Throwaway05
2d ago
Not 100% sure on that since the source was a reddit comment but a cursory google makes it seem to be the case.
Throwaway05
2d ago
Clair Obscur had a prestigious award revoked after the game turned out to have a handful of temporary assets that were AIgen left i
My understanding is that this was not actually a prestigious award and may in fact have been done for publicity.
Throwaway05
3d ago
This is more of a stereotypical lib left answer than my own but it keeps people away from drugs and homelessness and being super foul tempered.
Throwaway05
3d ago
bronchitis
Lots of people got absolutely obliterated this year, it isn't just you!
...hope that helps?
Throwaway05
3d ago
I apologize if I missed something here, it's been a long day at work.
You are making two mistakes I think.
The first thing to note is that the vast majority of restraint encounters are in the ED with mostly undifferentiated agitation. That almost always ends up being drugs or medical illness.
Patients who end up in a psychiatric unit, well the vast majority of restraints are for violence towards others not the self.
If you are a reader here and you've been in a psych unit it's probably been for suicidal ideation and it was probably in a cushy unit. The majority of inpatient psych work involves violent criminals, drug users, and the severely mentally ill (ex: schizophrenia, bipolar) - not depression.
An untreated manic episode prior to modern medical care had a 20-25 percent fatality rate due to getting themselves killed in one way or another.
Even if we gave up on the suicidal it really wouldn't solve the problem.
Protecting other people from the crazy and foul tempered is important.
Throwaway05
3d ago
I would really like to talk to a non-woke doctor from say Germany about how that stuff goes.
I'd suspect that this side of things wouldn't be as bad as you think since shit hole countries may have a tendency to just kill or lock away forever patients with serious mental illness or drug use.
Baseline criminality and poor understanding of Western cultural norms is more of a traditional police problem and dodges (some of) these tensions.
Throwaway05
3d ago
From what I've heard the U.S. patient population is much more dangerous and violent than in other countries, in a variety of settings.
Doctors in other countries seem to pat themselves on the back for not really using restraints but it ain't for the reason they think it is.
Drugs use is probably a large part of this. So is safety social net.
Throwaway05
3d ago
Oh no, released from police custody and does it? Def a Tuesday in the U.S.
Hospitals? Much rarer (in part because suing is an option).
Throwaway05
3d ago
This was an interesting exercise, actually kinda blows my mind.
Throwaway05
4d ago
People generally resist, because you wouldn't be restraining them unless you had to and you have to because they accidentally or intentionally want to do something dangerous, so they resist.
Restraining someone who is resisting involves them attempting to attack you, and you essentially attacking them. It is not safe. It is violent. It is dangerous.
People who do not have experience with these things can easily go "oh well it's a magic controlled situation" and underestimate how brutal it often is, which is one of the reasons I wrote this up.
Policing for similar reasons is inherently violent. The threshold for someone to resist the police is higher because of life long training to be scared of the police but people who do it present a threat to themselves, bystanders, the police.
And the left is training people to resist, violently or in a way that isn't distinguishable from violence in the moment.
That's why this woman died.
She didn't realize just how dangerous what she was doing was.
Throwaway05
4d ago
It's how our individual rights based system works. I'm usually okay with it but the problem is that many people have bought the progressive frame and never transition to actually managing the issue.
Throwaway05
4d ago
This means something very specific in a medical context, yes people can have personality problems in the sense that you mean outside of healthcare and end up in prison, but we have a specific suite of diagnostic identities called "personality disorders" (the most famous are probably: anti-social, borderline, and narcissistic) that represents a pattern of maladaptive personality features with a somewhat known cause that don't respond to medication and barely response to non-medical interventions like therapy.
Patients with these disease processes sometimes end up in a psychiatric hospital because of behaviors that are dangerous (towards themselves or others), but the purpose of a psychiatric hospital is to begin the acute stabilization process, if someone can't be helped by a psychiatric hospital and engages the in dangerous and illegal behavior than the correct location for them is prison, while in prison someone can try and treat comorbidities and begin loooooooooongitudinal therapy.
Throwaway05
4d ago
Most of my work has been in blue locations but I'd wager that even red ones aren't great about this, I'd love to hear anecdotes or data to the contrary though.
You'd be shocked at how soft the legal system can be, even in red areas. You see this in stalking and DV cases - threats and implications are often not enough to do anything useful and things end up being too late.
Throwaway05
4d ago
With the exceptions of oversized atriums anything in a hospital is necessarily going to be CQB. Between that and the fact that incidents of violence are either totally unforeseen (or missed, anyway) or planned in advance....not likely to help. Most city hospitals will have some armed police onsite in some capacity and they have strict rules about what weaponry where.
