Once, I came on for a night shift. At handover we learned how a patient with a long hx of suicide attempts had nearly succeeded earlier that day. She was both short and stick thin. She was on 1:1 observations. She was definitely depressed but not lacking in volition and energy. She had what we call ‘a trauma background’. She had a well-established intention and plans to escape her misery by suicide. In many ways she was a decent and ethical woman. Later she would have ECT and that is what started her successful recovery. I’m proud of what me and my shift did.
She was in her L shaped bedroom, in bed, being specialled by a nurse sat in the corridor outside the door, with line of sight on the bed and patient. The nurse was in a conversation with another staff further down the corridor. Perhaps because it was noisy and she couldn’t hear her colleague, the nurse left the bedroom door and went down the corridor to the colleague. The switched-on patient pulled her pillow under the covers to resemble her body, slid off the far side of the bed, now out of sight of the nurse, who was already on her way back. The patient silently slid herself along the floor into the part of the L shaped room invisible from the bedroom door. There was a tall wardrobe attached to the wall with hinged doors, about four feet high and some drawers underneath making the top of the wardrobe door 6 feet or maybe 5 foot 5 from the ground. Silently taking a bedsheet, she jammed it in the crack above the hinge, climbed up on the drawer unit, wrapped the sheet around her neck like a knot and dropped. Fortunately, the body, unlike the patient’s mind, does not want to die. It reacts and makes a lot of noise while doing so, thank the Lord. The nurse heard the patient gurgling for breath and slamming against the wardrobe. She screamed for help, held the patient’s (light) bodyweight up and staff arrived and cut the ligature.
(NB the next day, all the doors were removed from all the wardrobes.)
What I did next was assuredly NOT least restrictive. I was prepared to go as restrictive as necessary. At this point I was not engaging the patient under mutually trusting therapeutic relationship principles – how simply horrid of me – she was my opponent, she wanted the opposite of what I wanted and she was prepared to use any tool she could to win. Deceit, accusations, complaints, manipulating other staff against me – if she could. I expected she’d complain to our ineffectual manager the next morning. But I was going to win the contest – framed as ‘would she be alive or dead when morning shift took us off’.
She argued the toss on every point. Full lights on. Hands on top of the covers. No sleepwear. No knickers. Yes I do mean it and if you don’t take them off under the covers and hand them to the female staff right now, I’ll get a second female in here and they’ll take them off you. I’ll just turn my back while they do it. I organised the obs roster in a specific way, you don’t need to know about that. She was stymied. She knew she’d get nowhere on my shift. She’d just have to wear it for one night, bide her time and wait for someone else to let their guard down. Fortunately, no-one else ever did.
If you’re going to be more use than a chocolate fireguard in this job you need to be able to play both the ‘good cop’ and the ‘bad cop’ roles. Too bad, management have all but eradicated bad cops.
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