07 February 2006

Scary Dude

I am generally pretty conscious of security/safety issues in the ED. I work in a place which is pretty high acuity: we have a strong security presence in the ED, and though I have met many a person who was creepy and unsettling, I have never been attacked and never truly been in real fear for my personal safety.

Yesterday, I was working at a small rural place we also staff. There is no security except 911, but we rarely need it and with the lower acuity, security is less in the forefront of my mind. In the afternoon, a homeless guy showed up at triage and told the nurse that he had HIV and was really sick. He was pretty vague about the specifics and only wanted to talk to the doctor.


I went into a small exam room with him, and he indicated that it was kind of sensitive, and gestured to me to close the door, for privacy, which I did without really thinking. He stood near the door, and I leaned casually against the gurney. I immediately realized that I had made a serious, serious error. This poor fellow's brain was not working right at all. He was just a little jumpy, moved a little too abruptly, and stared with a manic ferocity at an invisible point about six inches to the left of my head while he spoke to me with an intense voice which gradually got louder and louder. He had many delusions about HIV -- his ex-wife had infected him with thought powers, he was infecting people on the street by looking at them, he could see the virus on his clothes, and he wanted to be sealed up in an airproof chamber to keep him from killing again.

This last bit delivered in a shout.

So, I reflected, I am in a very small closed room with a deranged, agitiated nutcase between me and the door. I slowly put down the chart and quietly assumed a "ready" stance, considering which blocks and joint locks would work best in the space available. I was a little bit bigger than the patient, which I hoped would help. And I started talking. I spent a while calming him down. It was really hard to redirect him from these delusions, but he had just enough insight to realize that they were an aspect of his mental illness, and finally, I asked him if he would be willing to come in to the hospital for treatment, and he agreed.

Greatly relieved, I asked him if he would pee in a cup for a drug test, and he agreed to this as well. I turned to look in the cabinet to see if we had cups, and a bolt of terror went through me:

Ohmygod, I just turned my back on him!

I spun around, but he was being good just then. Practically shaking with the adrenaline, I gave him the cup and slipped out the door.

An anticlimactic ending to the story, I'll admit. Or at least to that bit. Later, the guy did escalate, barricaded himself in the room, and the police were summoned to restore order. They discovered he had outstanding warrants and he left in their custody, with a directive for a psych eval in jail. And I went in to see the next patient with abdominal pain.

My job is never boring, but fortunately, rarely is it exciting in quite this manner. And I am going to be a lot more careful about closing the door in the future.


  1. Hoooooo boy!

    I imagine that was as scary as you described.

  2. If the Dumb Guy Award is still going on, I believe you, sir, are in the running for it!

  3. Yikes. Well, after your initial mistake, sounds like you handled it pretty well.

    My job is really unlikely to be interesting in this way. I like my job.

  4. I was sort of anticipating that part of the denouement would be that he'd thrown the cup and then pee'd on you. But I guess that occupational hazzard is mostly mine...

  5. I was an RA for two years as an undergrad and we were warned constantly during training to never, ever let ourselves get cut-off from the exit to a room we were "busting". Though I never much enjoyed the job, I did become quite good at deescalating situations that could easily have gotten out of hand. And I'm glad to hear that, even in respectable professions, that hard earned skill will come in handy.


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