Funny how things can trigger memories
Having written earlier this week , I started to recall the first time in my medical career when I was involved in which an acutely agitated patient required physical restraint and pharmacological sedation. This is commonly referred to as a “takedown” or “rapid tranquilisation”. In more recent years I have heard it referred to as “drop them” implying the use of droperidol as acute parenteral sedation. I dont use this term and dont endorse its use. Acute sedation should be used to reduce agitation and arousal so as to allow adequate assessment of the patient and to reduce risk of harm to themselves and those caring for them. The notion that it should be used to render them physically unable to stand up and hence drop to the ground is offensive in my opinion and trivialises the risks of sedation.
There are many firsts in medicine. Some you will never forget. The first baby you delivered, the first patient you pronounced dead. The first patient who suicided. Now I know some doctors will go through their entire career and never have to deal with an acute behaviourally disturbed patient needing sedation against their will. But many of us have had to do this. Certainly readers of the PHARM would be within that group. If ever you have had to work in an emergency setting or dealing with folks high on the latest street drug or just out on an alcohol fuelled binge of disinhibition or both then you will understand.
It was not long after graduating from medical school. As a junior hospital doctor I was doing a psychiatry rotation. It was late in the shift and a young woman had been brought in by the community mental health team under an involuntary mental health order for assessment of acute suicidality. I didnt know anything about her but it was my job to admit her to the ward so I went out to assess her. She was sitting with the mental health nurse in the foyer outside the nurses bay. She was tall and gaunt and didnt look happy to be there. I introduced myself,making sure I didnt sit between her and the exit door and asked her if she needed anything right away. She asked for a cup of tea and the nurse went and got her one.
I started to explain to her that she was on an involuntary mental health order when she smashed the ceramic mug and then thrust the jagged edge of what remained in her hand towards her throat and yelled “I’m not fucking staying here and you cant fucking make me! Dont come close or I’ll cut my throat!”
I did not know what to do but luckily the nurse did. He dragged me back into the nursing bay and called for help. The psychiatrist on duty was nearby and he quickly came over. He decided immediately that the woman would need to be physically restrained and sedated and it would take a team of us to do this safely. Sedatives were prepared, clonazepam injection as well as haloperidol and roles were assigned. I was supposed to distract her and the psychiatrist would try to get close enough to grab her hand wielding the broken mug then nurses would grab each of her limbs to do a controlled restraint to the ground. Sedatives would then be given either IM or IV depending upon how easily IV access would be in a struggling patient.
The woman was remarkably, still outside in the foyer. Apparently she needed a car to get to where she wanted to go and had decided best way to do this was to kidnap one of us with her and take their car. As I was first one to approach her ( remember I was the distraction) she chose me. “ok you are going to take me to your car and then we are leaving in it. If you dont do what I say I am going to cut my throat open!”
I didnt know how to react to this demand and glanced at the psychiatrist. he nodded slightly and said “Ok thats fine, you can go. Minh go and get your car..”
As he was saying this he was slowly approaching the woman , with his hands help up, palms open facing her. he looked at me and said “Ok Minh go get your car now”
I started walking towards the exit door and the woman turned slightly towards me
Then the psychiatrist pounced and grabbed the woman’s arm/hand holding the broken mug.He got punched around the head with the woman’s free hand but as he was bigger than her, dragged her to ground and yelled for the team to help him.
Nurses grabbed a limb each and quickly controlled the woman. The psychiatrist held her arm that had been hold of the broken mug which was now on the floor and he told me to find a vein to give IV sedation. In fact to aid me he found a vein for me and held her arm whilst I inserted the IV cannula. The sedatives were given and the woman became drowsy but remained awake. We placed her in the seclusion room and then the psychiatrist told me something I have never forgotten
“Now that we have sedated her, it is our duty to ensure she is safe which means we go back and check on her regularly”
