I came to believe that there's no one out there. No one but Weeza, that is. Weeza who took the time to comment on my blog, which I appreciate. Thank you, Weeza. Then a family gathering disabused me of the notion. They said they read the blog. You said you read the blog. So this goes out to my aunt -- you know who you are.

Someone told me today that she couldn't eat lunch because all her teeth have fallen out because they are Medicaid teeth. How do you respond to that? I said "Oh darn" (which is one of my stock phrases, along with "Fair enough" and "Well, to be continued"). "F*** you," she replied. Wrong answer, apparently.

I seem to be saying the wrong thing a lot lately, or at least my patients seem to think so. I have one guy -- he's a kid, really, who has an obsession with crafts and a hair trigger. It's an unsettling mix. He's big. Hulking big. With a boyish face, blond hair, red cheeks, and an awkward demeanor. Remember Mikey from Recess? He huddles over his various drawings and pictures, very intent. Cute, right? Just a big lunk of a guy, gentle giant, right?

Wrong. He's holding a basket full of lego and he asks to speak to one of the unit staff. I ask him what he needs, and he repeats the staff members' name as if I'm very, very dense. I tell him that I can try to help him if he needs something urgently I can try to help him, but otherwise he either needs to be in group or in his room. (That's the rule -- no goofing around or hanging around the nurses' station during group time.) Without missing a beat, he raises his fist with some plastic lego-like thing in it and makes like he's going to wing it at me! I was so surprised I think I actually ducked. He takes off down the hall, punches the phone, kicks some stuff, punches some stuff, swearing a blue streak.

Just about anything can set this kid off. Yesterday we're sitting together for just a few moments, and I tell him that he'll be going back to his crisis stabilization bed when he's ready to be discharged from us. "Who said that? I'm not going there!!"

"Your case manager told me it's all arranged."

"No way," he's yelling now, "I'm not going there!! That f***ing b**ch!! I f***ing hate her." Slamming of furniture and kicking commences as the yelling and cursing escalate, including demands to sign out of the hospital, return to mother's house and some nice, juicy bits about how much I suck. Ooops, said the wrong thing again.

At this point, you have to some quick thinking to do. Hopefully, you've already made the right decision about where to sit. Some people advise that you, the professional, should be sitting closest to the door so you can make a quick exit. Sound advice, but certainly not protective in every situation. First of all, positioning yourself between a patient and a door can make many patients feel trapped and nervous, especially patients with trauma histories or paranoia. Many patients are afraid of other people enough that if they start to lose control, it is more likely because you scare them and they want nothing more than to get away from you and return to their favorite activity -- usually lying in bed with the covers over their head. You want those patients close to the door.

Secondly, you might want to avoid turning your back on someone who's punching, kicking and throwing things, such as you might have to do were you to try to exit the room. Also, we have an obligation to the patients' safety as well as our own, and leaving an out of control patient in a room by himself only accomplishes the second thing. If you leave, someone has to go back in, probably with reinforcements. See above re: feeling trapped. As Sun Tzu says in the Art of War, a trapped enemy will fight to the death. He advises giving your enemy an exit to avoid unnecessary bloodshed on both sides.

In some rooms you can actually position yourself so that you and the patient are equidistant from the door. That's the best, I think. That way, you can try asking the patient to leave the room (he or she may very well cool off if you can just get the conversation to end and, if not, the commotion out there in the hallway will hopefully draw the attenting of the aforementioned reinforcements). And if he or she won't leave, you can walk out yourself (moving quickly enough to get out of the way of any flailing limbs or projectiles, but not so quickly as to add to the general air of tension and fear).

In the above situation, I started with telling the patient that the conversation would be over if he couldn't speak respectfully to me and control his behavior. Which SO did not work. Then I told him the conversation was over, and he actually walked out on his own. Stomped down the hall, slammed the door to his room. Of course, within minutes, he cooled right down and was back in the dayroom with his crafts.

I have to admit, I'm a little afraid of him. (Did I mention that he's BIG? And impulsive? He's like a 6-foot, 275-pound 6-year-old.) It's not a good feeling. Especially since people who are intimidating generally are pretty good at exploiting fear in order to, well, intimidate. And he uses his ability to intimidate in order to have unlimited access to arts and crafts projects. Not wealth, not power, not drugs, not sex. Popsicle sticks and glue.

I know when I put it that way, I sound pretty silly to be intimidated, but you really had to be there.

Until next time,

Madeline