Go Retire Psychiatrist

I just want to make a shout out to a former psychiatry resident I helped teach about 18 years ago. He and a group of other residents did an outstanding and hilarious job of making a couple of teaching videos about how to cope with violent patients.

I realize that news stories about health care professionals sometimes being the victims of violence from patients might make some think this is nothing to joke about. They were not joking. The video makes a good case for a method to manage the violent patient. It just makes it with an exuberant sense of humor.

As I recall, the Code Green team at our hospital consisted of a group of people specially trained to use non-violent measures to help patients who are violent get under control in order to minimize the risk of injury to themselves and others. These events are often intense encounters in patient’s rooms, hallways, lobbies, and other places in the hospital where patients who are confused and out of control can wander. First and foremost, we try to contain the patient to maintain everyone’s safety, and then ascertain why the patient is confused and at risk for imminent violence or already perpetrating acts of violent behavior toward themselves and others. This has to be done quickly so as to minimize injury.

One mnemonic, described in my chapter in our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry is CAN IT:

Amos, J.J., M.D., Assessment and management of the violent patient, in Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry, J.J. Amos, M.D., and R.G. Robinson, M.D., Editors. 2010, Cambridge University Press: New York. p. 58-63.

Containment before

Assessment before

Non-violent

Intervention before

Take down

The so-called CAN IT mnemonic is a reference mainly to containment before all else in order to protect everyone involved in a Code Green situation. An excerpt from the chapter on the importance of containment is:

“Containment refers to ensuring that you and the patient both feel relatively safe in the assessment area. Preferably, both of you should have easy access to the door for escape if necessary. At first, it may seem odd to recommend letting the patient escape from the room, but the point is not to force the patient to run over you to get to the door.

Another issue of containment is to ensure that the patient gives up any weapons before you agree to do the evaluation. Sometimes, offering food or drink (not hot enough to injure if hurled in your face) will help set a non-threatening atmosphere. It’s helpful to avoid making intense or prolonged eye contact with the patient, because this may be viewed as threatening.

Always make sure that plenty of other people are available to help you if a take-down situation develops.

Containment under these conditions sometimes is achievable by simply being honest with the patient who is still able to hear you by admitting that he/she is saying or doing things that make you afraid. This may seem counter-intuitive. But provided it’s delivered calmly as a statement followed by reassurance that you and everyone else involved are committed to maintaining the safety of all persons present (including the patient), this may capitalize on the patient’s own fear of losing control by assuring that you’ll do everything in your power to keep the lid on the situation.”

You can see the exuberant YouTube videos below, illustrating these principles made by talented trainees in our psychiatry residency program in 2008.

In 2009, Dr. David Mair, MD was the producer and director of the video. I think he’s now with Radias Health, St. Paul, MN. Below is his introduction to the videos:

Early in my training, I didn’t quite know how to react with potentially violent patients.  No amount of knowledge of medicine, physiology, or the DSM provided me the skills to address these situations.  Though we had excellent training during orientation, I really learned by observing skilled clinicians, and through my own encounters, both good and bad.  This was exemplified during my rotation in consultation-liaison psychiatry, when working with Dr. Amos, to learn his logical, step-wise approach, see him in these problematic scenarios, and to practice what I had learned. 

In making this educational video, I wanted to give incoming residents a quick way to make these observations, and present it to them in a way that was both useful and entertaining. It helped that I had a cadre of multi-talented peers and a faculty supervisor who recognized the utility of such a project.  Though managing these patients will be an eternal source of anxiety for all psychiatrists, my hope is that with this video, they will feel just a little better prepared. —David Mair, MD.

Well said, Dr. Mair. You were all very exuberant. He also made a short video about 7 years ago about the frustrating issue of bureaucracy associated with private health insurance.