Thursday, October 19, 2006

Fully Charged Battery

As Dinah once said early on in the Shrink Rap blog days, "I'm Concerned About Fat Doctor". Yesterday FD wrote a post about an angry, drunk former patient who showed up at her clinic and threatened to kill them all. This is not a good thing. The police responded, tracked the guy down and warned him away. While lots of comments offered support, I was left feeling a bit dissatisfied and disconcerted. Hopefully Angry Drunk will not return to the clinic, but even so it seems to me that he has successfully avoided any consequences for threatening to kill many people. It left me with the question that I'm going to post to the blog, although without a poll this time:

Should you press criminal charges against your patients?

This is a policy question that inpatient units wrangle with on a regular basis. It comes up most often on forensic units but it can also be an issue on general medical wards. When I was in training (back in the Days Of The Giants) our admission agreement, signed by all new admissions, stated that anyone found in possession of contraband (ie drugs) would be discharged. I didn't think too much of it at the time, but years later I thought it interesting that there was no mention of automatic criminal charges. To me that was like telling the patient, "We won't treat you but if you promise to leave quietly we won't call the police." When the stakes are higher and the behavior is more serious, the situation gets trickier. What if your inpatient beats up a nurse? This is dicey---sick people sometimes do sick things, that's why they're in the hospital---but sometimes not-so-sick people do sick things too simply because they're angry.

The decision to charge-or-not-charge is not an easy one. Off the top of my head I don't know of any hospital that has an automatic prosecution policy for assaultive patients. Usually the decision is left to the victim with or without the explicit support of hospital administration. Fortunately in correctional facilities there is a well defined process with consequences for behavior like this. Unfortunately for free society, it can be an uphill battle to pursue charges when the prosecutors themselves are reluctant to take cases involving inpatients.

On the "con" side of the argument (pun intended) there are those who state that prosecuting patients serves to punish people at the very time they are seeking help. Prosecution undermines the safe-for-the-patient atmosphere that is necessary for successful therapy and it further criminalizes the mentally ill. The most extreme anti-prosecution argument I've seen suggested that going to the police was itself a violation of confidentiality.

So there you have it. Let's hear it. And for the record, an assault or threat in my facility could get you 30 days in segregation.


Fat Doctor said...

Well, I do feel conflicted about this. On one hand, this guy has our whole clinic, especially me and my nurse, very freaked out. On the other hand, he's a drug addict with mental illness, and I really don't think locking him up is the answer. On the third hand (?!), part of the reason he is so upset is that his parole officer is gonna find out about the positive cocaine tests in our clinic. So maybe he will be locked up, after all.

My department chair moved quickly to install locks on the doors from the waiting room to the patient care area. The locks were in place within 18 hours of the threat. The poor receptionists up front may get blown away, but the rest of us will have time to run into the "safe room," a locked office within a locked office. That is, we'll be safe if 50 of us can fit in a 7' x 8' room with a desk, filing cabinet and chair.

We'll see. I'm feeling better about the whole thing. If he were gonna do it, he'd have done it by now. I think perhaps he's all bark and no bite.

Dinah said...

I'm all in favor of the safe-for-the-staff policies. If it's a violation of privacy to prosecute someone who beats you up, why isn't it a violation of privacy to file an Emergency Petition (i.e. for non-marylanders-- to send the police after a potentially violent patient to have them brought in for evaluation, from which they may be hospitalized or let go)?

Back to my thoughts on For The Record, since the majority voted in favor of Electronic Records, in our privacy-obsessed HIPAA world, why doesn't anyone care if you're a hospital employee and your own patients (if you treat other docs/nurses/healthcare providers) can access your most personal of information, and if you've found out that your psychiatric patient has done so, is it a violation of privacy to report them for violating your privacy? I actually love this question.

And if your patient is a healthcare professional in the same facility and they beat you up should you press charges and who's record in the Electronic Records does it go into: theirs or yours.??

Dinah said...

Note to Fat Doctor:
and maybe Clink should elaborate, but my guess is that if he's threatening you, ummm, maybe he's violating his probation? And maybe everyone would be a little safer if this guy was....
Sadly reminds me of several stories of ill/intoxicated people who were killed by the police, reminding one that we're not always protecting someone when we think we're protecting them...
Go to town Clink, and why can't we have music like NeoNurseChic????

ClinkShrink said...

Dinah: The charging documents go into the state's attorney's case file. The notice about the incident goes into the patient/health care professional's employee file. Your worker's comp filing and notice about the injury goes into your employee file. Your progress note about your patient's assault on you goes into the patient/health care professional's EMR.

