My father, a good clinician, would tell me, “Once you get out of the lion’s den, don’t go back for your hat.” In other words, identify what you can and can’t change, and when faced with difficult challenges, act within your control and don’t repeat a mistake. In this article, I have figuratively returned to the lion’s den.
My psychiatric emergency department (ED) engaged in intensive and continuous training, attention to unusual cases, and critical incident debriefing and dress rehearsal. This tested strategy fostered my team’s unshakeable positive mindset and implementation of helpful and compassionate patient care. Even with the most enraged, confusing, and violent patients, these approaches minimized patient and staff assaults. “Foreign” language here was at a premium. Often telegraphic and sparse, intricacies of psychoticism, personalized jargon (neologisms), idiosyncratic meaning, and illogical language demanded timely and critical analysis of content and course.
You may be familiar with these patients and the associated praecox experience. The ancient Papez emotional circuit and dorsal longitudinal fasciculus of Schütz, a hypothalamic autonomic discharge pathway, will scream within you, demanding an answer to this infinite fight or flight cry. The flesh will crawl (cutis anserinus, a.k.a. goose bumps) up the nape of your neck.
I present some lessons learned from two extraordinary cases (composited for anonymity). The first represents the absence of psychological health, and the second the presence of acute psychiatric distress. In each case, the value of early rapport de-escalated further explosive behavior. In the words of Louis Pasteur, “chance only favors the prepared mind,” or put another way, “the time to prepare for psychiatric emergencies is ahead of time.”
The Combat Cutter
From the ED, I was called to an open psych unit.
The attending psychiatrist informed me of his discomfort with (and fear of) a young man — a self-declared combat veteran — storming group therapy and demanding a tranquilizer. By the time I arrived, the disruptor had departed the hospital. Security had been called but had not yet arrived.
Suddenly, a bandana-headed young man announced his presence in the day room with agitated muscular power and a hunting knife. His bare chest was covered in blood from coarse cutting, deep lacerations.
His speech was pressured. He was conscious and not grossly psychotic. His eyes were wide without evidence of eye movement abnormality.
I remained upright and walked confidently toward him. I held my open hands away from my sides and in front. I asked him firmly to walk with me from the crowded area where his behavior had escalated to the unobstructed open hallway behind me.
Security personnel maintained a distance with my nonverbal reassurance. I asked for his headscarf and patted the wounds. “This will remain peaceful. Please give me your knife.”
“You really want my knife?” he said.
“Yes. As your doctor, I am going to help you with some medicine. I want your answer in the next 10 seconds.”
“OK. I’ll do what you say.”
I asked the unit nurse for a syringe filled with “vitamin T.” The patient handed the knife to me butt first. One minute and 75mg of intramuscular chlorpromazine (Thorazine) later, the patient, with my assistance, slumped to the floor.
The “Priest” Slayer
The “priest” had been slayed, a grizzly, bloody sacrifice. The suspect was now apprehended and was in the ED. He was an enormous and disheveled man, still unwashed with splattered crime scene matter. He miniaturized the treatment setting. (In fact, the local Catholic priest had not been killed. Rather, the patient believed his biologic father had become a pretender or imposter while the “real Father” was somewhere else — Capgras delusion).
The patient, unfamiliar to me, had a revolving door history. He had received antipsychotic medications, including injectables. “The voices came from a devil head. It spat blood and told me to stab the ‘father’ to death. Spat…stab…spat…stab. That is what I did.” Then, he opened his mouth wide to laugh.
His compelling and convincing murderous auditory commands, repeated clanging rhyme associations, weird word sounds, and incongruent emotional affect were strong.
The patient’s next question was loud and conceivably placed me between equally dangerous extremes: “Dr. Copelan, what is your religion?
I slowed down. This was not a commonly asked question, but a crucial part of our conversation. The falseness of his unshakeable personal religious delusion had already cost one life. I would not over-spiritualize this encounter by saying something perilous. My brain needed lead time. I required an immediate trusted space. I calmly started my sentence. “Mr. J. I am a Jew” (and I am).
I paused. I knew that if he remained silent he was listening to the voices in his head. I didn’t interrupt the moment. I genuinely wanted to hear what he had to say. “That’s good, Dr. Copelan.”
I provided a simple “Yes.” I focused on him, acknowledged him, and navigated quickly through his disordered thinking. I had earned the right, and patient’s verbal treatment consent, to direct a course of medical action, including critical tranquilization.
- Heightened self and situational alertness, helpfulness, confidence, and appearing in charge of your actions are the ultimate keys to de-escalating unusual mental health and social encounters.
- The 10 second rule and the announcement that you do not fear the patient (no fear appeal) are calculatingly unambiguous, security setting limits to which obviously dangerous patients often, but not always, fortuitously respond.
- Patients’ behavior is a form of communication. Train to respond safely. They cannot fight and talk at the same time. Physical response, takedown, and physical and/or chemical restraints, although restrictive, represent safe de-escalation when indicated and implemented safely.
- ED psychiatrists are a vanishing resource in training and practice. Yet, violent patients and psychiatric cases constitute a growing proportion of the ED workload. Hospitals should establish teaching guidelines for standardized and complex ED psychiatric care from hardened practitioners willing to return to “the den.”
- ED and hospital organizations must identify, promote, and reflect positive violence reduction change indicators, such as employers who are engaged, employees who are safe and satisfied, and patients and families who are protected.
- As threatening as these violence phenotypes may be, acute mental disorder does not preclude a person’s competence to provide informed consent for acute medical treatment. This decision rests in part on the patient’s ability to refrain from further violent behavior, meaningfully relate with examiner, and retain understanding of recommended (immediate) treatment.
Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry. He is a reviewer for Academic Psychiatry and founder of eMed International, an originator and distributor of violence assessments. One of Copelan’s four sons is an EMT/paramedic in Colorado Springs, and his daughter is a Denver-based physician assistant.