jon's blog

i could go on for 40 days and 40 nights about my blog title and bore you to bits and pieces with 10,000 different ideas i actually had for the name of this blog but because of the 500 characters limit that is imposed upon this mechanism which, by the way, is supposed to promote free speech, i shall shorten it to just two words basically describing what the hell this is all about and who this hell belongs to.
Monday, June 16, 2008

why i never endorse the use of restraints on patients

i vividly remember my posting at the Institute of Mental Health during my nursing student days. it was an old building located at one of the most inaccessible parts of Singapore. true, there were buses and taxi and people living in the area, but the nearest train station was about a half-hour's bus ride away. in Singapore where our train stations are constantly expanding their branches and networks, a populated area like this being isolated from a train station is something out of the ordinary.

i recall the whole place giving me the impression of an English countryside. the complex stood proudly on a hill of green, like a grand old dame standing erect and stoically, watching the rest of the world with the eyes of weariness. maybe she's really tired, maybe she's on meds. who knows? what i did know and notice though is that a long winding road led to the main entrance. architecturally and scenery-wise, it looked like the place for a mental patient for a retreat. from a nursing and security perspective, well.... it's a long run down the hill if you're trying to escape. not forgetting the fencing and the security guards armed with tranquillizers. of course, you do realize i'm joking right?

on arrival, the lobby greets you with a very warm and relaxed atmosphere. genially friendly staff are there to guide you to the place you need to go. given that the complex is actually quite big, i daresay that it's a godsend. the aroma of fried noodles from the cafeteria and the scent of antiseptic wafts through the eerily quiet place, giving you the impression of hygiene and good food (which is the only way you want your food to be, no?). i allowed myself a wry smile as i thought to myself, 'i wonder if they serve noodles fried under aseptic technique'.

none the less, i was posted at a general ward which housed a grand total of about thirty male patients. some were truly insane. some were mildly off. some were questionably crazy. it's easy to tell the extremes apart. the really crazy ones and violent ones wore orange t-shirts. the questionably crazy ones wore the blue. but sometimes when i talked to those patients, i found myself wondering if they really deserved an orange after all. not because it's more suitable for their skin tone or it looks better on them, but rather the content in their conversation seems rather.... off+++. for all it's worth, several plastic shields and batons were hung in the nursing offices for emergency uses. and i'm sure those equipment are no respector of t-shirt colour.

one of the patients i talked to was a jovial old man who seemed like a mentally-healthy person. he talked about coffee and he talked about politics. and when he talked about politics, his face had this glowy 'in the zone' kind of look to it. it was obvious that he really enjoyed talking about politics. i wasn't that familiar with the local political scene during those days and i took everything he said at glowy 'in the zone' face-value. i mean, it really made sense and it didn't hurt to actually believe in the governmental conspiracy theory that he was relating about. unfortunately i decided to discard what he said on the second day when i started getting chummy with him. he pulled me to one corner of the psychiatric ward, and he whispered to me in hushed tones.

'Eh boy! since you're so nice to me, i'm going to give you something!'

'And what are you going to give me, uncle?' i replied with a cynical tone.

i was half-expecting some junk or some sweets or something silly. after all, these patients had very few physical possessions to begin with. this was for fear of them injuring others or hurting themselves. it was almost like Prison Break, except that you've got an all-star Asian cast. and the orange and blue t-shirts of course.

'I will give you....' he held his breath as he fumbled in his pockets for the mysterious gift, 'the personal phone number of the president!'

from his pant pocket, he took out a note book. it was the old and ratty type that punters and gamblers used to take down sweepstake numbers, copy down names of winning horses and quite possibly the mobile number of 'Krystal' who offers lapdances at bargain prices. he asked for my pen and proceeded to write down the number on a piece of paper. intermittently, he would look around to see if there were any Internal Security Act Agents standing around to arrest him. he tore the jotted-down number from the punter's notebook and handed it over to me.