Aack, forget it. The paperwork is too much darn work. Call security, change the locks and go out for a hot fudge sundae.

FD: If he's on parole and has positive urines he will get locked back up eventually. I'd have to disagree on whether locking him up is the answer---if he's this out of control, it is the answer. Especially if he's living with children and/or a girlfriend (just speculating here).

Dinah: We have music on the blog. Remember, you asked for it!

Dinah said...

No sweetheart, I asked for "still crazy after all these years."
This is NOT what I asked for. Plus I like how Carrie's plays automatically.

ClinkShrink said...

I decided to have mercy on our blog readers and not make Mein Teil play automatically---I could change that though if you want :)

OK, have it your way. Paul Simon is up, along with a couple other appropriate mellow songs. And one of mine.

NeoNurseChic said...

Aww I want to comment on this topic...however, I'm drunk with fatigue at the moment. Everything is slightly amusing, and I did just stumble into my bed...after making sure I set the alarms for the morning. (And no, I did not have one single alcoholic beverage today. I had candy corn and gatorade for dinner for Pete's my butt kicked by going back to work today!)

anyhow - all I really wanted to say was that glad you guys like my new music feature. :) Have you scrolled thru all the songs there? I think I have 8 different ones. I thought "How to save a life" was appropriate for many reasons....not just the obvious, although that's part of it, too - especially after a day like today! ;) I started to click on your new music player, but I'm serious when I say that I was half asleep before I heard a note of it and then snapped myself awake as I almost dropped my powerbook off my lap...

Guess that means it's time for bed, and I'll listen to your music tomorrow! Looking forward to it - I like the one..."still crazy after all these years..." Maybe I should add that to my list...noooooo...I do, however, have psychological reasons behind many of the songs on my list. I should blog about that. Tomorrow.


Judy said...

My son works as a security officer at a local hospital. He has a very good relationship with the local police. Sometimes they bring the patients in. Sometimes they take visitors or patients out. It all depends on the situation. Bad form to swing at ANYONE in the ER - staff, patient, or visitor.

Another thing I learned from him. It's apparently not a HIPAA violation to notify the police when obviously intoxicated visitors head for their vehicles.

Dr. A said...

I have to tell you the music caught me off guard. No, not the specific song. Just the addition of music.

I say - Book 'em Danno! I agree that compassion should go a long way. But, if safety is going to be an issue with a particular patient and/or future patients, the law is there to protect us as well, even though people may be reaching out to us in times of need.

Anonymous said...

EEK, This is a very complicated issue. As someone who worked in the field of EMS as a paramedic for thirteen years I must say that I had been threatened many times. Each situation was different and I feel must be considered on a case by case basis. For exampl, the hypoglycemic diabetic who throws punches because he has no clue what he is doing, automatically becomes apologetic when his sugar in leveled. The psychotic who threatens opens another totally different can of worms. I have seen police take brutal measures to protect me and my partner when a threat exists and I didn't always feel good about this. When the patient is turned over to the hospital the dynamics change. It is hard to say whether one should be prosecuted if help is being sought an attempts are being made to remedy the very behavior in question.
However I do have problems with criminals who are deemed innocent by reason of insanity. What comes immediately to mind is the case of Jeffery Dahmer. He was tried and convicted and insanity plea was overruled, but how can someone who did what he did be sane.
I tend to take the opinion of the previous comment. "Bookem Danno" Hanid I love you. abf

Anonymous said...

This reminds me of the debate over Andrea Yates. Mental illness or not, I personally thought she belonged in prison.

Dinah said...

let's not go there

a psychiatrist who learned from veterans said...

What are you going to charge somebody with who scares the bejeebers out of you? Absconding with state power? There is a saying, which occurs in the Spanish language, 'A barking dog doesn't bite.' Since he has a relationship with the clinic and you all have been a friend to man per the previous post, one might assume that he is experiencing something of a regression and is identfying with a (previous) aggressor. A little antipsychotic might be appropriate if he needs help to keep in mind that he might lose the supportive object if he goes to far. While you hide in the safe room, your front secretaries would probably appreciate your having left Wyatt Earp, possibly in an 'are you kidding me blazer and tie' out front with them if it is all that serious. For your mental health, I'd stay away from, say, moving to Russia and treating enemies of friends of the Kremlin.

Steve & Barb said...

It is indeed something one has to decide on a case-by-case basis. I've always favored charges if there is assault... unless it is from someone who doesn't seem to know any better or have control (moderate mental retardation, delirium, dementia, floridly psychotic).

