By Susie Branagan, BSN, RN
They called it the pediatric psychiatric pod. It was a lecture hall.
Before COVID the room held staff meetings and grand rounds, not patients. It was built to carry one voice from a podium to the back row. Hospital beds sat on the flat floor where the chairs had been. Plastic curtains hung between them on rolling frames and moved whenever anyone walked past. The stage was still down front. The exit signs glowed red at either end. The lights never went all the way down at night because we had to be able to see. There were no doors and nothing that locked.
Behavioral health care depends on structure. A real psychiatric unit is built so you can hold the whole floor from one position, so a patient can feel where the boundaries are without being told, and so there is somewhere to bring a kid who needs to de-escalate. We had a lecture hall.
I was there because of the schedule. During COVID the hospital put its managers on seven days on, seven days off. The reasoning was infection control. If a manager spiked a fever or got exposed, there was a rested counterpart to step in and no gap in coverage. What it did was hand one person everything for a week. I was the nurse manager for five inpatient units and the emergency department, and during my seven I carried all of them, seven days straight, with no day in the middle. I never met a manager who wanted this plan.
By day four, you are running on almost nothing. I undressed at my own front door at the end of those shifts. Sneakers off outside. Scrubs peeled off in the entryway and dropped into a bag before showering. It was only then, after I had scrubbed my body until it burned, that I was able to give them big hugs! Then bed, then up, then back in.
The staffing for the auditorium was me, one nurse, and one aide. Three adults for a floor of children in a psychiatric crisis.
Those children were boarding. They were waiting for inpatient psychiatric beds that did not exist, some of them for days, some for weeks. No school. No outside. No visitors, because the pandemic policy stopped their parents at the door. They slept under lights that stayed half on. They changed clothes behind a curtain that moved. They were watched while they slept because they had to be, and for a good number of them being watched by adults was the thing that had broken them in the first place.
One boy stood up on his mattress and urinated out onto the open floor while staff moved in to redirect him. He was fourteen and he had nowhere private to have a body exposed. Another screamed himself out of a nightmare in the middle of the night, and the room carried it to every other child in there. Then those children were up and escalating and it took hours to bring the floor back down. That was a normal night.
Two of the boys came at me together. They were teenagers and they had been in there long enough to work out that no adult in that room could make them do anything.
I did what I was trained to do. I assessed, I looked underneath the behavior, I kept my voice low, and I gave them space, because behavior communicates something, especially in kids who do not have the words for what is really wrong.
Then the frustration turned toward me, and it turned personal. One of them started in on my appearance and settled on my hair, taking something as ordinary as being a redhead and building it into a run of sexual comments about my body, each one testing whether I would react. While he talked, the other one moved. He came around my shoulder and behind me, close enough that I could feel his breath on the back of my neck, and then he started adding his own.
One boy in front of me escalated, one boy behind me I could not see, and behind that one a sheet of plastic from the civil war instead of a wall. Nothing at my back would have stopped anything. Raising my voice meant setting off the whole room, and I knew what noise did in there.
The door was forty feet away and I could have reached it. Nobody was holding me in that room. I could have turned around and badged out and found another adult inside of a minute. What I would have left behind was two escalating teenagers and eighteen other children in crisis, with one nurse inside a curtain and one aide across the floor, neither of them free. Going to get help meant taking the third adult off that floor at the exact moment the floor was coming apart. The exit was right there but using it was a more dangerous choice.
I looked for anyone. The nurse was inside a curtain with her own patient. The aide was across the floor with her hands full. Neither of them looked up, and there was no reason they should have.
The other children were awake and watching. Whatever I did next was going to teach twenty kids in a psychiatric crisis what happens to a woman who gets cornered. I stood there with my jaw locked, holding back tears, keeping the calm professional face a nurse leader is supposed to keep.
I understood what was happening clinically. I could have written the note myself. Two adolescents in crisis, escalating, testing, reaching for the only power left to them in a room that had taken everything else. I was also afraid of them. I have never gotten the feeling of that breath off the back of my neck.
When they decided to stop, the nurse came straight to me, and the aide came as soon as her hands were free. Both asked if I was okay. They meant it. I would have asked whether one of them could cover me for a few minutes so I could get a glass of water and put a cold cloth on my face. There was nobody to cover me. The three of us were the staffing. Stepping out for five minutes would have left two adults on that floor.
When things calmed down for five minutes, I filed an incident report.
The only way to ask for help was to go get it myself. There was nothing to press and nothing to pull, no way to signal from where I stood, nothing that let me say I need someone in here now without announcing it to two escalating teenagers and every other child within earshot. The building had a system for fire. It had none for this.
When my replacement came at the end of the shift, I walked out of that room, finished the shift, and came back the next day. I had told the nurse what happened to me and said I would call Senior Leadership regarding the incident to see if we could get security in there. Unfortunately, they were tied up in the ER. There was one way to get help, and it went out the door, and going out the door meant leaving them.
A button would not have made me a better nurse, and it would not have changed anything about what those boys were living through. It would, however, have access to silently bring a second adult and/or security into the lecture hall. Every option I had cost somebody something. Life before safety technology was dangerous. It was traumatizing and it allowed for way too many injuries, trauma, turnover, and more.