'Don't look at it until i've gone away!' he said again in a harsh whisper that was in close proximity to my right ear. unfortunately, my Jackie Chan nose was also in close proximity. i could smell the fetid breath of halitosis as he quickly attempted to mingle with the rest of the patients again.

when i opened the folded piece of paper from the punter's notebook, the following numbers to the president's personal telephone were written down in a somewhat childish and untidy scrawl:

1 2 3 4 5 6 7 8 9

indeed, government conspiracies. he was really funny though and i enjoyed his company thoroughly.

another highlight of that particular posting in the institute involved a fellow nursing student. this fellow nursing student was the ardent Christian type. the type that says grace before food, the type that drops the name of God intermittently in every two or three sentences. the type that says 'Thank God!' and really means it as 'Thank you God my precious saviour and all that thou hath done for me!' aside from the zelous nature of hers, she's pretty and she has a mole on one cheek that really befitted her. i called her 'The Christian Beauty Spot'. i found her enjoyable to talk to and we shared a lot on how our churches are like and alike.

none the less, Christian Beauty Spot and i were on duty that particular day. she mentioned in the morning that she felt tired and weak. i shrugged it off as a lack of breakfast. and as if to chastise that nonchalance to her general body condition, she fainted right there and then on the spot. i manage to catch her in time just as a few other patients were trying to make a grab for her. according to other nursing students, they had a lecherous look on their face. i can't really tell if that was true though i seriously think they were trying to catch her too.

but that's the problem with mental health: how mad is mad? is eccentric really mad? and can mad be sometimes simply shrugged off as eccentric? the homeless chap whom you pass by everyday - everyone so readily labels the poor chap as insane and mad. but the professor of science and the arts and all his weird little idiosyncrasies is no more than eccentric. there seems to be a bias in place when it comes to the definition of madness.

none the less, over a cup of milo in the tea room, she thanked me. there was a look of adoration in her eyes that i felt really embarrassed about. not helping was that her beauty spot of a mole turned into a dimple when she smiled. charming. over the next few days, she kept would bring up the event and reinforce to me that she had had breakfast in the morning. to which we would have a good laugh over and reenact the moments and snippets when she fainted. at the end of the posting, she gave me a CD of a sermon by a famous preacher in her church. the title was something along the lines of wealth and health.

these days when i see her in the hospital, she still looks pretty. my father inherited the CD which she gave to me and occasionally listens to it with plenty of scorn and cynicism.

--

the concept of restraining patients in the hospital setting has always been one of questionable ethics. when do you need to restrain a sick person? why do you need to do it? is there no other alternative? what about sedatives? how do you go about doing it then? do you know how to tie a knot? why do they call it 'tying the knot' when the only firm sort of knot that you know of when 'tying the knot' is most likely a 'dead' knot?

rubbishy questions aside, the ongoing understanding from having worked in the hospital for several years coming seems to be that only restrain when the patients is doing something harmful to themselves. then again, how do you define harm? a person slashing their own wrists and doing bodily injuries to themselves or others is definitely within the boundaries of harm. but a 'naughty' patient who tries to remove his blood transfusion cannula and refuses treatment when he's already of a questionably unsound mind and low haemoglobin level seems to fall under that category as well. there's loads of factors to consider when the decision to apply restraints on someone is considered.

even so, application of restraints comes with the proper technique. cotton pads are applied to the wrists when hand restraints are used. charts have to be set up to ensure that the nurses check on the restraints regularly to see if they are too tight. the doctor has to be informed. the relatives have to be informed as well. and there's the fact that most relatives, just like parents who receive news that their child has done something wrong in school, almost always refuse to believe that their loved ones are unmanageable to the point of restraints. i knew of one patient whom a colleague had restrained in the afternoon. throughout the night shift, that particular patient's relative constantly called every hour or two to check on the condition of the patients. she apparently slept peacefully throughout the night.

