May 21, 2016

My Threshold is Coming Down

I remember a call from a couple of years ago where I blasted a 12-year-old female with Haldol. At the time, it felt wrong. In hindsight, I should have given it sooner.

My partner and I went to a junior high school for an “Unknown Medical.” I arrived to find the school security guard with a story: A student walked past one of the security guards smelling of weed, so the guard stopped her and attempted to search the kid’s backpack. The student was resistant to that plan, so she was taken down. But she was, you know, taken down all gentle-like. So they didn’t think she was hurt. But they would like me to “just check her out.”*

The sixth grader was covered in the smell of marijuana like Pigpen is covered in dirt in the Peanuts comics. She was making my eyes water and my mouth dry out, just being near her. Her secondary exam and vitals were fine. The school had attempted to contact her parent or guardian listed in her records, but there was no answer. The funny part of the call was when the security guards were surprised that I was going to transport the student.

"Wait. What? You need to transport her? She isn't hurt!" (Then why did you call me?!?)

Just check her out, my ass. A minor, without parental contact, in a still-ongoing cloud of marijuana, and with a report of trauma (however minor) is going to the hospital. I don’t know what they expected to happen. Anyway, we went to the ambulance and that’s where the brawl started.

See, the kid agreed with the school security guard, at least in this case. She did not want to go to the hospital. Just getting her in the side door of the ambulance was like getting a cat into a bath. All four limbs locked with hands and feet on the door. We’d break down one limb, only to find another locked out. Eventually we got her onto the bed, put the seatbelts in place, and restrained her wrists with Velcro restraints on the pram.

One EMS secret I have learned in my time on the street is that there is no patient more impossible to restrain than an enraged 13-year-old female. The only way to make it worse is to find an enraged, drunk, 13-year-old female. Twelve is close enough. No f**ks are given, no joints are undoubled, no pain is felt, no logic can reach them, and no restraint shall hold them. I have a theory – the problem is that medics don’t want to hurt 13-year-old girls. If it were a drunk 22-year-old male, dude would be restrained. Thirteen year olds present a problem. And they are angry, flexible, and surprisingly strong. Restraints pose no problem.
Maybe I could transport them safely in this 19th Century mess...
Eventually, I had to administer some IM haloperidol.

What kind of jerk gives chemical restraint to a thirteen-year-old girl? Me, that’s who. In hindsight, I spent too much time and energy negotiating, begging, and cajoling the patient into holding still and submitting herself to transport.

I could have maintained her to the hospital on the pram with physical work and physical restraints. I know how to cowboy up and get someone to the hospital. But fighting and escaping in a moving vehicle is dangerous. Dangerous and exhausting.

I need to lower my threshold for chemical sedation of angry/violent/confused patients. I am a reasonable person. If your behavior is such that it is pissing me off, your behavior is outlandish. You should be sedated. In addition, it is dangerous to fight and escape in a moving vehicle. Flight nurses and medics friggin' paralyze people to avoid combativeness in their moving vehicle. And here I am, counting on Velcro or kerlix restraints, negotiation, and physical holds.

It is dumb. It is too much work. It leads to people being inadvertently hurt. It leads to people escaping. It leads to medics and EMTs being hurt. It leads to a loss of dignity for people who need our help. 

So I am lowering my threshold for administering chemical restraint.

I’m not saying that everyone needs Ketamine. Appropriate force escalation and medication choices are still important. Physical restraints and negotiation are fine in some cases. I find that Haldol works fine on psychiatric- and alcohol-related combativeness. Versed works fine on sympathomimetic combativeness. Ketamine is fine for excited delirium.

But I think I should use each of them more often.

As an aside, this is a psychiatric hospital with patients restrained with wet blankets. Wet. Blankets.

*Future blog post rant about “just check her out” to be published soon…

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