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Hello, everybody. My name is Dr. Scott Zeller, I'm an emergency physician who focuses on emergency psychiatric care. And I am an Assistant Professor at the University of California Riverside School of Medicine. I'm also past Chair of the National Coalition on Psychiatric Emergencies, and the American Association for Emergency Psychiatry, published several books on agitation and research in that field. And I'm here to talk today about agitation, and I'm joined by some real leaders in the field, Dr. Sharlena Wilson and Dr. Michael Gooch. And I'm going to let them both introduce themselves. So I'm going to hand it now to Dr. Wilson. Please go ahead.
Hi, I'm Sharlena Wilson, and I'm a psychiatric physician. I'm currently the Vice Chair of the Department of Psychiatry at Providence Little Company of Mary Medical Center in San Pedro. And my main focus is emergency psychiatry in crisis settings.
And Dr. Gooch.
Hello, and I'm Michael Gooch. I'm an emergency medicine nurse practitioner. I currently practice both in community emergency medicine as well as academia, and do some time in transport and flight as well. And I'm an Assistant Professor of Nursing at Vanderbilt University in Nashville, Tennessee.
Thank you so very much. So today we're going to talk about how we can optimally manage and de-escalate people who come into emergency settings, whether they might be an emergency medical department or a psychiatric crisis or emergency setting. And how can we really approach folks and put aside the medical condition and the diagnostic aspects for a second, but how important is it that we have all of our staff well trained in some kind of real basics of de-escalation and calming techniques? And I'll start with you, Dr. Wilson.
Well, I think it's extremely important to have all of the staff trained in de-escalation and, you know, verbal calming techniques, because that's something that can start right away. That can start as soon as your patient hits the door. So from nurses to security guards, I've even seen be, you know, awesome at de-escalation, setting that calming atmosphere, reassuring the patient that we're there to help them, and that we are going to be working with them and try to help them feel better, can start right away. And that can be done before you even, you know, get medications, before you get vitals, before you start a workup. Having that whole calm atmosphere can really go a long way in connecting and building rapport with that patient.
And yeah, I think that's such a great point. I think when you talk to somebody who's newly presenting to your program, your facility, whatever it might be, helping them to understand that, ‘I'm here to help. I'm not to hurt. I'm not the jailer. I'm not the sheriff. I want you to get better. That's what I'm here for. And you have nothing to fear for me. How can I help you? Tell me how I can help you?’ And above all really be listening? What would you like to add to that, Dr. Gooch?
I think this is an important topic. And sometimes it's a paradigm shift what we do in emergency medicine. We're, you know, fast paced, go in, do it, get done, get out.
And we need to work on a change and back up a little bit and so to slow down, and sometimes that show of force is necessary, and sometimes it's not. And sometimes trying to make the patient feel comfortable and maybe even asking them, ‘Hey, do you mind if I talk to you? Do you mind if I enter the room?’ and trying to scale back some of that approach that we have sometimes can really be helpful. And sometimes just asking, ‘Hey, what can I help you with today?’ Or what - you know, ‘What can I do for you?’ and trying to give that patient some autonomy can sometimes really help them because it gives them a little bit of control. Because probably they've lost that control or they've had some rough things going on, and sometimes it's that little bit of autonomy can just be helpful in trying to de-escalate that situation and give them that power back.
Such great points. And thank you so much. I think one of the key things that both of you brought up is giving people a chance to tell you what's on their mind. Listening is something that is such a game changer. And it's so obvious when we're talking about it, you know, away from the scene of a kind of frightening, agitated threatening, combative individual. But when you actually are there in the heat of the moment, it might not come back to you, and you might resort to the typical ways that people deal with scary situations. But to really think about it, the best way to work with somebody who's agitated is act like you care. You don't have to act like it, you actually do care. But the - give people an opportunity to tell you what the problem is, say, ‘I'm here to help.’ And then listen. And the most important thing is listening.
When we've done research studies of agitation patients in the past, the one thing that always comes up over and over when people have had really unfortunate experiences is like, ‘If somebody would have just listened to me, things would have gone differently.’ And I think that's such a key point.
So really offering our patients a chance to vent, if you will, but really saying, what's going on? How can I help you? Is there something you need? Are you hungry? Are you thirsty? Are you cold? Is there something making you particularly angry that I can help you with? And be a conduit towards solutions rather than - I think that whenever I see there's real problem with an agitated patient, it's people coming in and saying, ‘You need to stop this,’ or, ‘This is a problem. We're calling security. You need to sit down and shut up.’ And I will ask anybody in the audience, if you've ever been told to sit down and shut up, is that something that made you feel calm and feel better, and avoided becoming agitated? I don't think so. I think instead, if somebody said, ‘What's on your mind? Tell me what's going on you,’ that gave you an opportunity to share, and then the person that you're working with can listen, and offer maybe some opportunities to find some common ground. What do you think on all of that, Dr. Gooch?
I think it’s really important. And one of the big things is have a plan of attack. Not necessarily an attack, but try to have things worked out before you enter that room or enter that patient’s purview. And here's what we're going to try first. And obviously, we may have to escalate this up, or be ready to de-escalate down on. But have a plan. And it may not work for every patient, but have something in place. And that may help you stay focused on the mission.
Dr. Wilson, can you add?
I agree, and make sure - for me, I like to make sure that the patient is part of that plan as well. So a lot of times, I might ask them like, ‘Hey, is there something that you know, normally helps you feel calm? Or even if there's a medication that you normally take that's helped you in the past?’ So they feel like they have that autonomy, and they're having a say in their care, and that they are actually also helping themselves feel calm and feel better.
That's such a great point. And when we've really researched, people becoming agitated, they always feel like the worst part of their agitation was when they, quote unquote, lost control. And as you were pointing out, Dr. Wilson, giving them an opportunity to regain control. And that might be as simple as offering choices. And them being able to make their own decisions or relate their own information about their feelings about those decisions, is a means towards regaining control. And if we're able to do that, that's going to help create a therapeutic alliance with our patients. And all those things combined are going to help reduce the level of agitation, reduce the level of aggression, and dramatically reduce the risks of anybody getting hurt. And everybody's a winner when we do that.
So a fantastic conversation with two amazing experts in the field here. And there's some more information that you can get here on the website. And thank you for joining us. I'm Dr. Scott Zeller.
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