in my humble opinion and principles (hey, i actually do have some of those okay!), i don't really believe in restraints. it's demeaning and besides, most patients on restraints tend to struggle even more than they previously did when they were unrestrained. this basically ends in really knotty situations whereby you spend even more time undoing the restraints that were enforced on the patient. actually, come to think of it, i'm about as capable with tying restraints as a junior boy scout member. i mean, i can do enough knots to get through a couple of shoes, a neck tie, a wedding gift, a plastic bag of general waste and perhaps a session of light bondage that is not even convincingly tight. but since when was a Windsor applicable to a pair of hands? which is why every knot i tie ends up as easily removable as a shoelace or as permanent as a dead knot. most of the time, i cut the damn thing off with a pair of nursing scissors.

my other colleague whom i work with on the permanent night shifts is a strong advocate of restraints however. she's been in this permanent night business for about three years coming. and believe you me, three years of irregular sleeping hours and horrid colleagues handing over terrible work for you to follow-up during your shifts can really make one bogged down and burned out. she has the dark eye bags and permanently tired look on the face to prove it. six months into this gig and i have already sallow skin and a permanent frown on my face as battle scars.

my colleague usually considers restraints after three warnings to patients against whatever silly things they are doing. some are plainly confused. some are irrational. other are just bordering on pure disobedience and bastardry. why come to the hospital when you're going to refuse treatment and cause so much trouble? either way, i think that the 'three warnings' system is quite possibly the best method to go about hinting at restraints. but then again, i'm stubborn and stick to my principles sometimes like a frozen tongue on an alpine ski lift.

i steadfastly refuse to restrain my patients. so much so that if they are restrained at night, i would secretly untie them in the dark of the night. Pangkeng (whom i have taken to calling 'Xena, Warrior Princess these days due to his overall lack of gentleness) gets extremely pissed when i do that. most of the time, the patients don't really do much damage themselves. they pull out their cannulas, they attempt to climb out of bed (but rarely ever manage to do so). nothing that can't be resolved. in fact, most of them actually sleep better at night when they are unrestrained. but then again, the only patients i usually nurse are men.

now, the reason why i brought this story up was simply because of a lapse in my principles several weeks ago when a patient under the charge of my colleague was admitted for a suspected bleed in the gastro-intestinal tract. her blood count results showed a low of about 7.0mmol/L. couple that with a previous history of a duodenal ulcer and she was thus scheduled for a scope the following day. during the course of the night, she was transfused two bags of bloods to 'top up' her blood supply. according to my colleague, she was really nice and all during the day when the bloods were still transfusing. post-transfusion however, she was caught attempting to leave the bed.

there was nothing wrong with actually leaving the bed, but the fact that she actually leaving and walking all the way down to the other end of the ward corridor - now, that's a worrisome fact. we asked her of course, what she was trying to do by walking down from one end of the corridor to the other. she just said she was looking for her relatives. it was about 3.20am at that point of time. when i thought about it, it was pretty obvious that she was trying to look for an escape route from the ward. she was constantly opening doors and on the lookout for an exit. not helping was that she did the above-mentioned with all the subtlety of a brass band's percussion section.

as nurses, we always attempt to try the nice method first. the more forceful alternative would always remain as a secondary plan. of course, the forceful words always come after we settle whatever issue a patient has at the pantry ('What is wrong with this old man? he wants me to hold his penis so that he can pee properly???' - this is true, i heard it at the tea room before). we attempted to convince the old lady to go back to the bed and take a rest as her blood levels were low and she was at risk of fainting at any moment. we tried helping her by guiding her at the arms. she slapped my hands off and ended up slapping me in the nose. which basically gave my Jackie Chan nose a reason to start up a sinus party. i couldn't stop sniffling after that.

after parking her in her bed, she attempted three more 'escapes'. 'escape' is in inverted commas as there was absolutely no stealth in her attempts. you could hear the loud click as she undid her bed rails. the flip-flops she was wearing truly lived up to their noisy names. one bizarre thing though that made us question whether she was of sound mind or not was that she didn't even try to run or walk briskly. she was actually must sauntering about and looking about for that elusive escape route of hers.

