A forty-three-year-old man was admitted to a different hospital in our community. There, he was found to have abdominal pain and fever. A CAT scan of his abdomen showed a mass in the pancreas and he was scheduled for further testing to determine appropriate treatment.
In order to have the test done the next day, his doctor ordered that he not have anything to eat or drink after midnight. When he asked for water, the nurse reminded him the doctor didn’t want him to have any. When further demands for water brought the same results, the patient got mad and signed out of the hospital against medical advice. Rather than leave the premises, he went down to the emergency department and pitched a fit, yelling and throwing furniture around the waiting room.
Police were called. They handcuffed the patient. Rather than take him to jail, however, they took him outside, called an ambulance, filled out a psychiatric commitment form and sent him to our emergency department.
When the patient arrived, he was not confused but was very nasty and uncooperative. When I tried to get him to tell me why he was in the emergency department, he gave me flip, evasive answers and told me to ask the people who took him there. He also demanded water to drink.
After getting very little from him that would help me understand what was going on, I called the other hospital and was filled in on the events prior to his arrival at our emergency department.
What was I to do with him? Since he was on a psychiatric hold, I couldn’t discharge him. I either needed to do further medical testing or send him straight to the psychiatric emergency department.
While I was struggling with my decision, he went crazy. At first, he only thrashed around on the bed. Because of the violent behavior he had displayed at the other hospital and toward the paramedics, he had been placed in two-point leather restraints: a thick leather band around one wrist and another around the opposite ankle, both secured to the bed. These kept him on the bed but he still had two limbs free.
As the nurse and I tried to calm him and get him to relax, he started hollering for a drink of water then started violently rocking the gurney back and forth. Each time he would throw his weight form one side to the other, two wheels of the gurney would lift a little farther off the floor. With each rock, his momentum took him a little closer to tipping over. All this time, he was hollering, “I want a drink of water!”
When the nurse and I intervened to keep the gurney from tipping over, the patient spit straight in the nurse’s face. Then, he tried to hit and kick us with his free arm and leg.
This turned what had been a measured, calm response to his obnoxious behavior into a full take down. I was standing at the top of the gurney by his head. To keep him from spitting on the nurse again, I grabbed his sweaty, greasy head and pushed his face into the mattress. I held it there as others grabbed his free arm and leg and placed them into leather restraints as well. A sheet was placed across his chest, under his armpits and was tied to the top of the gurney. A specially designed spit mask was placed over his head, allowing him to breath but forcing him to keep his oral secretions to himself.
At this point, I would have just washed my hands of him – literally and figuratively – and sent him to psych. There was just one little problem. He had a temperature of 103 degrees! He obviously needed more medical evaluation.
After a few minutes, the patient tired of his thrashings and settled down. He even started acting almost like a normal person. He relaxed and agreed not to attack anyone. Three of his five restraints were removed and he was given a drink of water. Blood and urine tests were done and I made arrangements for him to be admitted to the hospital to figure out why he had a pancreatic mass and a fever. I am sure they will figure out what is wrong with his abdomen but I wonder if they will figure out what was wrong with his head.
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