** Names and details have been changed to protect patient confidentiality, privacy, and dignity **
What drives a patient to violence and agitation? Are there any factors, or "warning signs" to predict an impending explosion? Textbooks list "prior behavior and agitation" as risk factors, but I believe iatrogenic factors may be even more significant. Consider the following situation:
Rodney was admitted to our psych ward for detox from cocaine use. He was a "frequent flier", having many prior admissions, but otherwise healthy. My resident and I met with Rodney several days after his admission. He appeared anxious, and voiced a need for discharge in 2 days in order to appropriate his check before his roommate did. The resident agreed that discharge was plausible by that time, and the interview ended amicably.
The next day, Rodney again voiced his concerns about leaving, because staff had not given him any information regarding discharge. He reported that he was "feeling better", and his withdrawal symptoms had subsided. The resident stated again that discharge was scheduled. Later that day, our attending physician interviewed Rodney. When asked if he had any suicidal ideations, Rodney responded that he would be "a dead man" if he didn't get out by the time scheduled for discharge, because he would lose his check and thus, his housing. The attending took his remark as a suicidal threat, and decided to commit him involuntarily.
During pre-rounds the next morning, I was asked by a nurse to aid in a "show of force" for a "Code Grey". Rodney was pacing the floors, glaring at the terrified staff who had barricaded themselves behind the nursing station. He was cursing, yelling, and kicking around a plastic chair, accusing the staff of lying to him. More and more staff began to gather, until the mass of 20+ people began to corner him. The nurses prepared a needle of Haldol and approached him. Three of the larger male staff members grabbed his arms, and escorted him to the seclusion room.
The following day, Rodney seemed calm and apathetic. I talked to him alone, and passed along some numbers for inpatient rehab facilities. He relayed that since yesterday, he had been ignored, scolded and forced to take medication, but no one had offered to help him with his problem. At the court appearance, the resident testified that he had been non-compliant with medications, and had voiced suicidal and homicidal threats. This resident had never interacted with Rodney; he had only read medical records written by staff and social workers. Rodney was not receiving any medication ― how could he be non-compliant? The judge decided that Rodney would be committed for an additional 2 weeks. Rodney cursed under his breath as he was excused from the courtroom.
Like the Bob Dylan epic "Who Killed Davey Moore", one must ask where the responsibility lies in a situation like this. Was it the patient, who has a limited repertoire to express himself besides acting out and becoming hostile? Was it the resident, who lied to the patient, and dismissed his concerns? Was it the attending, who possibly misinterpreted a remark and missed the opportunity to educate the patient? Was it the staff, who escalated a situation instead of diminishing it? In medical school, we are taught to value patient concerns, and delve into underlying issues that may affect patient behavior and overall health. Rodney's anger seemed to be triggered by his worry about his finances; instead of helping him with this issue, we committed him and further removed him from a solution to his problem.
Did we fail this patient? Is this incident just an insignificant speed bump in Rodney's life, destined to recur during his subsequent hospitalizations until he succumbs to his addiction? Are we saving him from himself? Would Rodney have reacted differently if we handled the situation in a calmer, more straightforward manner? I suppose we have to wait until the next Code Grey.