and thus a final warning laced with a hint of restraints was issued to the lady before we enforced on her the inevitable. i couldn't bring myself to do it as i was just being a real prick with me and my principles. but one could really hear it was a tough job despite the fact that Pangkeng was there to help. bloodcurling screams and shouts pierced through the quiet night air. and Pangkeng was occasionally spewing vulgarities. he only uses vulgarities when he's with me or when violence ensues. so he was obviously getting physically abused. it was either my friend getting kicked or my principles. i decided to screw them for once and help Pangkeng.

at the bedside, it was truly an ugly scene. gauze wrappers were strewn all over the floor. blood could be seen trickling out from an ex-cannula site that the lady had forcefully ripped out from a vein. the lady was screaming, shouting and kicking everything and everyone in sight. the rest of the patients in the same room as her had woken up and wondering what the commotion was all about. she had even managed to pull her pyjama top open. a button lay at the side of the bed and she had one breast exposed. she looked savage and she looked vicious. in my mind, i made the mental connection between the lady and the harpies in Van Helsing. my colleagues got bitten and pinched. i got kicked twice in the chin. Pangkeng, the warrior princess got slap on the face and his balls kicked. but he's resilient.

it was with all that violence that we decided to reinforce the entire set of restraints - a body vest, a pair of hand restraints and a pair of leg ones. Pangkeng did the ultimate of plonking his entire hulking 98kg frame on her legs to stop the kicking. and it's really ugly to see a woman scream and shout when you usually see them very well in control of their emotions. i felt bad as throughout the whole ordeal, she was screaming and appealing to us not to tie her. she mentioned that we were bullying her as there were four nurses tying her up. she stated that she was old and that tying her up was a sign of disrespect. being Chinese and having a father who imbued me with respect for the elderly, i really felt that the whole thing was... demeaning or disrespectful or well, i can't pinpoint an exact word. but i hoped that i was doing the wrong thing for at least the right reasons.

and restrain the lady we finally did. exhausted, Pangkeng and i decided to head to our secret spot in the hospital for a quick smoke. when we came back an estimated fifteen minutes later, we found that the entire bed had been shifted out to the ward corridor in front of the nurses' counter.

'She actually managed to undo her restraints!' my colleague exclaimed in exasperation.

upon closer inspection, 'undo' was not really the correct word. she actually ripped out her restraints. and those weren't soft, cottony gauze restraints. we used linen restraints that were double sewn at the seams and connecting points for extra strength. as we did her restraints again, she got even more violent and abusive this time. somehow or other, she managed to get hold of a bottle of Chinese medicated oil that she stashed underneath her pillow. she start sprinkling the entire vial of mentholated fluid at us. it was burning. it was hot. and resolved all of us nurses to quickly get the job done.

when we managed to restrain her the second time she suddenly started singing a bizarre song in Hokkien. there were some old Hokkien words in there that i couldn't understand and my Hokkien is l33t. but what i did grasp was that she was trying to call upon the spirit of her in-laws to destroy us. and being Chinese, calling your in-laws for help is sorta like the last resort, given that most Chinese in-laws are quite the horrible bunch. we were kinda freaked out as her unnatural strength, her loud screams and shouts, her Hokkien in-law song... we were thinking along the lines of demonic possession actually.

suffice to say, when she was more settled down and asleep from all the physical exertion (or maybe the demon left her, who knows?), i managed to catch a breather with my colleague.

i asked her, 'you think it's worth it to tie her up after all that kicking and scratching?'

she was scratching at the already inflammed area on her arm where the medicated oil had landed. on her other arm was a slight hint of a bruise. the other arm was a redness that came about from a pinch from the patient.