Ultimately we are trained and "required" to accept being victimized instead of defending ourselves, this isn't always the wrongest thing in the world - delirious granny, well it's not her fault I'm not going to shoot her.
Incidents like the banger with a gun are rare, and almost always we have a damn large team and a million people in earshot, that lowers the risks.
Hospital policy is almost always going to ban people from bringing their own weapons but you definitely run into people who ignore that. It has been on occasion comical, some people will have capped syringes in their purse "just in case."
Coming to work armed is going to be more common in outpatient - you are more likely to be alone or semi alone, in the hospital someone can always hear you scream.
Sometimes that person is another patient - the second patient in the wrestling anecdote was actually helping restrain the stabber.
Throwaway05
4d ago
You need us to make sure they don't die from intoxication or withdrawal? Fine. Cut themselves on a window breaking in, or got hypothermia? Fine. Need us to psychiatrically clear? Fine.
You'll see presentations that start this way though: "Patient brought in by police for threatening to push people onto the subway tracks while clearly high on a serious drug, two other incidents this week, and was brought to the hospital 14 times in the last 2 months for similar presentations but the police decline to press charges."
Probably not actually the police fault there but that's what the docs like to blame, but we see tons of dump jobs where we are just waiting for the guy to do something bad enough to not be caught and released and its an actuarial game. Seldom anything medical or psychiatric to do.
Big scandal in NYC recently after a state hospital cut someone loose and they immediately went and stabbed someone in a Macys. Doctor scuttlebutt is that the patient wasn't psychiatric - pure personality. Should have been a criminal matter front to back and now somebody is quite likely going to get sued out of the profession for something no physician has any control over.
Throwaway05
4d ago
Salsa with ingredients straight from your garden you made yourself is life changing. Still prefer the high end canned stuff for my sauce though.
Throwaway05
4d ago
They drop them off at the nearest ER, shrug, and say 'your problem now.'
Yes absolutely, so many patients end up dumped in the ED who aren't really medical or psychiatric, they are just difficult enough that the cop figures it must be a healthcare problem.
Then we are left discharging this massive liability as soon as they sober up or whatever.
Throwaway05
4d ago
On Provision of Violence: (And some mild trauma processing).
I will try and avoid directly mentioning the Minnesota situation, but that’s obviously why I am writing.
I am not a police officer or active-duty military in a combat zone, despite that I have one of the few jobs that involves legalized provision of violence to individuals without their consent.
In healthcare this happens a few ways, one of which is treatment over objection, which happens for a variety of medical and psychiatric reasons and is in most settings a slow-motion problem that involves court and ethics committees. Emergency care absent consent is almost always adequately established retroactively without issue.
Far trickier is restraints.
Restraints happen for a lot of reasons. On the medical floors the classic example is delirious grandma flailing at the nurses. On psychiatric floors, well it should be obvious. In forensic (correctional) settings you have a variety of places where these becomes necessary because the patients are pretty much definitionally assholes. However, psychiatry and the ER are probably where this happens the most.
Fundamentally the reason for restraining patients is to protect the patient, the other patients, and staff. Plenty of people are a serious threat to themselves or others. Sometimes it is drugs. Sometimes it is delirium and confusion. Sometimes it is mental health, and sometimes it is pure personality.
People don’t usually appreciate being put in restraints. They fight back. Hard. Sometimes they attack unprovoked early which is a whole sperate problem. The impact of violence on healthcare workers is grossly underappreciated. It almost always goes unreported and unprosecuted. “The patient was sick” and it gets swept under the rug.
Nurses and techs are more risk than doctors, but it is a common way for careers in psychiatry and emergency medicine to end – tired of the threats and just giving up or injured and forced to bail out. Rarely people die, but it does happen.
During medical school I once got covered in my supervisor’s blood, and on another occasion, I had to carry away a chunk of somebody’s scalp. A guy I know from medical school once responded to a code in the middle of the night and found two patients and a nurse wrestling in the nursing station while another nurse slowly bled out from a neck wound.
I’ve been swept by a gun during a trauma (fucking search the bangers before, thanks), and handed a knife by a guy who was already searched while alone in a room. Yesterday, a nurse at another hospital in my region almost had their finger bitten off while restraining a patient, which is why I decided to write this.
And none of this occurred in the correction setting, which is far, far worse.
Below I have some lessons I’ve learned while dealing with this sort of thing.
-Violence is uniquely hard to deal with. At this point in my career, I can handle a medical code just fine. The risk of death is present, but the “enemy” is a disease. It fights back in predictable ways. Other people can get hurt (and I’ve seen it) but it doesn’t hit the same. Managing agitation is almost always far more uncontrolled and challenging. It is more likely to be different every time. It is enormously more stressful. And-
-It is hard to get used to safely managing violence. Training helps but very few people are actually dealing with situations that go pear shaped often enough to be calm, cool, collected, to learn lessons and get better next time. Most cops don’t deal with a serious incidence once. You can drill all you want but that isn’t enough real-world practice time to be actually good. It requires a lot.
