My name is Caleb.
Ive had this pain in my arse for 2 weeks now. The doc says its a hemorrhoid or something. All I know is, it fucking hurts like shit.
I am supposed to have surgery, but the hospital has cancelled it twice now. Says its too busy.
My doctor gave me painkillers, but they don’t do fuck-all. I ran out on Monday, and I haven’t slept for the last 3 nights ’cause of the pain.
I haven’t been to work, and now I think I’m going to get the sack.
I can’t get in to see the doc till next Monday. And all the other doctors are booked out.
Cant stand the pain for another second.

So I go back to the hospital.
I wait for ages, then the nurse at the front counter finally calls me in. I tell her how much agony Im in and that I can’t stand it.
She tells me that I will have to wait for a long time and that she will bring me some painkillers. I cant sit in the stupid waiting-room, don’t you get it?
Then she goes off and never comes back. Eventually I can’t stand it no more. Stupid bitch.
I get angry an yell for someone to bring me some painkillers.
The nurse comes back, and then this big bastard male nurse comes over and tells me to shut up. He’s a real smart-arse.
That’s it….. I totally loose it.

Next thing I know they’ve called security and they push me outside. In front of everyone. My girlfriend sees it all. She is screaming.
I can’t stand the pain no more, and nobody is doing anything. Whats wrong with these people? They wouldn’t treat me like this if I was a white fella.
Next thing the fucking cops arrive.
They stand around me, but I don’t give a shit….the pain is so bad. They can shoot me for all I care.

Then another nurse comes over. She talks to me. She tells me she will get the doctor and give me some meds. Finally! I just start crying. Ive totally had enough of this shit.
Its like, whatever.
They put me in a wheelchair and wheel me over near the door outside. The cops leave and the nurse and a doctor come out with my meds.
FINALLY!
What sort of fucking service is this?

My name is Karen.
Its a busy Friday evening and I’m working the Triage desk. The department is full, and the waiting room crowded.
A 22 yo male presents complaining of rectal pain. I know this guy, Caleb. He was here last week with the same presentation. He caused some trouble then and this time he has attitude from the moment we meet.
He was supposed to get surgical followup, but he is back.
I can see that he is in some considerable pain, and unfortunately for all of us, he is going to have a long wait to be seen. I tell him I will get him some oxycodone to try to make him more comfortable.

At that moment, a critically unwell patient arrives by ambulance. The paramedics are preforming CPR and need some assistance to move the stretcher into resuscitation.
A couple of minutes later, as I walk back to the desk, I hear him. “you fucking cunts….I’m going to kill all of you!”
He locks eyes with me. ” get me some fucking painkillers NOW, bitch! And get me a DOCTOR”
He picks up a chair and throws it against the desk.
I’m scared, the clerical staff are scared.
One of our nurses, Michael, comes out to see what’s up.
He is great in these sorts of situations. “This behavior is unacceptable my friend”
Caleb steps up and pushes him hard. ” don’t get smart with me cunt!”
Clerical call a code black, and then they call the police. We have a strict zero tolerance policy for this sort of behavior.
Wardsman and security arrive quickly, and manhandle him outside.

I’m still shaking when two police cars roll up a couple of minutes later.
I see one of our senior nurses, Jane, walk over to the group.
Next thing, the police are leaving….and the wardsmen sit Caleb in a wheelchair and wheel him over in front of the ‘No Smoking’ sign for a cigarette. I was like, what??
Then Jane and a doctor go over and give him some painkillers, and a script. He leaves shortly afterwards with his girlfriend. A smile on his face.

So much for zero tolerance. I mean, this guy was rewarded for this sort of behaviour. He assaulted a nurse and for that…. he jumped the queue, and had a doctor and nurse attend to him outside while he had a cigarette! Not happy.

My name is Jane.
I’m the team leader for this evening. It’s super busy, and a cardiac arrest has just arrived when I hear trouble out at the Triage desk.

