LimpSpatula]

You’re so arrogant and sure of yourself yet you have several psychiatrists who work inpatient disagreeing with you..I would take a step back and think about things before continuing rather than telling us we’re plain wrong or delusional

You are bringing up strawmen. The argument is that this pregnant lady is at risk of being beaten to death lol. I may be arrogant, and my responses might challenge your view of the world, but it doesnt make it wrong. Maybe you should reflect on the fact that none of you have been seriously assaulted by a patient, while most likely witnessing patients assault your staff, before grandstanding about how dangerous it is.

 

[Old&InTheWay]

You are bringing up strawmen. The argument is that this pregnant lady is at risk of being beaten to death lol. I may be arrogant, and my responses might challenge your view of the world, but it doesnt make it wrong.

I don't think that's the argument. Pregnant people are vulnerable because a single blow to the abdomen could potentially cause a miscarriage/abruption/etc. That's why the pregnancy aspect is an extra complication for OP (but mostly irrelevant to the question at hand). Perhaps no one else should "have to" put themselves at risk in their place, but many of us would be willing to.

 

[Stagg737]

To your first point, she shouldnt. To your second point I’ve never seen psychosis driven violence last weeks. Have you? Ive actually never seen it last more than 24 hours.

Not weeks, but I have seen several cases where psychosis-driven violence lasted 3-4 days and one instance where it lasted 6-7 days (this one was a co-resident's patient). All but one of the shorter ones and the 6-7 day one had a substance component (typically meth). The shorter one thought he was the angel of death and actively tried to kill any non-Hispanic people on the unit. Didn't come out of the isolation room at all for the first 3 days and required chemical sedation d/t assault attempts 2 or 3 more times after that. The other one was bizarre. The guy couldn't even talk and would just grunt at people for the first week. Would try and assault anyone that came within 10 feet of him. Was on our unit for about a month but couldn't even get meaningful speech out of him for nearly the first two weeks. Very bizarre case.

To clarify though, when I was talking about antipsychotics taking weeks to treat the psychosis, not weeks for the aggression to resolve.

I'll also add that I think these patients are most dangerous when they're first calming down and not when they're actively aggressive. As they start to improve people start letting their guard down but the potential for reactive aggression is still there. Legit question, have you ever had a patient take a swing at you or actually attack you other than just throwing something?

 

[LimpSpatula]

I don't think that's the argument. Pregnant people are vulnerable because a single blow to the abdomen could potentially cause a miscarriage/abruption/etc. That's why the pregnancy aspect is an extra complication for OP (but mostly irrelevant to the question at hand). Perhaps no one else should "have to" put themselves at risk in their place, but many of us would be willing to.

Have you ever received a blow to the abdomen? There are several precautions you can take to ensure you dont get hit in the uterus. But I agree with the sentiment. My issue is that its being used out of context to diminish women in the workplace. The idea that people here feel the need to do this, and subsequently cry when I call them out says a lot.

We aren’t soldiers (but please ask one if they feel wronged when their fellow service member is pregnant and cant be near a combat zone.) We are extremely privileged people who have staff that take on violent risk for us. Thats their job. Lets not pretend to be something we’re not.

A hospitalist or surgeon takes on more risk to their fetus by the nature of their work. Get back to sitting down and taking your time fellas.

 

[LimpSpatula]

I'll also add that I think these patients are most dangerous when they're first calming down and not when they're actively aggressive. As they start to improve people start letting their guard down but the potential for reactive aggression is still there. Legit question, have you ever had a patient take a swing at you or actually attack you other than just throwing something?

I agree with you on that. I’ve never had a patient take a swing at me, but I do my best to mitigate those risks, including not engaging when they’re escalating their aggression towards me. I’ve had one very small lady charge me and sugar tap me, but I couldn’t help but lose my professionalism and laugh for a second (she was looking for that reaction).

I’ve had one patient attempt to murder me (wont get into specifics), but the safety measures of the psych unit protected me.

 

[Bartelby]

While I agree that psychiatric nurses and techs take on a higher risk of assault I strongly disagree that psychiatrists are not assaulted. I have been (a minor assault with no injury), and I know others who have as well (in some cases with serious injury). As the psychiatrist with the ability to make the final call about keeping the patient in the hospital, you can also become the focus of the patient's rage. This may not be a bad thing, because again the staff who actually do not have the ability to make those decisions are at higher risk and I would prefer the patient's anger be targeted toward me rather than toward those more accessible team members.

I don't think anyone has to take on a violent patient from a pregnant colleague, but as others have mentioned I would have no problem doing so.

 

[Crayola227]

What he’s saying is spot on..if your wife is pregnant she can choose to not work but I’m not seeing her violent patients because she’s pregnant..

Being pregnant, especially of a size where someone else can tell (makes you more vulnerable as an obvious target) and movement is impaired and a kick to the stomach is likely to do real harm, is so time limited though.