'maybe,' she said, 'i mean, it was either her or us.'

was the lady with the low Hb condition mad to begin with? or was she just plain 'naughty'? those thoughts made me pensive for the rest of the evening.

but i'm thinking it's mainly due to me being really anal about my principles.

posted at 9:28 am by the nurse | Permalink |

17 Comments:

hey jon..

good morning! i suppose you just back from night shift and blog before you went to bed. i did my work overnight and just broswe through your blog before i went to bed.

i had not gone to IMH but i know it is pretty discriminatory in the 1980s, when someone said he knew someone who was from woodbridge, or live near woodbridge. pple used to make jokes using woodbridge as well. i think the change of name to IMH eliminates some of the fear..it sounds more like a hospital than a 'madhouse'.

i remember when i got sick in army and was send to a ward. it is full of terrace houses, full of trees and quiet. i was alone in a ward and asked what hospital is it. the nurses said ttsh. i was surprised as it does not look like 'C' ward of sgh or cgh. i stayed there and bathed (using the public soap) and my dad came to visit me. he told me my mum was not coming. i thought 'why'? i passed by the place and could see patients are isolated. hmm...is this a 'A' ward, all patients are so rich? then i happen to see a patient sitting on the floor, body full of blisters and marks. i felt pitiful for her trauma.

then when i go back home, my mum told me it is cdc where some pple with terminal illness stayed there, that is why she dared not to visit me. alas! i was there without knowing that pple are suffering from the stigmatize disease and i even used the public soap! but this fear fades away over the years as i learnt more about this stigmatize disease. i suppose I shld take a walk around IMH to eliminate any of my fear eh?

sermon CD..i suppose she 'rock'? i know of huge local charismatic churches preaching "prosperity gospel" which are considered heretical to pple like the father...did she preach the gospel to you and invite you to her charismatic church eh?
By Blogger asianthirst, at 10:50 am  

funny and entertaining.. great work
By Anonymous siao, at 7:13 pm  

I love my mad patients when they are not delirious...

that lady seems to be in pretty bad shape... was she in sepsis or something?

brachy
By Anonymous Anonymous, at 11:14 pm  

A very entertaining entry, i can imagine like a demonic possession story, you should send it in to Ch 5 Incredible Tales!!
By Anonymous Night Shift Worker, at 8:55 am  

principles serve as guidelines but they need not be rigid.. depends on circumstances..

i mean, it's either the patient gets hurt or you get hurt or anyone else.. where do we draw the line at that? =)
By Anonymous junior, at 7:07 pm  

Woodbridge. yeah, I think the name's synonymous with madhouse over there - just as Tanjung Rambutan is over here. Just like you I found Tanjung Rambutan far from the deranged mental asylum of my sick imagination.

Looked more like a hill resort honestly.

And then came this fella ranting about stabbing folks wielding his rolled up tee shirt like a weapon.

Hmmm..
By Blogger savante, at 8:14 pm  

ur job is highly hazardous.
By Anonymous Anonymous, at 12:27 am  

when i went for my imh posting restraints seemed to be few and far in between. and those who got restrained cooperated rather quickly and knew how to let themselves out after they had calmed down.

however i was in a male ward which was considerably calmer than the female wards above and below for i could always hear screaming and the crisis alarms set off at least once per shift. hmmm.

most of the patients that were 35 and above seemed to be oddly fixated with LKY and company. that is something that still puzzles me til today.

i don't endorse restraints per se but sometimes there seems to be no other alternative. there was once it took 4 of us to hold down an elderly lady who fought us off with such brutal force that all 4 of us landed up with various scratches and bruises. ironically she calmed down after we were done with the restraints -_-" the next day she was prescribed some oxynorm and everything was fine and dandy.
By Anonymous Lulu, at 11:45 am  

awww.

