This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
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.
This is the core issue. Violence is easy. Minimal amount of violence necessary to achieve your goal, with the understanding your actions will be under the microscope in hindsight by others with all the time in the world is very difficult.
I have so much respect for healthcare security and medical staff for dealing with the worst of humanity.
Do you know what cops do when they assess that someone is out of their minds (either psychologically, or due to drugs)? They drop them off at the nearest ER, shrug, and say 'your problem now.' The worst types of criminals and mentally ill aren't dealt with by cops, but the healthcare system. The medical staff are meant to treat someone in a psychotic aggressive state without harming them or allowing themselves to come to harm. Imagine a George Floyd once a week except he's screaming and trying to bite your face off like a fast moving zombie from 28 Days Later.
Get it wrong and you've lost a digit, been stabbed with a junkie needle or are in fear of losing your job based on the outcome of an administrative panel review (that cares about the corporate image more than your wellbeing).
You couldn't pay me enough to do that.
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.
What options do the cops actually have otherwise?
Kinda sounds like buck-passing all around. How can society deal with low-grade socially corrosive people? Without offending the bleeding heart types who do nothing to help but condemn anything that might?
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.
Yeah, I would guess this is a blue city soft on crime prosecutor problem. A crazy/drug-addled person threatening to kill people should actually not be left free to be a violent random encounter for the citizenry.
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.
True but you think those'd have more inherent grey areas than the litany of 'moderately violent homeless person is brought in 50 times until finally actually murdering somebody' if it's a defective relationship between two societally-functional people versus a person who is clearly just not beneficial whatsoever.
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.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link