It's a Very Thin Line

Between what? Well in this case between apathy and cruelty.

I had a rough day at work yesterday, being on the neurology unit is always challenging. Many of the patients have had some type of brain injury, either from head trauma, stroke, years of alcohol and drug abuse, dementia, any number of causes. As a result of this, their behavior is affected, and as a nurse, it's part of my job in caring for these patients to take that into account, and still treat them with dignity and compassion.

One of the patients I had this weekend was a 30 year old man. He was profoundly mentally retarded, severely autistic and partially blind. Mentally his age was about 2, and he had a sitter in the room with him for his safety. The sitter he had until 3 pm was very good with him, but the patient doesn't respond well to men, and around 1 pm, when his sitter was giving him his bedvbath, the patient became aggressive. I went in to help him, and he got hold of my arms, dug his nails in and drew blood.

Not the first time this has happened to me, so after we got him washed up, I scrubbed off my arms, put on some antibiotic ointment and band aids, and continued on with my day.

But the patient continued to be aggressive towards the sitter, and finally we had no choice but to restrain him.

Now, there are VERY specific rules regarding the use of restraints in the hospital. You have to use the lowest level of restraint, restraints have to be released every 2 hours, other interventions have to be tried first, the restraints have to be tied with a slip knot so they can be released with one hand, ect, ect. All of these rules were followed to the letter while the daytime sitter was there.

Then at 3, a new sitter came on. Again, a male, a CNA I've worked with before. He's a decent CNA if he knows the nurse is on top of him, but he'll slack off at the first opportunity, and I know this about him. So I gave him report on the patient, he went in to sit, and I started passing my meds.

After about an hour, I heard yelling coming from the patients room, and I went in to see what was going on.

The patient was laying in the bed, half of his vest restraint was up around his neck, and he had 2 restraints on each wrist, both of which were so tight that his hands were mottled and cold. He was twisting and yelling, and the CNA was sitting in the chair with the TV turned up full blast and ignoring him.

I asked WHY he had 2 restraints on each wrist, and the aide said he was getting free of the first ones, so he put a second set on. I asked if he had noticed that the vest was around the patients neck, and he said "I'm not getting close enough for him to hit me, he can stay like he is"

So, while this asshole stood there and watched me, I started re-adjusting the restraints. Every one of them had been double knotted, again, a HUGE no no. The CNA again said something about not wanting the patient to hit him when I asked why he was tied like that. I got everything squared away, made sure the patient was OK, stood there stroking his cheek and singing to him to calm him down, and then went and called the supervisor and told her what had happened and requested a female sitter for the patient.

A female sitter came up, and she was wonderful with him. She was kind, gentle, and compassionate. At one point we were both in the room and she and I got him singing "You Are My Sunshine". He was calm for the rest of the day, and we were able to leave him in just the vest and take the restraints off his hands.

I know this is a long intro into what I wanted to say. The thing is, when I looked at this patient, even though he's 30, I saw him as a child, because mentally, that's what he is. I also saw, that at a lower level of functioning, and without the early intervention, that could easily have been my son in that bed, so that's how I treated him. The sitter that came in at 3 saw something completely different. All he saw was someone who could potentially hurt him, not a sick, confused, disoriented human being. He classified him as a potential threat, and so any potential compassion he might have had went right out the window. He was there for a paycheck, he didn't give a crap about the patient, and so he was willing to jeopardize the safety of someone who was completely helpless to protect himself.

The thing is, when dealing with patients who are confused, for WHATEVER reason, it's our responsibility as caregivers to maintain their safety. And the key to this is all in how you approach them. With this patient, speaking in a soft gentle voice, using a calm tone, treating him in a way that was appropriate to his MENTAL age, was all it really took to calm him down.

Regardless of how confused or how developmentally disabled someone might be, they can still sense when someone genuinely cares, and when they don't. And no matter how diminished their capacity might be, they will respond accordingly. I'm not saying that they'll turn into sweet little kittens, I've had more than my share of bruises from confused patient to ever say that! But, what I AM saying is that ALL behavior is communication in some form, and when a confused or developmentally disabled patient acts out, it's because they're trying to communicate something. Pain, hunger, fear, having to use the toilet, being too cold or too hot, even just wanting some attention. They're trying to tell us something, and it's our responsibility to find out what that something is, rather than just deciding they're crazy, or a threat to our safety.

I hate like hell that this poor patient had to spend an hour with someone who clearly couldn't have cared less about him. I know the patient won't remember , but I will.