There was an interesting situation at work recently. I'm gonna keep it vague for privacy, but basically the husband of a patient threatened to shoot hospital employees after he perceived they were ignoring his wife's situation. Which, looking at the case, people were like, yeah, this patient was in prolonged discomfort and had delayed care over multiple shifts due to factors that weren't malicious but were careless. Basically, the task that would have helped this patient was classic "third thing on your to do list." It had to be done, but it didn't need to be done urgently. The impact of not doing this task likely wouldn't be felt on your shift. The work of doing this task would require the coordination of a couple different people. Very easy to just keep pushing it back, and because it wasn't an emergency (until it was), it just kept being pushed back.
You could do a root-cause analysis of the whole thing (and we have) to really break down what happened, but ultimately the effect was the same as if the neglect had been malicious. I'm sympathetic to the husband, as were a lot of people in this situation, because, yes, hospital staff dropped the ball in a way that meant the patient was in unnecessary pain and discomfort with delay of care for over a day, despite multiple requests from patient and family to address the situation. The husband reacted emotionally to a situation where he'd felt helpless and ignored. Institutional neglect ground away at him until he verbally snapped.
And the way he snapped was to tell staff, "I'm going to come back with a gun and shoot you all for what you've done." Which is about as explicit a threat as you can get. Does he get to keep visiting the hospital after that? How do we be fair to him, to the patient, and to the staff? He probably didn't mean it. Right? But how do you ignore a statement like that? If he does come back and commit a shooting, how will you justify ignoring his threat? But does one sentence said at an emotional breaking point define him? How much more traumatic are we going to make this hospital stay?
A couple years back, I worked on a floor a few hours after a patient had been escorted away for inappropriate behavior--by the way, you can't imagine how inappropriate the behavior has to be for us to do that. I have never seen another case like this. That patient said he was going to come back with a gun and shoot nurses that he identified by name. This didn't come to pass. Whether that was because the patient didn't mean it or changed his mind or was prevented or simply was not mentally coordinated enough to follow through on the plan, I don't know. I do know that shift fucking sucked. I remember the charge nurse telling me that it wasn't our jobs to die for our patients. If there was shooting, she told me to run.
There was another situation recently involving a patient in restraints. I despise restraints. I think the closest legitimate use for them is in ICUs for stopping delirious patients from ripping out their ventilators, and that should still be a last resort. I discontinue restraints whenever I inherit them, and I am very good at fixing problems before restraint seem like the only solution. Having said that, I work in a hospital that uses restraints, and so I am complicit in their use. Recently I walked into a situation involving restraints with zero context for what was happening, just that there was a security situation involving a patient who had been deemed for some reason to lack capacity to make medical decisions. They were on a court hold and a surrogate med override, which means they cannot refuse certain medications. The whole situation was horrible, and I've spent the days since it happened thinking about every way I personally failed that patient and what to do different next time.
At one point, the patient called one of the nurses a bitch, and the nurse said, "hey cmon, that's not nice," and the patient replied, "if you were in hell, would you call the devil a nice name?" And yeah! Fair! It is insane to expect people who are actively being denied their autonomy to be polite to us as we do it.
Then there was another patient on the behavioral health floor who got put in seclusion. It's so frustrating, by the way, that staff put them in seclusion because it would have been extremely easy to avoid escalating the situation to the point that it got to. But the situation did escalate, and by the time the patient was locked in a seclusion room, they were shouting slurs and kicking the walls. Other patients were scared of the patient even when they were calm because the patient talked endlessly about guns, poisons, bombs, etc. When I checked in with the patient in the seclusion room, they called me a cog in a fascist machine just following orders. And I was like, yeah. Fair.
Another patient: one night when I was charge nurse, I replied to a security situation where a patient trapped a staff member in the room and tried to choke her. The staff member escaped unharmed. She told me later that the patient had been verbally aggressive to her all day, but she hadn't told anyone because she knew he was having a bad day, she didn't want to get him in trouble, and she didn't think anything was actually going to happen. She said, "Patients are mean all the time."
And another case: I had a different patient with the ultimate combination of factors for violent agitation--confused, needed a translator, was hard of hearing so the translator was of little use, in pain, feverish, scared, withdrawing from alcohol, hadn't slept in two days, separated from his caregiver who had also just been hospitalized--the whole shebang. He shouted at us that we were human trafficking him and could not be reoriented to where he actually was or that he was sick. I tried all my usual methods of deescalation, which I am typically very good at. I could not get him to calm down. He had a hospital bed where the headboard pulls out so you can use it as a brace during compressions. He ripped that out and threw it at the window, trying to shatter the glass. At that point, with the permission of his medical surrogate and with help from security, I forcibly gave him IV medication for agitation and withdrawal. He slept all night with a sitter at his bedside to monitor him. I pondered when medication passed over the line into chemical restraint, but I stand by the decisions I made that shift.
Last one: I had a different patient who was dying who had a child with a warrant out for arrest. We didn't know for what, and no one investigated further because no one wanted to find out anything that might prevent this person from visiting his dying parent. Obviously, "warrant for arrest" could mean literally anything, although it was significant enough that security was aware of the situation and wanted us aware as well, but I was struck by how proactively the staff protected his visitation rights and extended him grace. Everyone was very aware of how easily the wrong word could start a process that would result in a parent and child losing the chance to say goodbye to each other.
In the case of the husband who threatened a mass shooting, you'd be surprised how many of the staff advocated for him to keep all visitation rights. After all, the patient wanted him there.
Violence--verbal, physical, active, passive, institutional, direct, inadvertent, malicious--pervades the hospital. It begets itself. You provoke people into violence, and then use that violence to justify why you must do actions that further provoke them. And also people are not helpless victims of circumstance, mindlessly reacting to whatever is the most noxious stimuli. But also we aren't not that. You have to interrupt the cycle somewhere. I think grace is one of the most powerful things we can give each other. I also think people own guns. Institutions have enormous overt and covert power that can feel impossible to resist, and they are made up of people with necks you can wring, and those people are the agents of that unstoppable power, and those people don't have unlimited agency and make choices every day about how and when to exercise it. We'll never solve this. You literally have to think about it forever, each and every time, and honor each success and failure by learning something new for the next inevitable moral dilemma that'll be along any minute now and is probably already here.
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