- On St. Joseph’s inpatient psychiatric unit, around 8:00 a.m. on Monday morning, the patient Melonie blocked her door with her bed and set fire to the mattress.
It was Monday, after the long Fourth of July weekend. Management staffing had been down for four days. Most of the staff had no idea who had been admitted to the unit or what condition the patients were in. At 8:00 a.m., about fifteen staff members would have gathered in the staff lounge for morning report.
Unit 3-6 is designed in a T-formation. The locked unit is entered at the base of the T. On the left is the day area; patient rooms are on both sides of the main leg of the T. At the intersection, there are the nursing station, staff lounge, and patient’s lounge. To the right and around the corner from the nursing station is a second set of doors, frequently locked. Patients who are particularly disruptive or assigned to seclusion are locked in the back. Melonie was in a room in the back.
Which patients are secluded in the back is usually a nursing decision: the decisions are being made very poorly. In one week, two patients were assaulted by other patients; both victims tried to call the police and were dissuaded by the nursing staff. Both patients who committed the assaults had been disruptive enough to warrant restriction from the main population but were not secluded.
The nurses who make the decisions rarely leave the nursing station; they are predominantly pushing pills and papers. Direct patient contact with a nurse is carried on through a Plexiglas wall with a separation of about four feet. Nurses rely on information from counselors, who are on the floor. When one of the assaultive patients cursed a female patient in a wheelchair and raised his fist to her, the counselor—young, healthy and ambulatory—dismissed it with, “Oh, he does that to me, too.” She took no action to protect the patient.
Restricting patients to the back may keep the rest of the population safe but it does not keep the patient safe. One woman in the back, usually at night, cut and gouged herself on six different occasions. She was not put under constant observation; she was not protected from herself. It was eventually learned that the patient had dissociative identity disorder; at night, in her room, an alternative ego was surfacing and engaging is self-injury. Patients are neither safe from themselves nor others on 3-6.
What happened when the fire started? Possibly a smoke detector went off. Since the sprinkler system went off, there may also have been a heat detector.
During report, there are usually only a couple of staff members on the floor; at least one is in the nursing station. Did an alarm sound in the nursing station, or was the smell of smoke the first indicator that was noticed? What was done to alert the staff? On one occasion, three counselors filled out paperwork and discussed lunch while six feet away from them an “urgent” call light flashed and an alarm bell rang.
There are no fire drills on 3-6. Staff members who had worked on the unit less than a year suddenly found themselves in an emergency that required medical, fire and security response. In addition to the front entrance, there are two elevators and two fire exits. All are locked. It is a daily happening on 3-6 that when you ask a staff member to provide access to a locked space—i.e., laundry room, contraband cabinet, meeting room—the staff member’s response is, “I don’t have my key.” How many staff members had their keys to get patients out of a burning space?
How did the patients get moved off the unit? Until after morning report (8:30 a.m.), the day area is locked and breakfast does not come to 3-6, therefore most of the thirty patients still would have been in their rooms; some would have been asleep. How did the staff get into the room that Melonie had blocked with her bed? How did an inexperienced staff, under inexperienced management, respond?
When the hospital calls a code—a special signal for fire or medical emergency—the volume of the public address system is kicked up a notch. In response to the hospital-wide notification of emergency, three or four security guards and their chief would have been among the first to arrive. The security guards are frequent visitors on 3-6.
When it is decided that a patient needs to be kept under constant surveillance, a psychiatric staff member does not do it: a member of the security staff does it. Occasionally the patient is a large, combative male, but it is just as likely to be a small, hyperactive girl. From the point of view of the psychiatric staff, it is essentially a police action. The security guards, however, frequently resent being used to sit watch on a patient: why aren’t psychiatric staff members doing the job as a therapeutic intervention? Why is sickness being treated by security? What could become intensive therapy for the patient is, in fact, blinding tedium for security guards who sit with patients for hours that turn into days, sometimes weeks. (To be continued)