-If you do get enough experience, being callous is nearly inevitable. The behavioral response team at a busy city hospital is going to be putting multiple patients in holds and restraints a week most of the time. They might get used to being punched in the face or nearly punched in the face. Some of their number may end up seriously injured. The fear is always there, but once you get used to it, you get used to it. You tune it out and it takes serious diligence to not blow things off and become blase. I don’t think I’m good at this. Someone with less training or dedication? Fuck no, it is an impossible task, anybody who could do it wouldn’t because inflicting violence sucks. You feel bad. You don't want to be in that position. You don't want to do it.
-Communication is hard. Restraining someone is like most police action. You have a large group overpowering and bum rushing one person. This should make things easy. I am also in charge, they can’t touch the patient without my explicit order, nor can they administer IM medication or put the patient in restraints. Everything runs through me. Clear communication. Should be easy, no? Fuck no. Everybody is shouting, the patient most of all. Uncontrolled things are happening. Somebody drops the keys. Somebody trips.
Tearing open the chest of a patient in a clamshell thoracotomy is a more controlled and clearer situation. A sub 90 second C-section is a more controlled situation. A “fight” hampers communication like nothing else. And that’s in a hospital with more than enough people and an experienced team.
-Everybody can’t breathe. Some patients who need to put in restraints are more “behavioral” (this means that instead of someone who thinks the doctors are leaches from Mars or is zonked on a UTI…. they are just an asshole). These patients almost always loudly shout they can’t breathe while being restrained. They say they can’t move their limbs while flipping you off. They'll claim racism no matter your race and their race. This goes double for forensic patients. You start to tune out these complaints since they are “always” lies. The connection to law enforcement is clear, I hope.
-We don’t like it. I’ve never seen staff bad enough that they enjoy restraining patients because they like the power, sometimes you see people who get disrespected and get some gross catharsis out of it. For the most part they hate it. The emotions afterwards can be hard to manage, even if you are a good person who didn’t like it. People say things. Stuff comes out.
-Lastly, violence isn’t safe. No form of violence is safe. Some are safer than others, but patients used to die in four-point restraints (now we have strict limitations on use and have to nanny patients, but bad shit still happens). Holds are dangerous to staff and patients. Chemical restraints have a risk of respiratory depression and other side effects. We minimize risks but if you do these things an appropriate number of times something wrong will happen eventually.
Restraints are a bad option, but they are a required option. In life that happens sometimes.
Throwaway05
5d ago
I can tell you that on the healthcare end of things the issue is that the people who want to be serious about "shopping" over focus on customer service and end up with awful care as a result.
In many other types of engagements customer service is a large part of the service so I imagine it is a bit easier.
Throwaway05
5d ago
but, but muh volcanic soil!!!!
Throwaway05
5d ago
I mean, I can't even tell you how to get the right doctor. Shit is hard as fuck.
Lots of people use word of mouth within an IRL social network or via something like Facebook. You can find lists in your area or otherwise online (and with Telehealth...world is your oyster). Many people are already seeing an MD for med management and they have referral networks. More so than general medicine getting something that matches your insurance is harder since so many do cash, which in that case you gotta match the financial resources.
On top of those considerations you have an element of "if this one doesn't work for you, try someone else."
Frustratingly many people stop after the first one or continue with the first one even if it's not a good match.
Throwaway05
5d ago
In my interaction with therapists I think many of them aren't as broken by social justice as you might expect from the training and reading material. Fundamentally the goal is to help people, and the reality of the darkness you see helping with mental illness sands off some of the naive edges I think.
So great at playing the language games though yikes.
Throwaway05
5d ago
I stopped by Red White and Que (Green Brook NJ) on a road trip and found it to be excellent for east coast BBQ.
...Still think the KC/Texas options or Pappi's in STL are way way better.
Throwaway05
5d ago
Hmmmm what I'm really trying to find a way to emphasize is that the personality and the style they have to offer is part of the modality in therapy in a way that doesn't apply for other interventions. Yes the type of therapy matters but some people are never going to respond well to a more "ooey gooey feelings" type, or (frustratingly!) think they'd never respond well to that but would do great.
I think it's more common in the MD psychiatrist realm but you do see plenty of men who speak the male language and are heavy on tough love while still doing traditional therapy, which naively I imagine would work great for most of the Motte complainer types who mostly imagine a SJ adjacent "feelings" therapist.
I imagine the issue is that we (physicians) have a tendency to write with certain tics, these not seeming like normal writing to most people.
Since you've AI'ed a bunch already I imagine others are going to see that and make assumptions?
More options
Context Copy link