Thursday, July 30, 2009

Violent patients in the OR

This blog article in the LA Times about violence against ER nurses reminded me of the times that violent patients have come into the operating room. I've had some swings and misses against me. Most of the time the patients were agitated because they were under the influence of drugs or alcohol. But one particular incident is still vivid in my memory.

I think I was in my second year of practice after residency. A patient was transferred from the psychiatric hospital next door to ours for emergency surgery. When he came he would not allow anybody to touch him. Of course he had no IV. Any attempts to touch him produced loud screaming and yelling and violent flailing against his restraints. His disruptive behavior caused great anxiety to the other patients in preop holding to the point we had to move him into another room that normally wasn't used for patient care. Naturally I was the one who had to put in the IV as the preop nurse said she couldn't do it. Even with several people holding him down it was impossible to hold him steady to start the intravenous. Everybody stood around looking at me for directions.

So I made the decision to mask him down. We wheeled him into the OR. No monitors could be placed on him. Again using several strong men we held him down tightly. I cranked up the Sevo and nitrous and slapped that mask on his face as tight as I could. Once his motions slowed down, the circulating nurse placed the monitors on him. I had her hold the mask while I went around and started the IV, just like how they trained us for pediatric inductions. Once started, I intubated the patient and the case started. I was afraid of how he would act in postop. But surprisingly he did very well. No more screaming or punching. Go figure.

Afterwards I asked a senior partner what I could have done differently. He said casually he would have given him IM succinylcholine with intubating supplies on hand. I asked wouldn't that be very traumatic as the patient would be fully aware of his intubation? His reply was that it didn't matter as long as it got the job done. This is an anesthesiologist know for his swagger and doing a lot of complicated cases. Others later on said I should have given IM ketamine. That sounded more reasonable but any IM injections in this patient would have been terrifying. So now I've learned another lesson. Some things they just don't teach in medical school and residency.

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