Transactional Call-and-Response: A Real-World Example

I was talking to a friend of mine, who is a CNO at a hospital, about my essays on transactional interactions and she told me a story that highlighted how, in a situation where even when everyone is acting to the best of their abilities, the give-and-take of an interaction can still have things spiral out of control because they are treating the other as an obstacle and not a partner in a broader goal.  She agreed to let me discuss it.

I like this story as an example precisely because it is messy; it is real life.  When I say that people acted to the best of their abilities, I do not mean that they were perfect, or congruent, or even rational.  They were not thinking strategically; they were responding in the moment.  In short, they were being human beings responding to immediate stimuli without the luxury of time to reflect on consequences and as a result treating the other without respect to who they were or where they were in their life’s journey. 

My friend was rounding in their emergency department when she heard some yelling and scuffling in an exam room.  When she went to the room, she found five staff members trying to subdue an extremely agitated patient.  Instead of jumping into the fray, she went to the head of the bed and started speaking softly and calmly to the patient.  She told the patient (a woman), that she was in a safe place.  When the woman said things like “Get off me!” or “I don’t want to die!” my friend repeated what she said, affirming that the patient was being heard, and then helped her take some deep breaths and built common cause by telling her that the hospital didn’t want her to die, either.  As the woman began to calm down, my friend was able to convince her that, if she would remain calm, she could get what she wanted, which was to have people get off of her and work to keep her from dying.  In the span of about a minute (though I am sure that felt like a LONG minute) she was able to calm the patient to the point where the five people could loosen their restraint, a central line could be started, and care could begin. 

Afterwards, my friend learned that this patient was in the active throes resulting from a self-administered dose of meth¹ and was in the emergency department while under the loving embrace of the local law enforcement.  With this back-story, it is easy to imagine how the situation escalated to the point where my friend entered the picture.  This woman, non compos mentis, engaged with police officers, who brought her to the emergency department.  From here, one of two paths emerged.  Either one person went in to gather vitals, take a lab draw, and start a line of fluids, only to have the patient become agitated, which necessitated additional staff, who upon arriving, agitated the patient even further, which then required even more staff, which then led to the need to use more direct force to subdue the patient.  Or, being presaged about the patient’s current mental state, a team went in expecting the worst.  Either way, vicious circle compounded upon itself.  Had my friend not entered the room, at some point, the patient would have been subdued and care delivered, though, it is unclear what injuries, or damage would have been caused in the process.

Now, I imagine that those reading this will have a few different responses to this story, so let me answer a few of the most obvious responses.  If you have a thought that is not addressed by me, feel free to leave it in the comments section.

But the patient was wildly irrational

Indeed.  The patient was untethered from reality.  I would argue, though, that this makes the story more valuable.  This wasn’t a learning exercise or a practicum.  This is real life.  The word “wildly” is a judgment call, but many (perhaps most) people who come into an emergency department did not think that this is how their day was going to go.  Life intervenes.  This woman was going through some things.  It was beyond the average for many in the emergency department, but it isn’t outrageously outside the norm.  I have seen, firsthand, how families and patients respond when they arrive via ambulance from a shooting or car accident.  I have seen parents panicking in an emergency department because their child is not being seen quickly enough.  Triage is a useful approach, but to many patients, triage is “me/my family first, everyone else second.”  This is both understandable and irrational.  In a vast majority of interactions between a patient and a clinician, the patient is the less rational person in the conversation.  Because this woman chose² to take drugs and those drugs might be fueling the irrationality, it doesn’t make her irrational behavior less understandable.   

But the staff deserve protection, not blame

Yes, I know that my story could be interpreted by some as being insensitive to the staff actively engaged in physical restraint, so let me be clear: workplace violence is a serious problem in healthcare.  Further, my story is not to blame the healthcare workers trying to do their job.  The point of the story is that real people can end up putting themselves in difficult and even dangerous situations by simply responding to negative behavior in a way that will fuel additional negative responses. 