By the time I can get out there, security have moved this guy outside. I looked after this guy last week. He has had a pretty tough life. Just got out of jail actually. I remember him telling me he was really scared that he might be about to lose his new job if he took anymore sick leave. he has three kids, and one of them has some sort of congenital heart disease. A poor prognosis.

Anyway, the police arrive, words are being exchanged and the whole thing is escalating. The whole group is now obstructing the main entrance to the department, and I can see a few very upset people trying to get past. I think it must be the family of the cardiac arrest. The police have lost patience and are about haul him off.

I kinda feel sorry for the guy. He is obviously in a great deal of pain… and has just lost the plot.
I think I can de-escalate this situation and bring some sort of resolution. I don’t think he remembers me from last week, but I walk in and sit down beside him. With all the police around, I’m not feeling threatened, and I spend some time talking to him.
He bursts into tears, sobbing loudly.
All he wants is enough painkillers to get him by till he can get in to see his doctor. If the police haul him off he is only going to come back later. It’s the weekend, and he won’t get in to see anybody till next week.

I think I can finish this quickly. I go and grab a doctor and explain the situation. The police are happy to leave once he calms down a little.
I feel good that I have managed to stop this situation becoming violent, and ending up with Caleb away from his family.
Within five minutes, he has had some painkillers, has a script, and leaves.
I notice the Triage nurse give me a curt look as I walk by, but I’ve got too much happening right now to talk to her.
I hurry back to meet the family of the man who has just died in resuscitation.

19 Responses to “1 shift, 3 stories.”

  1. Yes, these different points of view do dramatically highlight the challenges nurses face. ED nurses are too often put in impossible positions but we mustn’t forget that we also have the right to ask for charges to be laid against offending patients. The rule of law does not exclude nurses – we have the same rights, protections, privileges and responsibilities of any other citizen.

    Should we also think about how well our systems work and be vocal about insisting on the basics? These three viewpoints all reinforce the need for adequate resources in ED and the important role of the triage nurse. The triage process can’t be rushed, is absolutely crucial for best patient outcomes and should be adequately resourced so that it can be done properly. OK a code blue does take priority, but it’s not as though a code blue is unexpected in an ED, we should have adequate resources for these as well, e.g. a code blue response team, MET team call it what you will.

    All EDs have busy times, these need to be communicated to the powers that be, and we need to be vocal about when we need extra resources and how they can be provided. Any staff undergoing such events as described above need some sort of debriefing or follow-up. This is clearly an OHS minefield for hospitals if staff then need time off for stress, burn-out, etc. A hospital needs to provide more support for prevention of violence, especially for high risk areas such as ED, not just push out a policy and a few ‘zero-tolerance’ signs.

  2. You know, it makes me sad when we have to “reward” this behaviour. No one should tolerate this crap, yet emergency workers deal with this every single time we go to work. And I don’t have time to think about this one person in the waiting room whilst simultaneously looking after the other 20 or 30 people-so I tend to capitulate and get whatever this abusive person wants, thus rewarding the behaviour. Or I get the team leader to deal with it and document. :)

    • You dumb bitch!, I hope your in seroius pain one day and no one helps you or gives you pain killers, See how you would act.
      People like you is why people dont get understood or helped.
      Next time you get in seroius pain…remember the man you just called said was a idoit.

      • I don’t know how mistreating and disrespecting the people who are there to help me is going to help them help me faster. I have been on that gurney in the ER with multiple dislocated joints. Did I scream and threaten and curse the nurse as a “dumb bitch.” No, I did not. But then I was raised better than that idiot who does than the person who does that.

        When you are in the ER, someone who comes in who can’t BREATHE out-ranks pain. Someone who come in BLEEDING out-ranks pain. Someone who comes in COMATOSE out-ranks pain. Sometime the only option is to suck it up, buttercup.

