Disclosure: This is a reflective piece on the manner in which a pediatric mental health crisis is being handled by two different health systems in two parts of the world. The statements written here are my own personal opinions, and not reflective of the hospitals that have employed me. Mental health is a complex subject and this reflection is only a pin point of information on the topic. Patient details have been changed to maintain patient privacy.
The Patient, A Child
The ambulance phone rings alerting me of an incoming patient: a teenager who is refusing care, and will be arriving in police custody. The patient has had increase aggressive behavior the last two days leading to assaulting multiple family members today. He has behavioral disorders, and possibly undiagnosed mental health issues.
The patient arrives handcuffed and is brought to a bed for evaluation. He refuses to have his vital signs check, and hurls his body towards anyone that gets close. The police are blocking the door after his third attempt to bolt out. I attempt to reason with him, talking in a calm steady voice. “We want to help you and keep you safe. I need to check your blood pressure.” But as I get close, he tries to bite me. He glares into my eyes as he gathers his spit in his mouth, preparing to send it my way. I take a step back, a safety stance, but with space, he starts banging his head against his knees. It doesn’t provide enough harm, and he moves towards the head rail.
I stop a moment and try to imagine what it is to be this child. You are out of control. You do not know how to gain control of your body again. You have never been given the tools to cope with big emotions. You are mad at yourself for hurting your family. You are unable to go home.
Is home a safe place? The police are the ones who took you away. Can you Trust them? No one is advocating for you. Everyone talks about you as though you are not there. What adult has ever helped you out?
As a nurse, I am blinded to his home environment. I only get a glimpse of it from the police report. But one thing is clear, his home life is unpredictable and unstable.
One of the hardest parts of my job has been placing children in four-point restraints, the strapping down of each of their limbs to prevent violent behavior. I will never get used to it, nor should I. Prior to placing a patient in restraints, whether child or adult, I do attempt to deescalate the situation, verbally and environmentally.
In the United States
This happened often during my years working in the United States; this patient, this situation, a familiar one. Back home the patient would have been strapped down soon after arrival. The idea behind restraints is to protect the patient and the staff from harm. The patient is then medicated with an appropriate sedative via an intramuscular injection. Only after the patient is sedated are the four-point restraints removed. Usually, we would remove the restraints within an hour, but during that time, we complete the blood work, including an alcohol level and drug test. The patient is continuously monitored one to one, one patient to one staff member.
Once the patient is medically cleared, a consultation by a social worker is started with a final disposition to either a mental health facility, or back home with community support. This process can take as little as three hours, or as long as three weeks, depending the complexity of the case. We always keep the threat of restraints available in case the patient attempts to harm staff, or themselves. There are times I remember where a patient would be restrained three or four times over a 24-hour period.
In England
Now, working in England, I find the use of four-point restraints extremely rare. After six months here, I have yet to see it done. Instead, I find the practice is to guard ourselves against the patient. If restraining the patient is required, security personnel apply the restraints. It is so rare used that nurses are not trained in restraints. You are not even allowed to restrain a toddler with a blanket hold for suturing.
On a side note, one of the most magical things I have seen in A&E (Accident and Emergency, the British equivalent to the American ER) is a three-year-old with a deep laceration being sutured while standing with only the use of topical analgesia (LET cream) and distraction.
It was only after six months here in England I faced my first pediatric patient in a full-blown mental health crisis. When the police brought him in, handcuffed, I could not use my American training of putting him in restraints, or even hold him down to protect myself. I had to maintain a safe distance, and gently use the deescalating techniques I had learned through my years of nursing.
None of them worked. He was attempting to jump off the hospital bed, hitting his head against his knee, and trying to bite me, and the police. He yelled, “Don’t touch me!” And “Let me go. I want to go home.” Through short clear statements, we attempted to explain to him that we wanted to help him, that we wanted to keep him safe. But by this time, his rational thought process was gone. He was in fight, or flight mode. We removed the handcuffs in an attempt to provide comfort, and present the A&E as a safe place, but it only allowed him the freedom to swing his arms more fiercely.
Holding him down for a moment, we managed to administer two intramuscular injections of a benzodiazepine, Rapid tranquillization, since he was placing himself and others at risk, per policy. As the medication worked to slow down the surge of neurotransmitters, he became limber and stood like an overcooked noodle. He still refused to sit on the bed. The banging against the wall continued, but now played out in slow motion, allowing me to place my hand, and then a pillow, between his head and the wall.
Two hours after his arrival, I found myself in a sort of dance with him. I stood nearby, my arms in an arc, guarding his every move, ready to catch him if he fell. I spent another hour sidestepping and monitoring his every move, never touching him, or holding him down. Finally, tired, he sat on the floor, still unwilling to fully let his guard down. There, in a closed-off hallway, still sitting, he fell asleep. I let him sleep an hour, and when I gently woke him up; I could calmly move him onto a bed. Still guarded, he fell back asleep sitting up on the bed. I gently nudged him into a prone position once he was sound asleep. No blood tests were done. He was transferred to the pediatric ward with a designated mental health nurse. After the patient would wake up, he would get a full mental health evaluation by a designated mental health provider, all to be done within a day.
After so many years of putting children and adults in physical restraints, strapped down to a bed, and having to scratch their nose for them, I am glad to know I can take a break from this for now. The comfort for me lies knowing that, even though this patient will have trauma from this event, being tied down to bed will not be one of them. And even though it required me to “dance” with him for over four hours, applying chemical restraints with intramuscular injections, it was physically harder, but emotionally, much lighter – probably, I think, for both of us.
My job is so easy
I don’t know it involves cutting out a lot of little pieces of cardboard and gluing them back together, detailed meticulous work…not sure I can do it.
As the parent of a child that has been restrained in the ER, I appreciate the differences in how this situation was handled in the UK. A mental health crisis is scary enough without being restrained!
Shawna I completely agree. We need to take new look at the way mental health especially with children is handle in the USA. One of my goals coming to the UK was to learn new ways of doing things. I plan take all I have learned and hopefully apply it to my nursing practice and maybe make some change??