Monday, February 22, 2016

Downey VA Hospital Implements the One Bite Rule

As  you age, events from the past that seemed like an acceptable practice when viewed through the eyes of a youngster come back to haunt you. The event I will be describing seemed like an unusual but acceptable practice when I was a young nurse. Now it just creeps me out and seems cruel and indefensible..

At Downey VA Hospital in the early 1970's there was an expression that said; "The right way...The wrong way...The Downey way."  Downey was an 1800 bed long term psychiatric facility that was the lifelong home for people with serious mental illness.

One of the problems encountered at Downey was patient assaults. Patient to patient - Patient to staff- and patient to civilian (usually innocent visitors.) These assaults were so common that the administration had a form letter prepared for the victims. I don't have a copy, but the essence of it was that Downey was unpredictable, the assault was not a deliberate action, preventive actions are not always successful (no kidding), and we hope you have a speedy recovery. It also went on to state that only a small minority of Downey patients were assaultive which was true.

There were 2 categories of special observation at Downey, Suicidal and Homicidal. For suicidal observation, the patient was always within eyesight and never more than 8 feet distant. You never turned your back on a homicidal patient and tried to keep a physical object like a desk or dresser between you and the patient. A good pair of running shoes was a prudent choice.

We used to have practice  drills using a mattress as a type of shield to corner an assaultive patient and then upon utterance of a previously  agreed code word, have 4 people grab an extremity and transport the patient to a seclusion room where leather restraints were used.


The variety of weapons used in these assaults was unimaginable. I have seen pool balls hurled at such a velocity that they actually chipped brick walls and pool cues used as bats and skewers. The triangular device for racking the pool balls could be forced over a hapless  victims head and used as a collar.

 Ping pong was supposed to be a safe replacement for pool, but I never thought that an ENT consult would be required to remove a ping pong ball from some poor soul's sinuses. What ping pong paddles lacked in mass could be made up by swinging them at a velocity that was probably greater than the speed of sound. I swear, sometimes you could hear the victim scream before the smack of the paddle striking their head.

Another type of assault at Downey was biting. Ears, fingers, arms were all areas prone to receiving human bites. One psychopath actually sharpened his front incisors with a fingernail file and then strutted around smiling menacingly at potential victims. This type of assault was aggressively dealt with at Downey VA.
CAUTION: The one bite rule is being aggressively enforced.

It was widely known that there was a one bite rule in effect at Downey. Whenever anyone received a bite the assaultive patient was told that if this occurred again, all of his teeth would be extracted. There were no appeals or consent, the second bite triggered a full mouth extraction.  This crude, but effective strategy did work. Pulling the teeth worked like removing the bullet from a gun. Not only were the sharp injury producing teeth absent, but the distance the mandible had to move to inflict  a bite  was increased. The increased mandibular travel greatly decreased the pressure of the bite.  I heard one edentulous, assaultive, biting  patient threaten to "gum the hell out of you," but was never able to seriously hurt anyone by gumming.

The patients teeth were extracted in the operating room under general anesthesia. A naso-tracheal intubation was done  which provided anesthesia residents a chance to use Magill forceps. The throat was packed and all teeth were removed. It seemed like a reasonable idea at the time, but now seems barbaric to me.

There was one patient named, "Alfred" who must have been very difficult to deal with. He had both a lobotomy and full mouth extraction done. His hands were in constant pill-rolling motions caused by the Parkinson's induced antipsychotics. I can still visualize his toothless mask like face as he walked up to my med cart for his 2000mg. Thorazine  HS  dose. When I questioned the dose, I was told he had been on it for many years so don't skimp on it. Senior nurses always advised to add a little extra of the Thorazine Concentrate because, "Some of it always sticks to the medicine cup."  I declined.

The treatment of mentally ill patients always bothered me. It would be nice to think that mental health care has improved, but when you consider prisons and jails have become the default provider of mental health services, it's questionable.

Any thoughts?




1 comment:

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