Suicidal

A few months ago I was working a night shift and I was allocated the care of an 11 year old boy who was currently in A&E awaiting the arrival of an RMN. The reason for admission was that he was suicidal and had made attempts on his life that day.

We didn't really feel that our ward was the most appropriate place for this young man, usually we try to put these children into cubicles for some privacy and peace and quiet, unforutnatly the only cubicles on our ward are too far away from the nurses station and out of sight to be able to closely observe him. We decided to allocate him in our second bay in a bed opposite the nurses station. Not ideal as there were 4 other young children in that bay.

I tried to ready the bed space removing an items which could be used to harm himself, not an easy talk considering every bed space has a suction unit with lengths of plastic tubing and the child next door was an on IV infusion with long power cables coming out of his machine and plugging into the socket right next to this child's bed. I made the space as safe as possible, got a not-too-comfy chair for the RMN, pulled back the curtains and waited for the call.

When I got downstairs to the A&E department I was told that he was with his mother and the RMN in a room just out in the corridor. Then ursing staff weren't able to give me a very good history as he had been seen by the on-call psychiatry team almost immediately and they had had little to do with him. The story was that the boy had twice that day tried to run out in front of a car but had been stopped on both occasions. His mother had brought him into hospital because she was concnered abotu this and his recent behaviour. He has recently lsot a friend, and relative a little while ago and he dad was currently in prison.

I took the paperwork and joined the young man, his mother and RMN in the side room. I introduced myself and explained I was there to take him up to the ward. At this point he completely refused to come with me, said he wanted to go home, that he didn't need to come into hospital, that his mother had tricked him there.

So began an hour of negotiation. I explained to him that he wasn't in any trouble, but that his mum had been worried about him and that's why she had brought him in, and that we just wanted to keep an eye on him overnight.

He told me that he was fine, there was nothing wrong and that he didn't need to be there. Now his mother joined in, at times being constructive and helpful and at other times frustration getting the better of her and she would lose her temper with him.

She tried being the authorative parent, saying she had made the decision as his parent that he needed to be there and he would do as he was told. She tried explaining that she was concerned about him and about what he had done today. She got angry and told him how he was upsetting her.

I watched a lot of this, intervened when I felt it would be helpful, tried to placate mum when she got angry. Simon (not his real name) became increasingly frustrated, saying that he wouldn't do it again, that he didn't need to be here, said no one would believe him when he said he was okay. He slammed his fists into his lap, got up and banged his fists against the wall then sat in the corner of the room.

I tried to explain that it wasn't that we didn't believe him or thought he was lying, but because of what happened to day it was my job to make sure that he was okay, and that whilst he might feel okay at the moment and feeling one particular way sometimes this can change and we needed to make sure he was safe overnight.

Between angry outbursts and protestation he would become withdrawn and tearful refusing to make eyecontact with anyone in the room and not registering when someone spoke to him.

Every now and then the RMN would chime in with helpful comments such as "You're wasting time down here" and an inappropriate moments (e.g. mid conversation) "Let's go up to bed". I did my best to ignore this and manage to refrain from telling her to be quiet or giving her the "evil eye".

Simon was convinced that his uncle was going to come in and take him away, he kept telling us this and his mother explained that this wasn't the case and that his uncle would say he had to stay.

Almost an hour after arriving in the department I left the room to give him a few moments with his family (oh an the lovely RMN) whilst I had a discussion with the A&E nursing staff.
"You're still here?!"
"Yes, and I can see what you mean about the RMN" (They earler had described her a bit "odd")
"You know she came out of the room before you arrived asking for us to sedate him as he was upset?"
"I'd probably need sedating if I had her looking after me."

Although the child was upset, it was "normal" upset in my eyes, I would probably feel exactly the same way in his situation. He wasn't violent or aggressive, jsut very frustrated and did calm down. I felt that I had been making progress with him and that he was becoming more resigned to being admitted, however I now didn't feel the bedspace we'd allocated him was appropriate and that he needed a more private space.

We contacted the bed manager and reallocated him to a cubicle on our adolscent ward close to the nurses station. Although he was below the age the unit would usually accept we felt it would be better for him and they would be able to provide better care there.