Where drugs or alcohol are a significant factor, "book 'em" is right. Sometimes, legal burdens can be the only way to get someone to realize they have a problem (this sentence reminds me that the English language needs a singular, non-gendered, pronoun... if google and youtube can be verbs, surely we can come up with something better than 'he or she').

Oh, and Stop the Music! I don't like the music either... it plays without asking me... but I seem to be in the minority among my co-bloggers.

Dinah said...

I liked the idea, but I've never gotten the music. Fine with me if Clink stops it.

FooFoo5 said...

As I have mentioned elsewhere, I had to rescue an intern caught between two locked doors with a floridly psychotic man. Sparing you the details, I did manage to get him to the floor and contained until colleagues responded and the police arrived. He had fractured my skull, broken my ribs, spit in my eyes & mouth, and bit me deeply on both forearms. When I got to the trauma unit, I seized twice. I took Combivir prophalactically for 30-days (which made me feel astonishingly sick) and was tested for HIV/HCV for a year. I continue on lamotrigine.

I tried to "book him." The San Diego Police, however, were "too busy" to come to the trauma unit and take a report. I had to pursue them until, finally, after a week, a very uninterested officer "took my statement." I can only presume that the DA was not interested in pursuing the matter, as to this day - two years post fact - the DA has never contacted me. I received a total of $430 from the California Victims Assistance Fund for my hospitality.

The point: while I fully believe that any patient who threatens or is assaultive should have charges filed against them, the decision to prosecute is not yours.

NeoNurseChic said...

Foo - You couldn't have done any sort of civil suit where you, yourself hired an attorney to prosecute that guy? I mean seriously......if someone comes after me and they do that much damage, then you bet I'm going right after their bank account. But then, I don't know how the system works if the guy was already in jail or in a hospital, etc...

I don't remember reading that story, but I'm really sorry to hear that. That's very scary...

I've already mentioned the times when I personally was hit while working in the hospital (really minor - stunned me more than anything) and other times when I've been a little worried by verbal outbursts. I also told a story about a nurse that was all-out attacked in a really brutal way by a drug mom.

Right now, I can't get into the situation, but there is something going on at work that makes me want to bring a can of mace or wear a bullet proof vest to the unit. It hasn't escalated to that by any means, but some of the behaviours and related issues are making me a little fearful. Other families around this particular situation also have voiced concerns to me about how uncomfortable they are. We are all aware of the unpredictability... It does make one nervous... If anyone ever goes after me, then I'm going all the way with it and pressing charges - especially if this particular situation escalates to that, which I really hope it does not.

I understand instances that Roy brings up that include situations when a person could clearly not know what he or she is doing. (I also agree about the need for a singular pronoun that does not include "it"!) However, people who DO know what they are doing - they must be held accountable. People cannot hide behind psychiatric diagnoses as an excuse for certain behaviours - granted this is within reason. In those anticholinergic toxicity reactions that I had, I had absolutely no idea who I was. In the 2nd one, I was wide awake the entire time, but I don't remember any of it until I started coming out of it. What if I had hurt someone? Would I have been held accountable when I didn't even know my own name? I really dont' think that people who are completely dissociated at that moment can really be held accountable, but at the same time, a lot of people will try to use a psychiatric diagnosis as an excuse for unacceptable behavior. That's unacceptable, IMHO!

In the meantime, they ought to pay us more (well..nurses at least!) for being at such high risk day in and day out, don't you think? I can't leave the room of my patients unless another nurse is in there, but there are times when dangerous things do happen. I don't usually think about how I'm risking my life, but I truly believe I shouldn't have to think like that....although there are times when I do have to keep my own safety in the front of my mind in certain situations.

Foo - I also took the combivir - for 30 days after a needlestick at a free clinic in West Philadelphia. The man had been positive for Hep A and B at one point, unknown for Hep C. He'd been HIV negative but his last HIV test had been something like 5 years prior. He refused to retest, so I ended up going on the combivir out of worry. I actually didn't feel sick. Everybody is always telling me how sick they felt on that. I just chalk it up that maybe the fatigue and sick feelings that people get on that is not worse than my normal baseline (isn't that sad?) so maybe that's why I had no side effects from it. It really did absolutely nothing to me. I'm glad for that or I might not have been able to continue taking it for the full month.

I'm glad you're okay, but sorry you have to stay on the lamotrigine. Hope you don't have SE's from that. That's another one that really gave me hardly any side effects, which was nice.

Take care,
Carrie :)