Psychiatric Restraint

A narrative medicine story

By the time I passed through the locked door between the hospital proper and the children's comprehensive psychiatric emergency program, there were already upwards of 40 people standing around.  Doctors, nurses, security guards.  I counted later, and it was actually 38.  Your brain remembers these things wrong, reliably.

The security guards looked particularly unsettled.  There were four of them. At Bellevue, the guards are all hospital police.  So they’re dressed like police officers, they stand like police officers, and kids respond to them like they’re police officers.  None of the names you will read are real.  Details have been changed for privacy.

“Nooooooooooo!” The shriek from within room one hurt my ears, and I was 2 locked doors away.  It has a combination of anguish and adolescent tonal instability that is both heartbreaking and ear-rending.  

I moved quickly and gave my key a quick twist to the right, and then another jerk, because the door had a sticky handle.  

I didn’t open it more than strictly necessary and essentially slid myself inside, pulling it closed behind me.

The click.  It was satisfying.  Now, whatever happens happens— but the door at least isn’t open because of me.  My control of the situation, thus, was exhausted. I tried to simply be.  It only worked so well.

The boy was tall, somewhere between 14 and 16, and the kind of slender body habitus meant that, to my eye, he hadn’t been in the system very long. Nobody had given this kid years of antipsychotics, yet with the associated weight gain.  He could pass for a private school kid.  He had straight hair.  It was unkempt, and puberty plus terror or rage made sure I could smell how much he was sweating.

I turned my head about 15° to the right, and I saw the Director of Nursing.  He was a short man, and I say that as a short man.  

The room in which this young person was pacing relentlessly back-and-forth was spartan. If bright white got sick to its stomach, that would be the wall color. There was a window with an extremely fine mesh metallurgical cover that once would have been called a grate. This safety device had clearly been clawed at by previous frantic children. 

The wooden bed frame was bolted to the floor, there was a thin foam mattress on it, but it didn’t have any sheets at this time, and there were two straps made of red nylon, one towards the foot and one 3/4 of the way towards the head.  The slight scent of chlorhexidine used to scrub down the mattress when the ER ran out of ammonia because of a budgetary crisis presented itself, tucked under the sweat.  There was a pillow.  That’s all that was in the room.  Bullshit excuse for a window.  Extra long twin bed. Bare mattress.  The nylon straps had what we’re supposed to look like not very menacing buckles.

This was the upgrade, probably mandated by the joint commission of endlessly modernized horrors, for the four-point leather restraints that used to be standard at the beginning of my training.  But nobody here was in any way confused about the intent of the bed, or the straps upon it.  They were designed to take the arms and legs of that child, pacing in that room, there, who looked terrified, frantic, anxious, and was screaming the word no, and give him no choice but to lay uncomfortably still.

And what turned out to be 38 people were crowded out in the hall, watching this robust young person, smelling this robust young person, fearing for this robust young person, fearing for themselves, as a child screamed, over and over again.  

“Don’t fucking touch me. Don’t you fucking touch me. Don’t you fucking touch me. No. No. No. No”

If a metronome had post-traumatic stress disorder and a history of psychotic mania, it would be this kid. 

I felt a hand on my shoulder.  The Director of nursing move closer to me, and, without taking his eyes off the young person, said, clearly and quietly in my ear: “ you’re the child psychiatrist on call?”

“Yes.” 

“Good.  You’ll do great.  The nurses already have pulled up a PRN.  I don’t think he’s gonna need it. Let me go in there first.”

Juan, without waiting for a reply, because frankly, we worked together enough to understand that I knew my place, smoothly walked from the hallway, pressed down the door handle, which was only pressed down for safety reasons, and opened the door to the child’s room, and entered.  He stood, with the door open, and his feet, angled at 45° to the kiddo.  This is the most non-threatening angle.  His position was breathtakingly in keeping with all training videos, but his stance said more than just precision.  One knee bent, slightly.  Contra-posto—Michelangelo, David, if he was a nursing administrator and 20 pounds overweight from all the overnights.

I was a first-year fellow at the Nyu/Bellevue School of Medicine child psychiatry fellowship program.   Managing psychiatric emergencies in the middle of the night has been my job for some time, because we do an ungodly amount of emergency psychiatry notations in the name of education.  Most of the sickest kids in New York, come through the space, and we have tried to reduce the use of restraint and seclusion, physical or chemical for years now. There had been news stories about how often children got what both they and the press colloquially referred to as “booty juice”— injectable Thorazine to calm them down, in the hopes of right away.

