MORE LETTERS FROM THE PIT FREE SAMPLE STORY

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HE’S OUT OF CONTROL

Dear Jack,

        I don’t usually feel threatened by circumstances that occur in the ER. The drunk and disorderly can usually be handled by forceful, verbal commands. And we have two, gun-toting police officers stationed out in the waiting room if that fails. Once in a while, a drunk will suddenly become assaultive toward staff. If the police aren’t immediately available, we take them to the floor ourselves, sitting on them for the brief time it takes the cops to arrive. It’s no big deal.

        During my residency training, it was much different. Friday and Saturday nights you could usually count on needing to take down three or four assaultive young soldiers who thought they could break the place up with impunity. It was common enough that the night crew had a routine that never failed. Never hurt anyone either. I’m embarrassed to admit that a few of us found the occasional wrestling tussle with an intoxicated soldier a nice break from our usual duties. But last night’s patient was a totally different story.

        I’m working the crash area when we receive the alert that EMS, with police escort, are en route with a mid-thirties male who’s out of control. There’s no other information available from the paramedics, but over the radio you can hear yelling in the back of the unit. Figuring it’s simply another drunk causing a ruckus, I go back to work. He’ll be here soon enough, and I’ll worry about him then.

        Several minutes later, they roll in. The patient is hardly talking now, lying on the gurney looking angry with Austin police officers on each side of him. Not an uncommon picture on a weekend night. Except for one detail.

        This guy is positively enormous. Probably six feet, six inches tall and 300 pounds of sheer muscle. Not an ounce of fat on him. His shoulders are shockingly large, and his biceps are the size of my thighs. His waist can’t be more than thirty-four inches. He has the appearance of an overblown G.I. Joe action figure. Not someone you want to handle physically at all. So I’m glad to see he’s calmed down.

        Not knowing exactly what his problem is, he’s placed in our overdose room. A secure room with a sturdy door and an unbreakable Plexiglas window. I think the nurses made a good choice putting him in there. I pick up the chart once it’s ready and take a peak in the window.

      I’m again taken by his size. He’s wearing short pants, and his muscles are impressive. This monster of a man must live in the gym and be on steroids. Weight lifters sometimes abuse a drug called GHB. They think it improves their workouts. Initially, after taken, there is some period of excitement and energy, and then it wears off. If ingested in overdose amounts, the drug can cause them to fall into a profound sleep. You literally cannot wake them up with any stimulus. After a few hours, they suddenly wake to full consciousness, fully alert, and ask to go home. It’s a weird event to witness.

        I walk into the room hoping he doesn’t get pissed off when he sees me. I move toward his bedside, leaving the door open just in case I need a speedy exit. Damn, this patient is utterly intimidating even lying still on the bed. I notice the nurses have applied our usual limb restraints on his arms and legs. I’m thankful to see them, but I doubt if they’ll even work on this man.

       I call out to one of the passing nurses to bring our “Tuff-Man” restraints. These are very strong, heavily woven, and with nylon-poly webbing that can be tied to the stainless steel gurney edges. They can hold a kicking mule down, I reassure myself. But I wonder if he’ll even let us put them on.

        I try a little explanation, telling him that his disorderly conduct prior to arrival has caused my mostly female nursing staff some concern. And that, for a short time, we need to change his restraints to a different kind. If he has no further outbursts, I’ll have them removed. And once they’re removed, he can have a sandwich and some Gatorade if he likes. He says nothing. Never even looks at me. With the two police officers in the doorway behind me, I change out the restraints limb by limb until all four are secure. I feel more comfortable, but he still looks very angry. Furious really, but stoically accepting his temporary fate. One of the officers asks, “You okay in here, Doc?” and I answer, “Yeah, we’ll be fine.” And they head off to the charting area to complete their own paperwork.

      It’s looking like this will be routine after all. No big fuss, we’ll untie him later, and he’ll sober up or come down off his high without further drama. Boy, was I wrong!

       I begin my examination. He remains silent through an array of my questions. “What did you take? How much? Have you been injured in anyway?” He just lies there in an emotional boil. I tell him I need to start my physical exam and then did just that.

        I check his heart and lungs and note nothing but a rapid heart rate, maybe 140/min. I call out to the nurse for full monitoring to be applied. And then I put my hand on his forehead, touching him for the first time. Holy smokes, this guy is as hot as a pistol. I’m not sure what his temperature is, because the staff was afraid to approach him in his agitated state so it was never taken. But I’m guessing 104°F or more. Something is really amiss here.

       My mind races through the differential for delirium with fever. I quickly determine the most likely cause is an overdose with a stimulant drug that’s created a mess of his central nervous system. Likely crack cocaine or methamphetamine (the medical terms for speed). This is a very dangerous and possibly fatal condition. Time is no longer on my side. I need a firm diagnosis.

        And then the big surprise comes. Right after the nurse sets up the monitors and steps out of the room, he becomes absolutely enraged. I ask him what’s wrong. His response, first with his right leg and then with his left, is to suddenly and easily snap the heavy restraints off of each leg. He turns his attention to his arms, and with one flex of his biceps and a shrug of his shoulder muscles, he snaps both free. Shit! I step back toward the open door.

