By Susie Branagan, BSN, RN
Eli weighed forty-one pounds. I know that because I weighed him myself on a Monday, in his socks, holding onto the bar of the scale with both hands and telling me he was going to be taller than his brother.
He was six. He was in our inpatient pediatric psychiatry unit because he had put a chair through a window at his school and the adults in that building could not keep him or anyone else safe. His history was nine minutes of reading, and it explained everything about him, all very tragic and shocking.
Small children in psychiatric crises are still small children. He liked a particular blanket. He wanted the light on in the hall. He asked me every night whether his mother had called, and he wanted us to read him stories.
One day we ran out of Hot Pockets. Hot Pockets were the snack that every single child that has ever stepped foot on my unit needed to survive. Literally. Severe bursts of escalation would erupt in the kitchen if these hot commodities were out.
He was on the floor of the dayroom before it happened, playing on his stomach with his feet in the air, running a truck along the base of the wall and making the noise. He had asked about the snack maybe forty minutes earlier and somebody told him yes without going to look. Nobody did anything wrong. That is usually how these scenarios start.
I crouched down and stated, “I am so sorry, Eli. I know you were told we had some, but we don’t today. The kitchen is out, but they are getting new stock at 7 a.m. tomorrow.”
He looked at me with a stare I can see as I write this. Then he put the truck down on the carpet, very carefully, and stood up.
“I was told there were Hot Pockets! Somebody needs to go get them now or…” he screamed.
He went through the dayroom with both arms going. He hit the back of a chair, and the wall, and the air, and then a person, and then the wall again. His eyes were open, but it was clear he was not seeing any of us. He could not stop his arms. He was in complete psychosis.
Eli got a fistful of the mental health tech’s scrub top, pulled, and the neck of it tore down almost to her collarbone. He got behind another nurse and pounded on her back with both fists while she was still trying to get him to look at her face.
We tried what we always try and what we are trained for. We cleared the room of the other kids. We got low. We gave him space and stopped talking at him. Somebody offered him choices and somebody else offered him the blanket. Two of us stayed out of arm’s reach on purpose so he would have somewhere to go that was not toward a person. None of it reached him, because there was nothing to reach. You cannot talk to a nervous system.
So, we made the call to move him to the seclusion room. Nobody in that hallway wanted to be the one who said it out loud. It was the right call, and I would make it again tomorrow.
I have helped hold a lot of people over the years and I have never gotten used to doing it to a small body. There were two of us on him. That is what we had, and two is not enough for a child who is fighting like that, because two people must work much harder than three or four ever would. His arm was the width of my wrist. I had his shoulder and I spent the whole time thinking about how hard my own hand was pressing. I started to tear up as I whispered in Eli’s ear, “Buddy, you are safe.”
He fought with six years of trauma leading the surge. He arched and twisted and he got a foot free twice. He screamed the entire time, and somewhere in it he stopped screaming words and just wailed almost non-human sounds. He bit the sleeve of the aide holding his other side and would not let go of the fabric, and she let him have it, because it was the only thing in that room he had any control over.
The screaming stopped before the fighting did. He was still going, still twisting under our hands, but the sound had gone out of him. Then the fighting stopped too, and what was left was a very small boy breathing hard on a floor with our hands still on him. Looking straight through me, he whispered with a rasp, “When is lunch?”
We came off him one at a time. He did not move. Then he rolled onto his side and put his thumb in his mouth. He was six and he had never once done that in front of any of us. He asked me if he could have the blanket.
He fell asleep in it on that floor and we let him, and I sat against the wall about four feet away and stayed until he woke up. The tech sat down on the other side of him and stayed too, holding the front of her torn scrub top closed with one hand.
The paperwork on that night was substantial. Restraint documentation, injury report, a debrief. Every form filled out correctly, and every one of them started at the moment we put hands on him.
No form had a line on it for the ninety seconds before that, when there were two of us in a dayroom with a child who had come apart and the only way to get more people was to shout in a room with closed doors.
Shouting works. It is also the worst tool in the building. It takes however long it takes for somebody to hear it and understand it and come, and while you are waiting you are down to whoever is already in the room, and every other person on that unit hears you do it. Three of the other children came to their doorways that afternoon. One of them was crying before anybody had put a hand on anybody.
The people who got there were the people who happened to be within earshot.
What I have wanted ever since is something on my badge that I could press with my thumb while I was still crouched in front of that child.
It must be silent, because the moment a six-year-old in crisis hears an alarm go off he learns that he is the emergency. It must know what room I am standing in, so nobody wastes twelve seconds looking. It must reach everybody at once, the people on that unit and security both. Security came that afternoon and they were the right people to come. They got there in three minutes. I needed somebody in one second. And it has to work when I am on my knees and not near anything mounted on a wall.
Everything I just described is a matter of hardware. It exists. We did not have it.
More hands sooner is not a bigger show of force. It is a smaller one. Two people on a fighting child are gripping hard and still losing position, repeatedly, and it goes on and on. Four people barely have to hold anything. It is over faster and it takes less pressure to do it. The more of us there are, the gentler it gets.
I made the call to his mother myself. I do not hand those off.
I used the real words. Restraint language is specific and I did not soften any of it, because she was his mother and she was entitled to know exactly what we had done to her son and for how long. Physical hold. Seclusion room. Eleven minutes. No injuries to the patient.
She was quiet for a second when I finished. Then she asked whether anybody stayed with him after.
I said I did.
She said OKAY. Then she asked if he had the blanket, and I said he did, he had it the whole time he was asleep, and she stopped being able to talk for a minute. She apologized to me for crying. Mothers do that on those calls.
I weighed him again the following Monday. Same scale, same socks, both hands on the bar, telling me he was still going to be taller than his brother.
Forty-one pounds with the strength of a thousand men.