  3. @ Andy – would have to totally agree with you. Unfortunately, although we have a ‘zero tolerance’ policy within our hospital – it is often the patient who is screaming, swearing, throwing attitude that will be seen quickly (no matter how minor the complaint). Nothing in this behavior ever changes and often they are the frequent presenters. We are ‘encouraged’ to complete incident forms, so that these patients can be followed up at home by a local friendly police officer, where their behavior can be discussed but if this does actually happen – it makes no difference. We will still see these patients at their next presentation exhibiting the same abusive, “I am entitled to be seen first” behavior. We get kicked at, punched, spat at often in our role – and yet still have to deliver a high standard of care?????? The maintenance of professionalism of care is easier said than done at times!

  4. Jessica is right- though I did cheer for Andy. If antisocial behavior is the root problem, it would be best if he finished his wait in our locked psych room.

  5. I’m in agreement with John….three different perspectives written out like this can open conversations up that can lead to better policies, and better safety measures for staff…as well as solutions to care in the midst of the madness. While Andy makes great points, he offers no solution other than to protect himself and the ED staff at all costs…which means addressing Caleb’s behavior by putting Caleb in the slammer without dealing with the root problem (which absolutely could be the antisocial behavior, brought to light by the pain). I think finding the root problem is the challenge in every situation….closely followed by finding the right solution to the root problem.

    Jessica Ellis, RN, BSN
    Nursing Media Coordinator
    Nursing on Coursepark

  6. Think Meg’s comments lead the way forward. Maybe an idea for situations like this to have everybody’s perspective in the mix, for planners to create better solutions. Staff meeting could benifit from having this sort of thing read out and exploring different perspectives. Thus identifying trends and maybe keeping those who dont do well, out of the mix.good luck tho its not easy to fix this as its everywhere.

  7. Andy, I cannot compliment you enough for your contribution. The blog post is interesting, particularly the varying insights but at the end of the day this kind of behaviour needs to be met with consistent and firm boundaries. “Jane’s” behaviour, whilst well-intentioned, will simply lead to further behaviour like this in subsequent weeks from Caleb.

    Too often we excuse this behaviour with reference to social or psychological factors and the perpetrators, who are often very dangerous people, are free to repeat their behaviour over and over again. There should be zero-tolerance, it should be firmly and routinely applied and prosecutions should follow.

  8. I think we all have to remember the speciality of emergency nursing is changing, and to thrive in emergency nursing these days we have to understand what the profession is. “The provision of care to anyone at anytime – emergency has little to do with it most of the time.”

    Kane

  9. Top post Andy. Jane thinks shes done a good job, but now he knows how to behave to get what he wants.

  10. Thanks Ian. I think different perspectives are important. It’s so very easy to get caught up in our busy lives and see everything only through our own eyes. Human behaviour and interraction is so complex, I don’t think any one person’s opinion is every completely “correct”.

  11. On the other hand he still is being rewarded for behaving badly. If the two presentations were a week apart he has had time to attend a gp for ongoing pain management. All that has really happened is he has learned that getting aggressive and potty-mouthed will get him anything he wants. Pavlov would be impressed.

  12. A few observations:
    1) Caleb has antisocial personality disorder, for which there is no cure, and essentially no treatment. Sadly people with this problem eventually end up in jail, (as he’s already been), often repeatedly. Should we empathise with him for being dealt a rough hand? Maybe. Bad genes, childhood abuse, parents who were a-holes, falling in with a bad crowd, drug abuse to cope with his shit life and poor impulse control. Used to using physical threats and violence to get his own way is the only way he knows how to function. It’s a one-way spiral that we know too well. Does any of that explain his behaviour? Probably. Does it excuse it? Not for a fucking minute.
    2) Assault is the perception of a threat. If you feel threatened at work, you are being assaulted and your DUTY OF CARE CEASES. If someone touches you, that’s battery and is grounds for pressing charges. If they make threats to KILL YOU, that is another level of seriousness that mandates IMMEDIATE removal from your hospital, and a date in court. If Caleb walked into a pub, withdrawing from alcohol, assaulted the bartender and threw a barstool at the staff in his efforts to get a beer, then threatened to kill them, what would happen? Would they say “oh sorry, our bad” and give him a beer? Fuck no. He’d get extricated by security and taken away by Police, and charged. If Caleb walked into a bank after he got mugged and had his ATM card stolen wanting to get some cash out so he could buy his 3 kids some food, and behaved like this (& threatened to kill the bank teller), what would happen? Would they serve him and give him his money? Fuck no. He’d get taken away by the Police, if he didn’t get shot first, and charged. If he behaved like this in a GP Clinic or Specialists rooms, smashed up their waiting room then threatened to kill them, would they hand him a script for Endone? Fuck no. He’d get taken away by the Police and charged, and told never to return.
    3) Using a health problem as an excuse for this sort of behaviour is utter bullshit. It’s not tolerated ANYWHERE else in society, but for some reason when people walk through the doors of an Emergency Department, the normal rules of society suddenly evaporate, and assholes like Caleb get rewarded for this sort of bullshit behavior.

