Tuesday, July 26, 2016

It's a Bird!..It's a Plane!..No, It's a Patient!

Hospitals tend to elicit the fight or flight syndrome in some patients. This is a contemporary image but you better believe the problem is timeless. I have had to contend with birds like this decades ago.

When assessing patients for flight risk here is a helpful pneumonic mnemonic  device from The OldfoolRN Institute for Enlightenment. It's elegantly termed APE because all primates love to climb and it's easy for old fools like me to remember. Now if I could only recall what I ate for breakfast!

A -  represents alcohol which causes patients to do all kinds of silly things.  If your patient has imbibed welcome to the world of unpredictable events. I know you whippersnapperns are fond of algorithms and computers to predict the outcome of events, but if alcohol is involved you are on your own when figuring out when your patient may take to the skies.   From my experience in the OR with trauma patients, alcohol causes more pain and suffering than cancer or heart disease. Trouble in a bottle.

Drugs are also capable of altering consciousness to the extent that elevation events are possible. Amphetamines, cocaine, and even heavy marijuana use can be the wind beneath the wings of contemporary ascenders. It is prudent to limit the opportunity for patients to climb, but a determined and drug intoxicated patient can always find a way to the ceiling. Onward and upward.

P is for psychosis. It's really sad that someone would comply with voices telling them to do dangerous activities. When I worked at Downey VA hospital there were two water towers and each of them was surrounded by security fencing. I remember one patient that tunneled under the fence (ground hog style) and proceeded to ascend the ladder on the tower. Luckily, he was easily lured back down with the promise of a pack of cigarettes. When we asked him the rationale for his climb, he provided the  mountain climbers mantra, "Because it was there."

E is for elevation opportunity. This can be tricky to assess, but anything overhead could be climbable. Here in Pittsburgh, many of the old industrial jobs required climbing. I've cared for many steelworkers and they are some of my most memorable and treasured patients. A dozen steel workers would be more fun to care for than a single stock broker, but that's a story for another post.

One time I walked into a patient's room and found him on top of the traction frame. He had been incontinent and was carefully positioning little compacted spheres of stool down on the dangling trapeze.  When I asked him what he was doing the indignant response was, "I am mixing cement." The elevated positon made clean up much easier and a Posey belt tethered him to the bed. Anything overhead can be used for elevation.

I never had to worry about legal implications or litigation, but times have certainly changed. Just about any untoward event could be fodder for litigation. No matter how careful a nurse is , bad things can happen and the nurse in the above illustration has a clever risk management strategy. It's called going dark. Whip off that nametag and slap on a mask.

One final tip. Avoid going vertical after the patient. It only encourages them onward and upward.


  1. LMHO!!! I know this situation all too well! Also beware the 72 hr. time limit... that is when the DTs start!

  2. “A dozen steel workers would be more fun to care for than a single stock broker.” Priceless.

    1. Before moving to Pittsburgh, I had a not so enlightened view of men that spent their lives in sustained hard labor in dangerous positions. Steelworkers were among the more colorful and full of life characters I've ever cared for and there sense of gratitude was a sight to behold. The bar was pretty low in doing something to please them. Even the most minor comfort measures were deeply appreciated. These guy were used to a hard life.

  3. I think you may have hit the nail on the head when you described a particular patient occupation. “ the bar was pretty low in doing something to please them.” Genuine, heartfelt gratitude and appreciation are indeed powerful motivators to be at the top of your game. Although I never worked with those employed in this particular industry, like many nurses, I could find a great many substitutes for “steel workers” who coerce me to keep getting up every day to go to work.