Thursday, July 7, 2011

Adventures in Sitting: Sundown Showdown

"Hey S, we're going to give you another one."
Aw man. I looked up and saw a quiet little old man (LOM) sitting demurely on a stretcher in the ambulance bay. I already had 3 patients I was sitting with. One had been smoking funny stuff and got violently combative in the ambulance bay. He was in 4 pt velcro locking restraints and medically knocked out, snoring. Hopefully he wouldn't wake up anytime soon. I had one suicide watch who was shifty, and another psychiatric issue lady, who was looking around nervously. At least this new LOM looked quiet.

My LOM shook my hand and called me dear when he was brought over. He was very polite and asked if I would hear his story- they were moving him from hospital to hospital, he told me, listing the hospitals. Maybe because they didn't know what to do with him, he sighed. This was strange to me- I wondered why none of those facilities could resolve his problems. That and, he just seemed so nice. "Well, sir, just sit back in your stretcher and a doctor will come see you soon." "Thank you for listening, dear, you are very kind." He sat back and watched me. His eyes were lively despite his muted demeanor and turned up at the corners. His manners suggested a high level of education.

For the first hour, he just sat, with his hands folded in his lap, pondering his situation, occasionally staring over at me. I smiled at him and asked him if he was comfortable. "Oh yes, I'm fine." Under "patient behavior", I wrote "calm".

At the two hour mark, he began to shift around. He started moving forward in his stretcher. This put me on alert, and I asked him, Sir, where are you going?
"Well my dear, I'm over 80 years old and sitting in one position is making me very stiff! May I just sit at the edge of this bed just so I could move my joints a little?"
It seemed a reasonable request, albeit one I don't normally acquiesce to, but he really was just a LOM.
"Just stay there, though, and move back when you feel better, Mr. LOM. I don't want you go get run over by a stretcher."
"Of course, dear."

I watched him more closely now. His eyes were shifting and his hands moving. He shifted his weight again and I saw he was going to stand up. "Just to stretch my legs, dear"
"Sure, sir, but you're not supposed to be up."
He sat back down.
He stood up again, then sat back down a few times. I relaxed a little. Poor guy, his legs must be sore.
Under "patient behavior", I wrote "restless".

"What's the weather like outside? Is it raining?" He suddenly asked.
"I don't know either, sir, as you can see, I've been here with you and have not been outside or near a window in a few hours."
"I think I'm going to walk and take a look."
"Sorry sir, you can't do that. I am watching 3 other people here. It's not safe. Can you please sit down?"

He stood up and walked a few steps. Seeing me watching, he said, I just need to take a few steps, that's all. I just nodded and watched him sit back down on his stretcher. Soon enough, he got up again, and started talking to the secretary.

It was a very busy day in trauma. Stretchers, x-ray machines, ultrasound machines, technicians, trauma surgeons were all milling about. We were right in front of the trauma room and the secretary was dealing with a lot of paperwork from the rest of the department.

"Sir, I'm going to ask you to sit down for your own safety. As you can see, there are many people and machines rolling around here. I don't want you to be injured."
"Young lady, I signed myself in here and I can sign myself out. Don't tell me to sit down." His demeanor changed completely.
"Sir, please sit on your stretcher and lie back all the way."

He ignored me and continued harassing the secretary.
"Mr. LOM, I know it's uncomfortable, but you could really get hit by a stretcher there. Can you just sit and wait for the doctor?"
"There was a statute passed last week that says I can sign myself out if I want to! You can't make me sit!"
"Believe me, if such a thing were passed, we'd be the first to know. Now, you're here for a psychiatric evaluation and you should not be wandering. This is my job on the line if you get hit." I tried to de-escalate the situation, but it didn't work.

He suddenly came at me and I took a step back. He towered over me a few inches from my face. "Do you understand English? I won't sit down. Call security if you have to."
He returned to have a perfectly civil conversation with the secretary once more.

Two officers came at my call; Mr. LOM introduced himself to each of them, shaking their hands and telling them how confused he was to be treated this way. He ignored me and the officers spent twenty minutes talking with him. However, when coaxed to sit on the stretcher to talk, he grew agitated and again refused, trying to state various articles of newly written statutes about his rights in the hospital. It was almost kind of funny how the way he looped the security officers around in non-sequitur or circular arguments.

I decided to take a look in his chart to see why he needed a psych evaluation. Apparently, he had attacked an aide at the nursing facility and was pushed from hospital to hospital for his misbehavior until he came here. This was someone who has been and could become dangerous.

The security officers requested doctor's orders for restraints; Mr. LOM was obviously not going to cooperate, so I called his doctor and nurse over. Mr. LOM took each by the hand and introduced himself, smiling and insisting that he was being misunderstood.

He seemed so nice, but reality bites.
The doctor didn't want to put him in restraints, but when I told the story of what really happened, Mr. LOM lunged at me, security caught him in mid-air, and they threw the old man onto the stretcher and put him in 4pt locking restraints. He let loose a litany of curses and threats as I've rarely heard in my sojourn sitting, but to no avail. He was soon sent to the psychiatric ward, so he didn't have the restraints on for long.

A security officer pulled me aside later and told me: Mr. LOM was once a very prominent, well-known lawyer who was lately placed into a nursing home for advancing dementia.

The doctor told me that it was a classic case of sundown syndrome.
Very scary. What an awful drop he has made from being at the top of the world.

This is a story that replays in my mind fairly often. I remember his intelligent eyes that bent up at the corners and his unrepentant fury. I hope he finds peace and dignity.

After Mr. LOM left, my PCP patient woke up, winked at me and asked me in every way he could think possible for my number/email/contact information for the two more hours I had to sit with him. "This city's a small place, you know, I'll find you." What a creepy job on a creepy day!

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