I went back to explain to Simon and his family that he would be going to a different ward with a nice private room of his own where he could get a better night's sleep. His uncle had by now arrived and was whispering in his ear, he didn't stop when I entered the room or after I stood there for a few moment (which I found a little odd). I said goodbye to Simon without a glance or acknowledgement that I had spoken and hoped on my way upstairs that I hadn't traumatised the child too much.

He was admitted to the adolscent unit next door where I was told he had a good night's sleep, was seen by CAMHS the next morning and discharged. I don't know if he had any follow-up in the community.

Steep learning curve

Once again I cannot believe how long it has been since my last post. The weeks and months seem to be flying by me at the moment, and work is keeping me busy.

So a catch up before the main focus of this post. I worked Christmas Eve and Christmas day and all in all it wasn't so bad. Everyone was in good spirits, we had several Father Christmas' visit and we got half the unit on home leave for the day.

I had a very welcome three day break in Cornwall over the New Year which left me feeling refreshed and ready to work.

Last week I started on a new ward. It is an adolescent unit. I have so far worked for long days there and it is the reason for my post title.

The first two days were spent looking after a teenager who had been involved in a gang-related fight. It is a whole different world to the one I grew up and live in, though not unfamiliar because of the kids my mother works with.

He would swing from being polite and well mannered to being angry and refusing to cooperate. On several occasions he left the unit unaccompanied which is against our rules as we are unable to ensure their safety if they do that. Despite reprimands, explanations and assurances he wouldn't do it again he did. He would also try some of the most unbelievable lies to get permission to leave the ward, and then would become angry when we wouldn't let him. He was never verbally abusive to me and I never felt threatened by him, I actually quite liked him. Soon his anger would blow over and he would be cooperative again, now allowing us to do his antibiotic. I made him a hot chocolate and got him a packet of biscuits after one particularly difficult argument and as I sat watching him dunk his biscuits I realised that despite the bravado he is little more than a boy. He has had a really difficult home life, has been excluded from several schools, is now involved with a gang, I'm fairly sure carries a knife and is in trouble with the police, he also has some degree of mental health problems and anger issues. He is not accepting the help he is being offered and it's really sad to think where this young man may end up, because beneath that hard outer shell he is a nice boy.

On my third and fourth days I looked after a young woman who has had many previous admissions for confusion post seizures, and she has been non compliant with her medication. We had a registered mental nurse (RMN) (which makes me giggle) to watch over her, which makes my job a lot easier. Initially I didn't have a lot to do with her and was busy with three other patients but as the afternoon wore on I became more concerned about her behaviour which didn't seem like confusion you may have post-seizure but a lot more like psychosis. I was told she has presented like this before but it still didn't seem right to me. She had delusional thoughts; that she was a witch was the most common. She was having auditory, visual and tactile hallucinations; people calling her name, a man trying to strangle her. She was convinced she was dying and would not believe any reassurances that she wasn't and didn't have cancer, AIDS, wasn't having a heat attack. She became increasingly distressed and said she wanted to kill herself.

Although she had been seen by CAMHS and psych in A&E there wasn't really any plan for her, and fortunately at this point we had a brilliant psychiatric doctor come and review her. She straight away recognised our concerns and finally someone seemed to be taking this more seriously. She prescribed a very small dose of Lorazepam to try and help with her anxiety as she was highly agitated and distressed. This was given quite late in the day and the night staff reported it really helped calm her and she went to bed.

The following day we had more members of the mental health MDT assess her and the decision was made to transfer her to an adolescent mental health unit for assessment and observation. Unfortunately my patient didn't want to go and with her parents permission she was sectioned under Part 2 (I believe) of the mental health act - a process that I had not encountered before and took several hours, needing two different doctors to assess her and signs a document and the the Approved Social Worker to complete the last part.

We then had to wait over an hour for transport. When they were scheduled to arrive my patient was ready and had been persuaded and accepted the move to another hospital. Unfortunately the hour and fifteen minutes we spent waiting for transport saw her agitation increase and once again she refused to go. I was concerned she was going to try and leave the unit and was becoming a little aggressive, but we managed to persuade her back to her bed (having wandered up and down the adjacent children's wards with her) and when transport actually arrived (and I made them get rid of the trolley they wanted to strap her to!) she actually went quite peaceably.

So as my title suggests those four days were a very steep learning curve for me. At this point I would like to thank MMW for her blog. The knowledge and insight I have gained from reading it really did help me with the care of a patient that was totally outside my realm of professional experience.