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Setting Limits at San Francisco General Hospital

Setting Limits at San Francisco General Hospital
Health care professionals often need to set limits on patient behavior, but what about when they feel compelled to set limits on other staff members? In an age when hospitals have been turning to faster discharges, more medication, and less dialog with patients, this irony can come true, and bring with it disturbing and hurtful consequences.
 
Hope Lands at San Francisco General Hospital
Hope was a young woman who ended up in the trauma unit at San Francisco General Hospital after she fell two floors at a rave party and severely fractured her left arm and leg. Laurie Barkin was a psychiatric nurse working 4D, the trauma unit at the hospital caring for Hope.
 
Toward the end of her rounds on 4D one day, charge nurse Trudy approached Laurie and told her about Hope. Trudy asked, “Do you have time for a little crisis intervention? The trauma team was just in to see her and she’s been sobbing ever since.”
 
When Laurie entered Hope’s room, the patient was propped up in a semi-sitting position. Her eyes were closed and she was hyperventilating. Suddenly, Hope began to claw her face with her fingernails in a frenzied motion.
 
“Hope, stop!” yelled Laurie. “You’re hurting yourself.”
 
A Closer Look Shows Another Kind of Trauma
Seeing Hope attacking herself, Laurie wondered if she was psychotic or maybe detoxing from a substance. She grabbed a pillow and handed it to Hope, instructing her to “squeeze this instead of your skin.” Hope grabbed the pillow and started rapidly and repeatedly bashing it against her head.
 
To help Hope calm down, Laurie asked her to do some deep breathing exercises. Laurie noticed scars up and down Hope’s arms and what look like cigarette burns on her hand.
 
Ten minutes later, Hope, a chubby, baby-faced 23-year-old, was relaxed enough to tell Laurie she fell from a swing in the warehouse holding the rave.
 
But Laurie also learned the injuries Hope sustained at the party were not the cause of her acting-out behavior.
 
“I’m a mannequin, not a person.”
As Laurie continued giving Hope soothing instructions to breathe slowly and to feel her neck and shoulder muscles relax, Hope confided in Laurie.
 
“It’s hard enough not being able to move,” Hope whispered, “but then they treated me like that.”
 
“Who did?” asked Laurie.
 
“The doctors,” replied Hope. “They barge in and lift up my nightgown like I’m a mannequin, not a person.” (A trauma resident and a group of students had visited Hope earlier to examine her injuries. They did not speak to her and lifted her gown without asking for permission.)
 
Laurie handed Hope a tissue for her tears. “Then they talked over me and I couldn’t understand if what they were saying was good or bad.”
 
In later discussions with Hope’s therapist, Laurie learned that Hope had a history of childhood sexual abuse that was triggered by the trauma resident and the way he treated her during his examination.
 
The Limit-Setting Treatment Plan
After her visit with Hope, Laurie wrote up a treatment plan for her chart that specifically set limits on other staff at the hospital. The plan stipulated that no more than two physicians were allowed to come into Hope’s room at any time, and a female staff member was required to be present at any examination. Staff must ask Hope’s permission to touch her and they must make a reasonable attempt to respect her modesty. Trudy agreed to the plan and said she will make sure all nurses and each team of physicians see it before working with Hope.
 
To learn more about one nurse’s compelling struggle to remain compassionate and sane while attending to the shattered results of human cruelty, social injustice, and dwindling resources, check out Laurie Barkin’s interview on episode 20 of Unrestrained, the CPI podcast series.
 
The Comfort Garden: Tales From the Trauma Unit
You can purchase Laurie’s award-winning book, 2011’s The Comfort Garden: Tales from the Trauma Unit, at Amazon.com and get the whole story of the five years she worked as a psychiatric nurse on the surgical trauma unit at San Francisco General Hospital. Told against the backdrop of patients who survived motor vehicle accidents, falls, fires, fists, bullets, and knives, The Comfort Garden is a meaningful metaphor for the emotional support caregivers need to cope with the vicarious trauma that may develop with routine exposure to trauma.
 
Do you ever need to set limits on other staff at your facility?
 
What policies and practices are in place where you work to ensure patient privacy and dignity?
 
 
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