    Imagine the rest of the people in the waiting room. Kids with busted arms, earaches and fevers, elderly folk with the flu and UTI’s, the depressed and suicidal, the lacs and the abdo pains, the Cat 2 chest pains waiting on the chairs at triage because there’s no beds. All forced to wait another half an hour because poor little Caleb had a sore bum and couldn’t control himself. All of them forced to wait because a squeakier wheel was getting the oil….

    I cannot believe anyone would let someone like this jump the que, and then given him a Schedule 8 opiate, which will lead to constipation, worsen his heamorrhoidal problem, and reinforce his appalling behavior. That doctor needs a serious talking to.

    For those that read this and think I’m being harsh, or still feel sorry for poor Caleb, you need to know this. People like Caleb punch male and female healthcare workers, (ambos, nurses, security guards and doctors) in the face without thinking twice about it. Have you ever been punched in the face at work? I have. Once in a blue moon one of those healthcare workers is going to go down, strike their head on the floor and suffer an intracranial bleed rendering them a vegetable in a nursing home being fed through a tube, or they’ll die (remember David Hookes?). If you can show me a piece of legislation, or a hospital contract, or any ethical principle anywhere that says I as an Emergency Physician have to put myself, my staff, or the other patients in my ED at that level of risk, I’ll give you a million dollars. Just because someone has a “health” problem does not give them limitless rights to behave however the fuck they want, and threaten not just my wellbeing, but threaten my life and the livelihood of my family. Sorry Caleb, your sore bum isn’t as important as my kids having a dad, having money to put food on the table, get an education and have a roof over their head. If you can’t work because of your sore bum, and your kids are going to miss out on those things, then blame the fucking system, the health minister, God, or some other fucker, but it’s not the staff’s fault you have a shit life and can’t the treatment you need.

    Caleb needs to be arrested and taken away, and be banned from the ED for a while, not given Schedule 8 drugs for assaulting staff. No-one’s EVER died from a thrombosed haemorrhoid, so he can use fucking Rectinol and ice packs and wait it out. He also needs to be told that next time he shows up he can join the que, shut the fuck up, sit down and wait like every other poor fucker in the waiting room, and if doesn’t like he can fuck off and leave. Life on the outside has rules Caleb, if you break them, you go back inside. Sadly, some people never learn.

    • Wow Andy!!!! I agree with everything you are saying here but what a lot of anger you seem to have. People who present to the Emergency Department are under stress and this also affects the way they behave when presenting. To them their problem is the most significant TO them and they are unaware and uncaring of the OTHER more significant issues that must take precedence in the Emergency Department. Perhaps a little de-escalation here is as effective as arresting and banning someone who does not understand the process due to stress and pain. And I am not a martyr to the cause- I have just found that a little time and understanding can go a long way

    • Here! Here!

  13. I think from a patient point of view this is a really interesting story, and as a carer I’ve seen this many times. I think it’s telling that no one really had the time to get the full picture and meet Caleb’s needs until it escalated into unacceptable behaviour.

    I’m not sure what the answers are, but I wonder just how many Caleb’s will be in our local A & E over the weekend.

  14. Excellent stories! I really like how, not only do they present different views and motivations, they don’t completely overlap and provide the same information. A reader needs to read all 3 to get the full picture.

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