“Hi, I’m Juan.  I’m a nurse here.  I’m actually the director of all the nurses for kids here.  What’s your name?”

“(Mumble)”

“It’s nice to meet you.”

“Don’t let any of those people fucking touch me.”

“Oh, that’s good news; we’re on the same page about that.”

“What?”

“Well, I heard you were really upset, and people are concerned about your safety, so many people show up to make sure that nobody gets hurt, but that can be really scary. If you don’t know, that’s what’s happening.”

“It doesn’t fucking look like that.”

“It doesn’t look like that. Not at all.”

“Well?”

“I have a better idea. Do you want to hear it?”

“Sure,” the kids said. Softening a little bit.

“So, a restraint has been ordered. And I’m a nurse, so I don’t get to say if it happens or not.  But what the order doesn’t say is who does that restraint.  A restraint is when you lie down in that bed, and the straps go on your legs, and then go on your arms.  But the order doesn’t say who puts them on.”

“Don’t fucking touch me.”

“That is kind of my point. The order doesn’t say who has to put them on, and it doesn’t say how long they have to be on.”

“A little weird.”

“Kind of a loophole…right?”

“Maybe,” the young man said, suspiciously.

“Do you wanna hear my idea?”

“Sure” said the boy, more firm now, his eyes a little bit wider, ready to bolt.

“Well, why don’t you just put yourself in?  And then tell me when you’re ready to get out.  And then we’ll let you out.  You only stay in the restraints as long as you need to, for you, and then we did with the order said.  Then we can get on with figuring out how to actually help you.”

“Seriously?”

“Seriously.  That follows all the rules, you get to choose, nobody has to touch you, and we get this thing over with because I’d rather talk— bet you would too?”

“Ok…”

I don’t remember the words that were said next between the two of them.  I remember that he lowered himself down gingerly, and Juan showed him how the straps and buckles worked. It was like he was instructing another nurse.  The kid took it in, breathed along, now calm, and focused on the task at hand.  First, he put in his left leg and fumbled a little bit with the red strap.  By contrast, the right leg was in one smooth motion, and his left arm, even more quickly. From what I can tell, he even left just the right amount of room for New York City safety standards around these things.

“I have a question,” the young man asked.

“Yep?” Respond Juan.

“you know how to say that thing about not touching me? I need to take it back.  I need your help with this last buckle.”

“Good point” said Juan.  He gently placed the buckle around the child’s wrist, pulled it, not too tight. 

“So I can just come out anytime I want?”  Asked the young man.

“Yes, anytime you’re ready.”

“Give me a minute or two. I’m not ready yet.”

“I’m on standby”

One minute and 37 seconds elapsed according to the clock on the wall.  The officers had already moved themselves to the back of the room, towards the door, the nurses were no longer in a defensive posture.  

“How about now?”

Juan reach down, and undid the strap he had placed.  

“The rest are all you,” he told the young man.  

“Thanks, I appreciate it.”

As documented in my note, that night was a total time of one minute and 37 seconds, and I checked an electronic box to indicate that no PRN medication was administered intramuscularly.  This was documented again in a paper note, which will be required to also be kept in the chart for compliance with the Office of Mental Health.  My signature on that form ended up being the only reason I needed to physically be there that night.  

The state standard for the duration of that physical restraint was four hours— before a licensed doctor had to check; legally, for the first time, on how it was going.  And then once every four hours thereafter till it was concluded.

Juan had signed the leave forms for every nurse who was put out on disability that year after being assaulted. The pediatric psych floors had the highest rate of workplace violence against nurses that year.  Thirty-seven other people, including me, could have taken the lead and kept Juan perfectly safe.  The psychological safety of the person who would have to remember being restrained by a hallway full of adults isn’t recorded past the time on the compliance form. 

This is the story that comes to my mind when anyone asks me about moral leadership in health care.  Leaders demonstrate mastery and compassion not by avoiding risk to themselves.  They act in ways that are unforgettable, so they don’t need to teach skills a thousand times—they need to show one, do one, and you can’t forget the lesson.  Ever.

—Owen Scott Muir, M.D.

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