you made me miss working in the hosptial!
By Blogger gApple, at 1:20 pm  

i didnt realize working in such an institution is so full of risks. great post Jon.
By Blogger Bengbeng, at 9:52 pm  

remind me of my clerkship @ the psychiatry department! anyway, your IMH is a lot better than we have here in indonesia. we do have some restraints, though. the mental institute that i was studying at is an old complex of the county general hospital, so it's pretty big, but lots of damage here and there. being there for almost 5 weeks gave me the sense of pity rather than worried to all the patients.
By Blogger luke!, at 6:58 pm  

I'm totally guilty of undoing restraints (temporarily) when a patient is of no immediate harm to him/herself or others, and more the victim of a restraint-crazy RN or MD based on inadequate staffing to assign one-to-one and/or just feeling overwhelmed by the situation/patient. It's also been my experience that male psych patients will struggle with the restraints for a bit and then give up, while female psych patients will continue fighting the restraints and staff for hours on end (even after a sedative has been administered). I'm not saying that to be sexist, but really just an observation.

I can do a quick-release knot, but I remember when learning about restraint knots, there was one 'figure-8' knot that nobody (including our instructor) just couldn't figure out. We eventually had all nine of us students and two instructors trying to figure out the directions in our textbook attempting to do the knot. It became almost a competition as to who could get the knot before anyone else. After 10 minutes, I began to think, "How many nursing students and instructors does it take to tie this knot?" In addition, I don't remember ever learning about knots in Boy Scouts... guess my mind was on 'other' things.
By Blogger DChizzle, at 9:08 pm  

reminds me of "delirious" from the sandman series...
By Anonymous ju, at 1:09 am  

Wow, that stuff is crazy. No pun nor offense intended, but I admire your resilience and patience. :)

Now when are we meeting up again!? I have a feeling the Lous are leaving soon. :(
By Blogger prawninator, at 2:52 am  

asianthirst: nobody likes to associate themselves with the mad and the diseased. but i'm thinking that it's all perceptive actually. having worked in the hospital for years, i think i've actually collected quite a few flu bugs and viruses. not that i'm sick or anything, but medically speaking, hospital workers are one of the most 'dirtiest' people around.

siao: haven't seen you around before, thanks for popping by and leaving a comment!

brachy: nope she was not septic. just very stubborn and having an ardent dislike for hospital in general. it's an old people thing i guess. not proven. just an observation.

NSW: i should. but incredible tales is actually quite tacky and very meh.

junior: you brought up a really valid point, junior. my principle is that when there's physical harm involved to oneself or others, that's where i draw the line.

savante: what a bizarre name this Tanjong Rambutan. but then again, we have Bukit PANJANG in singapore. it leaves you mentally wondering what so PANJANG about the hill, which isn't that long/high/tall anways. it's a hill!

lulu: sedatives seem to be the only way to tackle the deranged women, i've noticed. the men most of the time, i can reason with them before i really have to employ the use of restraints. and i'm not being sexist here, but i'm sure most health care workers notice this as well.

gApple: it's fun to work in the hospital. believe me. i have plenty of stories to share. just that there's a confidentiality bound thing going on.

BengBeng: thanks. nursing isn't easy. i sound like a commercial for nursing when i say this, but the internal rewards are really worth it at the end. job sassafraction and all that.

luke!: mental postings are actually quite relaxed. most mad people are actually quite okay until provoked. and nobody goes round provoking mad people other than children and people who are just asking for it.

Dchizzle: hey! haven't heard from you in a while. glad we can relate on the undoing on restraints. i feel really bad about restraining old people. i mean, maybe it's a chinese value kinda thing, but it's totally disrespectful. as for knots, i'm still a dead knot person. but most of the crazed men are strong enough to just rip out the whole thing. so dead knot or not (pun pun!!!), it doesn't really matter to me.

ju: my memory might be incorrect, but i think you are referring to Delirium, no? Sandman is a great series none the less.

prawninator: awww. you flatter me. none the less, the Lous, again?!?!!! then it's gotta be soon!
By Blogger the nurse, at 2:58 pm  

Yeah!

Used to work in the same institution as you for 4 years (:
By Blogger gApple, at 6:00 pm  

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