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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.
Okay, here is my hot take. Get rid of paternalistic involuntary commitment, and you will cut down the instances of violence by half. (Most of the remainder will probably be prisoners in forensic psychiatry, e.g. people who committed (mostly violent) crimes but were found not guilty for reasons of insanity. These are probably best considered prisoners first and patients second, just like normal, sane, sociopath serial killer serving life who also has a bad toothache is unlikely to be rendered less of a danger because of his medical condition.)
Specialties of medicine which respect patient autonomy presumably have a vastly lower incidence of patients turning violent. Take oncology. Breaking off a promising chemotherapy is probably among the treatment decisions which carry the highest QALY cost, outside of outright committing suicide while healthy. Yet for adult patients, society and healthcare professionals generally accept that it is the patients decision. Very few cancer patients will attack a nurse out of desperation, because if they want to leave, they are just one signature of their own death warrant ("leaving against medical advice") away from getting out.
Contrast with specialties which do not give a damn about patient's autonomy, psychiatry first and foremost. I wish I could say that a month in a psych ward had the same long term QALY gain associated with a month undergoing a promising chemotherapy, but while both treatments may share a similar quality of life during treatment (i.e. utter misery), the long term outcomes of these intervention are as different as different as a shot of rum and fentanyl are for pain management: in my experience, the main goal of psychiatry is to keep their patients alive for another day. A mostly functioning patient going into a locked ward for debatable psychotic symptoms might emerge a month later addicted to benzodiazepines (which effectively removes them as a further treatment option), prescribed some antipsychotic (which he will stop taking at the earliest opportunity), having experienced physical restraint (because people who mostly cope with life in freedom sometimes cope badly when put in very stressful situations) and a life-long conviction that anything related to the mental health system is utterly evil and terrible (which further limits their treatment options). (On reflection, likening this to rum for pain management seems optimistic, and it might be closer to chewing glass for pain management.)
(I am fine with people who attempt to kill themselves without success or are expressing the intend to commit suicide spending a few days locked up for their defection around social norms. There is no intrinsic right to fail to kill yourself or distress others with your plans. Just let them out after a few days, and hope that they have overcome their acute suicidality, learned their lesson either about threatening suicide, or the lesson about which way to cut and keeping their mouth shut -- suicide is a human right, after all.)
If a base jumper falls to his death, that is sad, but not particularly upsetting. After all, when he took on his hobby, he was perfectly aware that humans are ill-suited for gliding close to the ground.
If someone who has made it their profession to lock people up without them having violated criminal laws gets attacked by one of his prisoners, that is also sad (and generally wrong and evil on the part of their prisoners, because typically it will not lead to them escaping), but also not particularly upsetting. Treating people as unable to make decisions about their own life (which is why you lock them up, after all), while also expecting them to respect norms of polite society e.g. about not sticking a cake fork into through your eye socket seems to be both hypocritical and utterly foolish.
Further reading of my opinions.
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.
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