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Notes -
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.
To what extent do you (or legal or ethical theory) conflate or distinguish between force, and violence? Restraining someone is certainly forceful, but is it necessarily violent? If you had cheap, harmless sleep rays to aim at patients, would this be considered 'violence?' Such a technology "feels" unethical, even though it seems like it offers safety improvements.
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.
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