       The monitoring wires are ripped off and tossed into the corner. He looks like King Kong and stares at me for a moment. I’m certain he’s not mistaken me for Fay Wray or Jessica Lange, as I don’t see a milligram of kindness in his eyes, only pure fury. He jumps up and crouches on the bed, ripping his IV out as well. He grabs the IV pole, and I head out the door, closing it behind me and holding the door handle so he can’t easily open it. Fat chance I’ll have holding it with this beast pulling on it, but it’s all I have.

      His next move really gets our attention. He takes the heavy IV pole and starts slamming it into the Plexiglas window, which I no longer consider unbreakable after witnessing his performance with the restraints. I hear our clerk overhead, paging for police to the ER STAT.

       He bangs repeatedly on the window with the IV pole, and I can see it bow outward with each blow. I figure it won’t last long. The two officers who stayed to do their paperwork are at my side in seconds and help hold the door closed. Then the two from triage arrive and quickly assess the situation.

       Just like the police chief in the movie Jaws, they conclude we’re going to need a bigger boat. More street officers are summoned on their radios to respond to the ER. Everyone realizes the danger this guy represents, and I welcome extra help.

       I explain that I believe the patient is in an excited delirium from stimulant drugs. Possibly hyperthermic as well. I caution the officers against firing their Tasers as sudden death has been reported in such cases after their use. I’ve also seen Tasers have no effect on some hyperexcited patients. One of the officers says, “Three Tasers will put him down, Doc.” I repeat, “No Tasers.”

        The officer says, “Fine, I’ll go get the stun gun.” What? You’ve got to be kidding. That might only piss him off even more. It’s like a short-barreled shotgun that shoots out a beanbag with tremendous force. Plus, I’m not too sure it’ll work on this hulk, and, if he gets loose, we’ll need something short of their 40cal pistol rounds to control him.

        We watch King Kong pace back and forth through the window. He will not respond to the police officers at all. I develop a plan. My nurse readies a fresh IV and a dose of a drug that’ll temporarily paralyze him if we can administer it. I’ll then have to quickly get him back up on the bed, put down a breathing tube, and place him on a ventilator. It sounds good to everyone. And we get ready.

       The officers line up in twos like an entry team you see on TV. Eight of them first, with me and my nurse to follow. And then comes another surprise.

       Instead of a simple immediate entry, the officers crack the door open, and three of them at once direct pepper spray right onto the patient’s face. We hadn’t discussed that part. But I’m desperate to get control of this situation as my patient may be dying. The officers slam the door closed. King Kong throws his body again and again at the door. It too bows outward with each impact. I see two of the officers drop their hands to their holsters, ready to draw weapons. Jeez, what a mess.

        Fortunately, my patient is too disoriented to remember he must twist the door handle to open the door. After a minute or two he drops, writhing on the floor, rubbing his face, coughing, and having difficulty breathing. That was a lot of pepper spray and results in worsening his delirium.

        And then we charge in, and everyone piles on him. One or two officers on each arm, one on each leg, one on his chest, and one pinning his head sideways to the floor. Our nurses are the best, and this guy’s veins are the size of pencils. She pushes the paralytic drug in, and, within thirty seconds, he’s as limp as a rag. And not breathing. Terrific.

The officers look relieved and relax as though the emergency has ended. I yell at them, “We need to pick him up and put him on the gurney! He’s not breathing, and I need to get his airway controlled!” And like a scene from Gulliver’s Travels, the little people lift our giant off the floor and position him onto the gurney. I easily get the breathing tube down into his lungs and the ventilator attached.

       This time, I request that our old leather restraints be found and applied. These are very heavy leather straps, perhaps four inches wide, and quite thick. Reinforced as well with secondary straps and a heavy metal buckle to hold them on. I don’t think any human can break these suckers. I hope I’m not wrong.

       I ask for a rectal temperature on our patient as my immediate concern is his dangerously high fever. Made worse by all the physical activity fighting us. And, sure enough, his is a life-threatening 106.8°F now. We set up rapid cooling. I order a large dose of a sedative similar to Valium that’ll further relax his muscles and over-excited brain. Finally, I order a longer-acting, paralyzing drug to keep him down. 

       The remainder of his care seems a cakewalk compared with the exciting start. Ice bags, cool spray, fans, and a cooling blanket. And within ten minutes or so, we have his temperature-controlled and can do the rest of our workup.

        Ultimately, his drug screen returns positive for cocaine. An overdose is the cause of this entire ordeal. And with tubes down his nose, a Foley catheter for urine, and two IVs, he’s wheeled off to the ICU. I’m relieved we saved his life and take a minute to laugh with the staff about our memorable scene before turning to the next patient.

       During the rest of my shift, I think about all the other ways this case could have gone. Had the police officers not been so Johnny-on-the-spot and only two had been present, my patient would have likely been shot and killed. Had they not refrained from using three Tasers at once, he also might have died. And all the other possible bad outcomes, including injury to our ER staff, that were avoided.

        I know there isn’t enough appreciation for the work that first responders do in our communities. Police, Fire, EMS, and the ER staff all sometimes risk their own lives to save another. And rarely is anyone offered thanks.

        Those thank yous would be appreciated. But none of us really expects them. We’re just doing our jobs.

       As I leave the hospital for the night, I realize I’m looking forward to my next discussion with the hospital administrators who are intent on having our police officers replaced with unarmed security guards. A fool’s errand, if I’ve ever heard one.

I wish one of them had been there tonight. Or maybe had helped hold that door closed to keep King Kong in his cage. They might just change their minds.

                                     PC