How Much Time is Enough?

A 30-something-year-old male presented to the ER via EMS. He has a history of methamphetamine use. On this particular day, he had not made any threats of violence, was not suicidal, and was not homicidal. He had not committed any crimes. However, his pre-hospital behavior resulted in him being brought to the ER.

When talking with him, he was visibly paranoid and regretful of the decisions he had made in his life. He was worried about people talking about him and spreading lies. He stated multiple times that he just wanted good for everyone and couldn’t understand why people were speaking poorly of him or blaming him for things. He expressed repeatedly that he did not want to hurt himself or anyone else.

He admitted to using methamphetamine in the past few days. In my experience, it’s challenging to establish an accurate timeline of when patients last used methamphetamine. I’ve seen many patients with heart rates in the 150s, agitated, fidgety, and appearing acutely intoxicated, yet they insist it has been days since their last use. My suspicion is that methamphetamine use distorts one’s sense of time. It also seems that the effects of methamphetamine can become chronic. Even if a patient hasn’t used that day, lingering effects may still distort their thinking.

After my initial interaction with the patient, I ordered the usual interventions, including a telehealth consult, since it was the middle of the night and no mental health professional was available in person. I also ordered medications for agitation to be used as needed.

I proceeded to see other patients but was called back to the bedside because this patient was making people nervous. He was in a locked unit, but there were a handful of rooms where other patients were also present. He did not want to lie down in the bed and rest, nor did he want to take oral medication to help his brain slow down. The nursing staff, security, and mental health assistant were all nervous because he was at the door of his room and appeared as though he could explode at any moment.

Again, he had not threatened harm to anyone. But if you saw him on the street, you would avoid him. He was on edge, unpredictable, and refused to take any oral medication to help him rest. He was not in a state to talk with the telehealth provider because his thoughts were so tangential.

I returned to see the patient again, accompanied by the nurse and two security guards standing by. This is not the type of patient you forcibly restrain and medicate because he is out of control. In fact, he was not out of control, but he had everyone on edge. The question becomes: How long do we stand there and talk with him, trying to convince him to take medication so he can rest and his brain can slow down? Five minutes, ten minutes, thirty minutes, an hour? Keep in mind, this is the middle of my ER shift. On average, I see two patients per hour. I don’t have thirty minutes or an hour to repeatedly have the same conversation with this individual patient.

My recommendation to him was to take the medication—in this case, oral Ativan, a benzodiazepine used for anxiety, sedation, and seizures. A 1 mg oral dose is not heavy; it’s the same dose and medication often ordered for people experiencing anxiety before an MRI.

I stayed at the bedside and talked to this patient for probably a good ten minutes. I explained to him that his brain was running too fast and needed to slow down, so he should take the medication. He would then reply with a tangential, random story about something or other. I would return to the same point: “Sir, your brain needs to slow down and rest so you can talk with someone about what’s going on. The best option for that is the medication we have here for you.” At one point, I told him, “Sir, I don’t mean to be a dick, and I realize I sound like a broken record, but my message isn’t going to change. You need to take some medication so your brain can slow down and you can talk with someone about what’s going on. I don’t have another option for you.”

Keep in mind, I have other patients to see. The nurse has other tasks, and security has other responsibilities. How much time can we afford to spend at the bedside with this single patient, which takes resources away from all the other patients in the ER who need care? What’s the right answer? He still hadn’t done anything wrong or committed any acts of violence. He hadn’t threatened violence, but he was unpredictable. He was at the door of his room with rambling, tangential speech and appeared on edge. Patients like that are unpredictable, so ignoring them is not an option.

At some point, a decision must be made, and that decision falls to me. In this case, he eventually agreed to take the oral medication so he could rest. However, if he had chosen otherwise, I might have been in a position where I would have had to forcibly restrain him and administer medication against his will. Nobody likes that plan. I don’t like that option. But given the constraints of the system I’m in, I can’t afford to let people get hurt, and I can’t allow patients who are on edge and appear ready to explode at any moment to wander around my ER.

My job is to protect the patient and the people caring for the patient.