If a colleague was on crutches for a broken ankle and wanted to transfer the patient to me (I wear sneakers at all times) I would do it. Seems like professional courtesy for whatever the time limited reason is. It's only a problem if it isn't reasonably time limited.

 

[Mad Jack]

Assault or attempts at it, but we knew how to handle him (i.e. distance and lots of bodies) and he was obviously not the most organized (or quickest) person, often swinging out at hallucinations (broke a few doors and fell a few times while swinging). I think maybe he actually connected (in a negative way) with one staff member, but honestly that almost never happens. Our staff are very good at taking precautions and we have a very tight and well-staffed behavioral code team that are within a minute of the units.

Yeah, I have a patient similar to this. Nicest guy ever but when his psychosis acts up he thinks people are shooting him with pellets when he isn't looking and gets violent. He thinks there are soldiers in the ceiling shooting at him and will punch out celing tiles, and even upon seeing there is nothing there will insist there had been someone there shooting him previously. Takes weeks to stabilize, and had a paranoid focus on a staff member that he came to delusionally believe had been involved in the death of his sister. I really like him when he is stable, but when his mental illness is acting up he is highly unpredictable and requires a cautious approach

 

[Mad Jack]

What he’s saying is spot on..if your wife is pregnant she can choose to not work but I’m not seeing her violent patients because she’s pregnant..

It is the courteous thing to do for your colleagues. You should look out for each other when you're in need because no one else will. Maintaining a good relationship with your peers is the difference between long-term misery and career satisfaction

 

[Mad Jack]

While I agree that psychiatric nurses and techs take on a higher risk of assault I strongly disagree that psychiatrists are not assaulted. I have been (a minor assault with no injury), and I know others who have as well (in some cases with serious injury). As the psychiatrist with the ability to make the final call about keeping the patient in the hospital, you can also become the focus of the patient's rage. This may not be a bad thing, because again the staff who actually do not have the ability to make those decisions are at higher risk and I would prefer the patient's anger be targeted toward me rather than toward those more accessible team members.

I don't think anyone has to take on a violent patient from a pregnant colleague, but as others have mentioned I would have no problem doing so

I have been threatened a great deal, and know a psychiatrist that was beaten senseless with a coat rack on his unit by a patient. I've seen a couple attendings dodge punches. All but the psychiatrist that was significantly injured were attempted assaults or threats from patients with substance use disorder, either that were psychotic from amphetamines or that wanted benzodiazepines and were denied them

 

[psychacad]

Agreed; I've worked in several settings and there's always a story about a doctor who was recently beaten up. I stopped a day time moonlighting gig for what seemed to me an 'accident' waiting to happen. This is a high risk environment and you better be careful and on your toes all the time. I do think we should help out each other, but I can't agree that handing out violent patients as an expectation. This is a dangerous setting and one should factor that in their decision making to work there. I don't have stats, but my guess is that most assault towards physicians happen when you're least expecting them, so a 'policy' like this one might end up being counterproductive.

 

[Crayola227]

There's the whole statistic that psychotic or mentally ill patients are more likely to be the victims of crime than to be violent compared to gen pop, and stigma around mentally ill psychotic patients and being violent, and I thought I'd point out for anyone reading this that didn't know, the caution we're talking about having on inpt unit is different than the assumptions you need to make when someone tells you they've been treated for psychosis in the past, or Aunt Mabel's depression diagnosis, or you see someone walking down the street talking to themselves.

When someone has demonstrated they are a danger to themselves or others to the point of being hospitalized, and lost touch with reality, an abundance of caution is needed.

That said the caution level a female psychiatrist takes when it's just them vs they have a big pregnant belly weighing them down is different.

For the person mentioning mouths to feed, there's a difference to being beaten up and not able to work for money, and actually bringing in one of those mouths to feed into the exam room with you to see the violent patient.

Also there comes a point where the risk isn't even the baby dies. After a certain number of weeks resuscitation can mandatory for a premature baby. So whatever damage is done to it, both the child, parents, and siblings may be living with forever.

It's not worth it. Lay low after 22 weeks. If you trade, maybe don't make it a fair trade, take on more than one patient in exchange, take on someone extremely malignant but not violent, like the other doctor's nightmare patients. There's usually other nightmare patients on inpt than just violent psychotic ppl.

Also lol to the person saying you can avoid a kick to the uterus. Not saying this doc would get in a chair to see the patient, but you ever see a pregnant woman struggle to get out of a chair or get up from kneeling?

I'd like to see someone strap a 20 lb backpack to the front of them and see them try to defend it against some kicks. I'd pay money to see it.

 

[Old&InTheWay]

Have you ever received a blow to the abdomen? There are several precautions you can take to ensure you dont get hit in the uterus.

Fun fact: Chuck Norris didn't ask for a body double when he was pregnant and filming Walker Texas Ranger episodes.