By Susie Branagan, BSN, RN
Owen was nine, and for the first four days he was the funniest kid on the unit.
He ran the dayroom. He had the other kids going and had the staff going, and he knew exactly how far he could take it before somebody was going to have to pretend to be stern with him. Class clown is a diagnosis nobody writes down, and he had it.
On day four the team stopped his psychiatric medications.
There is a clinical reason for this. Families call it a wash. When a child has been on a stack of medications for years and nobody can tell anymore which symptoms belong to the illness and which belong to the treatment, you take the medications away and you watch what is underneath. It is the only way to see him clearly. It is also, for a while, terrible.
I have never found a good way to explain that to parents. The sentence is always some version of he is going to get worse so that we can find out how to make him better, and there is no arrangement of those words that a mother wants to hear.
The clown went first.
What came in behind it I was not ready for. He started leaving. He would be in the middle of a sentence and then he would not be there. His eyes stayed open and pointed at me and there was nobody behind them. It would last ten seconds or it would last two minutes. When he came back he did not know he had gone. He would pick the sentence up where he dropped it, and sometimes he would pick up a different sentence entirely, one from a conversation we had finished an hour before.
His parents watched every one of those. His mother was wearing the same clothes she had been wearing the day they brought him in. Not similar clothes. The same ones. I noticed it on day three and I never stopped noticing it.
They asked me the same three questions every day, and they were the right questions.
How long is this going to take?
How do we know it is working?
When is he going to feel like himself again?
I did not have answers to any of them. In behavioral health the honest answer is usually that we are watching, and watching is not a satisfying thing to say to a father who has already been watching for years.
I came in around two in the afternoon and the room was wrong before I had finished opening the door.
Owen was walking. Not pacing yet, just walking, wall to window to wall, and he was answering questions before I finished asking them. His mother was sitting on the edge of the recliner with her purse still on her shoulder, which is what a parent does when she has decided that any minute now something will require her to stand up. His father was by the window with his arms crossed.
I pulled a chair over and sat down, because sitting down is the cheapest de-escalation tool in the building and it is free.
For about ten minutes it worked. I said the true things. That the wash was doing exactly what it was supposed to do. That what they were watching was information, even though it looked like collapse. That nobody in this building thought their son was a bad kid.
His mother started to cry, which I took as a good sign, because crying meant something had landed.
Then his father said, “So we just wait?” and Owen turned around.
The pacing never worried me. Neither did the volume. I have been swung at by children who were shouting, and shouting children are still talking to you.
Then he stopped.
He stopped in the middle of the floor and went quiet and looked at the door. Not at me. Not at his parents. At the door, and then at the space between the door and where I was sitting, and he was measuring it.
I have seen that look on adults in the ED and I have seen it on nine year olds and it is the same look. It is the moment a person stops participating in the conversation and starts solving a different problem.
His father stood up, and Owen went for the door.
He was fast. He got past my chair before I was all the way out of it. I got a hand on the door frame and my body into the gap and he came into my hip with everything that nine years old and four days of this had stored up in him.
He was not trying to hurt me. He was trying to leave, and I was what was in front of the door.
His mother screamed his name. His father came across the room.
That was the room I was in. A nine year old trying to get off a locked unit, a mother screaming, a father moving, and me holding a doorway with one hand and a child against my hip.
I did not raise my voice, because raising it would have told him this was an emergency and he would have been right. I kept my hand on the frame and I asked him whether he wanted the beanbag or the blue chair, because a kid who has lost control of everything else can still be given something of his own to decide. My right hand went to my badge and I pressed the silent duress button through my scrub top.
Then I asked his mother whether he had eaten lunch.
The whole thing took maybe four seconds and nobody in that room ever knew it happened.
Owen stopped pushing. He backed off the door and stood in the middle of the floor breathing hard, and I stayed in the doorway, and for a while nobody said anything at all.
One of our behavioral health techs came in about ten seconds later with her gloves already on.
That is what you do when a duress alert goes off on a pediatric unit. You put your gloves on while you are walking, because you are expecting to put your hands on a child, and you would rather be ready and wrong than late and right.
She did not have to. She looked at him standing in the middle of the floor with his fists open, and she looked at me still holding the frame, and she read it in about a second and a half. She leaned on the wall by the sink the way you do when you have wandered into a conversation you are half interested in. She said hey.
He said hey.
That was it. That was the intervention. He had said a word to somebody, which meant he was back in the room and no longer alone with whatever he had been calculating.
What she gave me was arithmetic. Before she walked in, I was one person doing four jobs. I was talking to a child in crisis. I was managing a father who was frightened and standing. I was tracking a nine year old’s position relative to the door. And I was trying to be the person this family had trusted since the day they came in. Every one of those jobs was taking something from the other three.
With the two of us, I got to do one job. I stayed with Owen. She took the parents.
She asked his father whether he wanted to step out and get a coffee, and he said no, and she said okay, and stayed near him anyway, and that was the entire maneuver. She got between the father’s fear and the child without either of them noticing she had done it. She also put a second adult between me and the hallway, which was for me, and I noticed.
Owen took the blue chair. Not right away. He stood there for a while first, and then his shoulders came down, and then he sat, and then he asked if his mom could sit next to him.
By the end of my shift he was back in the dayroom.
I documented the interaction the way I would document any interaction. Increased motor activity, difficulty with redirection, attempted to exit the unit, family present, second staff member to bedside, patient calm at end of shift.
There was no incident report, because nothing happened.
No injury, no code, no security, no restraint, no meeting the following week about what could have been done differently. In the metrics my organization collected that quarter, that afternoon does not exist.
We count assaults. We count injuries and security calls and response times, and we should, because every one of those numbers is a person who got hurt. But those numbers only describe the days we lost. There is nowhere to write down that a nurse asked for help early and it worked.
So the work that actually keeps us safe is invisible by design, and then we wonder why it is hard to fund.
I could have handled that room alone. I need to say that plainly, because it is the thing that keeps nurses from pressing the button. I probably could have. Most days I would have. And on the day I did not, a nine year old never found out that the adults around him had been afraid of him, and I went home with my hands steady, and none of that is anywhere in the record.