From Nice to Nasty

The psychiatric emergency department at our hospital notified us they were sending a patient with chest pain. Everyone who recognized her name knew we were in for a challenge.

This middle-aged woman had been to our emergency department many times and was always difficult to deal with. She has serious medical problems but also serious psychiatric problems. This makes treating her especially challenging.

When she arrived, I went into the room and politely introduced myself, as is my habit. I asked her about her chest pain, the pains in her legs and her recent falls. She had a pleasant demeanor and looked comfortable as she described pain in her legs that made her unable to walk. Her physical examination showed no indication of serious injury.

I explained the tests I recommended to make sure she was not having a heart attack or blood clots in her lungs: electrocardiogram, chest x-ray and blood tests. She agreed. I then told her I was not going to be giving her any narcotics.

“That’s fine. I’m not here for drugs. I’m not a drug addict,” she said in a sweet voice.

I was glad she agreed with me and told her the nurse would be right in to get the tests started. I began to walk out of the room.

“Just a minute, doctor. What are you going to do for my pain?” she asked.

I reassured her we would give her all the medications we usually give someone who might be having a heart attack or blood clots but we would not be giving her any narcotics. I turned again and walked out of the room.

Then she went off. She started to scream at me at the top of her voice using every foul word you could think of.  At the same time, she grabbed anything she could get a hold of and yanked on it. First, she ripped the phone cord out of the wall and threw the phone on the floor. She jerked the monitor cables out of the monitor and threw them on the floor.

We responded to the noise of her screams and the sound of the phone hitting the floor and prevented her from pulling the courtesy curtains out of the ceiling. After we moved things out of her reach, she pulled off all of her clothes and threw them on the floor. Eventually, unable to get a hold of anything else, she started throwing her immense weight back and forth in the gurney, trying to tip it over. Since she was so extremely obese and was rocking so violently, she almost went over but was prevented from doing so by staff.

So there she was, an extremely large woman, butt naked, rocking violently, trying to tip her gurney over and screaming obscenities at the top of her lungs.

Her insults were mostly directed at me. She accused me of being a bigot and not giving her pain medicine because she was black. She yelled she was being treated like a slave on the plantation. She shouted if she were white or Hispanic or Asian, we would be giving her pain medicine. Her screams included the foulest swearing she could come up with and filled the whole emergency department, upsetting other patients and visitors. Staff had a hard time taking care of other patients and doing necessary duties like talking on the phone because her obscenity-laced screams were so distracting.

Extreme conditions require extreme responses. When people are violent and put themselves and staff at risk of physical injury, something has to be done to prevent this. In such unusual circumstances, we may need to put heavy leather straps around both ankles and both wrists then tie the patient down to the gurney. This was such an occasion. It took four security officers and several other staff members to get her into four point leather restraints. She refused all medical care and, even tied down, was able to keep staff from covering her naked body. I wanted to sedate her, but she said she was allergic to each sedative I proposed. All we could do was keep her in the middle of the room so she couldn’t grab anything. She screamed non-stop for the half hour it took us to make arrangements for her to go back to emergency psychiatry.

Once arrangements were made, she rolled out the door. I had assumed security would have at least tied a sheet over her but their efforts to do so had been unsuccessful. Her enormous thighs and gut covered her private parts, but her pendulous breasts were fully exposed. She left, still screaming at the top her lungs, “No pain meds for fuckin’ niggers,” over and over again.