Of course, once one heads down that highway, it becomes harder to find a good exit ramp the further you go.  In other words, the road to hell is paved with decisions that seemed like good ideas at the time.  I want staff to feel protected.  That means making sure that they are not put in harm’s way, or at least undue harm’s way.  It also means getting staff training to learn deescalation techniques, so the only solution to an irrational patient is not to simply and literally throw bodies at it.  Leadership, who are treating efficiencies as the primary measure for success, are just as much to blame for the situation because that first staff member was so focused on getting the lab sample to diagnose (or prosecute) that they did not approach this person as a person.

Onrushing events prevent thoughtful responses

This is certainly true.  Of course this accounts for many interactions in healthcare, especially the emergency room.  Heart attack victims, gunshot victims, stroke patients all require the right response done immediately.  The key is to take a beat, take a breath, and be thoughtful.  In 1983, Captain Pearson was flying a Boeing 767 that ran out of fuel at 41,000 feet.  The engines all failed, as did all primary electronics.  It is unclear what would have happened if he treated this like he was suddenly behind the wheel of a 150-ton paperweight.  But he paused, took a breath, and treated this like an unpowered glider.  He was able to expertly descend and land the 150-ton paperweight safely with no injuries.  Likewise, it is unclear what would have happened if that first lab technician would have considered alternate options before committing to the bull-in-a-china-shop approach.  This, of course, means that one has to be prepared for the possibility of an irrational patient, which, again, says more about appropriate training and reinforcement than the decisions made in the moment. 

But the patient started it

I know that my phrasing of this will lead some to imagine that I am dismissive of this reaction, which I suppose is somewhat true.  My initial response is the one you give a five-year-old making this argument, “They started it?  Well, I am finishing it.”  But this is not about lecturing staff to “be the bigger person.”  This advice tends to bring a more defensive posture in staff.  It creates its own vicious circle.

I think it is better to acknowledge that, YES, the patient was not being responsible, rational, or helpful.  That is clear.  I don’t think that first staff member went into that room expecting to be aggressive.  I think they went into the room, saw the situation and thought, “Oh, shit, here we go again.”  Or they were briefed on the patient and girded their loins for conflict before even entering the room.  Either way, they responded to a situation before it became a situation.  Instead of initiating a new circle, virtuous or at least neutral, they responded in kind. 

When I was much younger, no trip to my grandmother’s house (or her to our house) would be complete without at least one screaming match because she would say something controversial.³ Whether this was intentional or not, I would take the bait and soon fists would pound on tables and the windows would rattle.  Through more iterations of this pattern than I would like to admit, I finally realized that the solution was not in being right.  Being right is not a defense for being an asshole or feeding into a vicious circle.  I was never going to change her crazy opinions.  The best was to not to damage my own mental health by engaging in that craziness.

Whether by choice or not, that patient took methamphetamine and behaved in a way that drew the attention of law enforcement.  They got carted against their will to a hospital and responded with all the grace of a cornered and injured animal.  They started it.  But being right, being superior, being judgmental of the patient is not going to help that lab tech get a blood draw.  Indeed, it is in their best interest to not assert their superiority if they want to get the job done without shaking the rafters.  I don’t blame them, if after a long day, or because of personal life complications, they weren’t the best version of themselves when they went into that room.  They are human, just like the patient.  I would also, though, encourage them to, for future reference, consider how they may have approached things differently so as to avoid the same conflagration. 

Again, this story is not meant to judge anyone.  OK, it does allow us to judge the CNO, who was able to use sugar instead of salt, to reduce the temperature in the room.  The story is meant to illustrate how easy it is to fall into the trap of giving back what you receive and how that can lead us down a rabbit hole where no one is presenting their best self in the situation. 

¹Normally I might toss the word ‘allegedly’ into the mix, but since I have denuded this story of any patient descriptors and the events have probably occurred dozens if not hundreds of times in the past week all across this country, I shall dispense with legal-speak in this essay, since the patient’s privacy is protected.

²This opens two doors for discussion.  First, the notion of “choice” is fraught with subtext.  Addiction and unintended consequences can lead to outcomes that no one chooses.  The law can sort out whether the accident caused by the drunk driver, or the texter, or the person in a heated argument with another passenger in the car deserves different legal punishment.  I will argue that this should not be a concern for healthcare. 

³For those looking for an example, when AIDS first became a public health crisis, she suggested that it could be quickly and easily solved by simply rounding up all AIDS patients and immediately locking them up.  Problem solved.