Complicated Patient Receives Uncompromised Care
Clinical Nursing Narrative
By Margaret Costello
Margaret Costello cares for a patient on 15C.
While working on 15C on Sept. 6, 2005, I received a phone call from the Emergency Room with report on a patient who had just been discharged from the hospital and was now returning. Eric was a 23-year-old young man with a psychiatric history who had been admitted to Brigham and Women's Hospital the previous month after sustaining injuries when a car hit him as he was standing in the street. He suffered a lacerated spleen, a scalp de-gloving injury and a questionable head injury. He also had a tibial plateau fracture that was surgically repaired. He was discharged from the hospital to his apartment via chair car and was en route via chair car when he jumped out of the moving vehicle. He was readmitted to the hospital with a diagnosis of questionable traumatic brain injury, agitation and confusion. I had no idea at the time but this was the beginning of what would become a long and at times quite complicated relationship with this young man.
Eric presented some unique nursing challenges for our medical surgical nursing staff. When I admitted him to the unit, my first goal was to assess his neurological status and establish his level of safety. I quickly discovered that Eric had severely compromised short-term memory in addition to impulsive behavior and was a major risk for injury. Eric told me the car hit him initially because he was walking across the street holding a mirror, which he thought, would make him invisible to drivers and therefore safe from injury. For the first three weeks Eric was at the hospital, he had a one-to-one sitter to observe him due to his poor judgment and impulsivity. During the first few weeks as Eric's mental state began to clear a bit, we began to learn more about Eric. He told me he lived in a rooming house in Lowell and had free meals daily from a local organization. He described a very lonely life with few friends and no local family. He told of how his parents divorced when he was quite young and he never saw his biological father. He grew up in the Lowell area with his family. He was an only child until his mother remarried when he was 5 years old and had his little sister. Eric said he considered his step dad to be his father. When Eric was 19, his parents moved to Arizona. Eric decided to stay in the Lowell area. Eric describes how he had a house cleaning business and friends, including a boyfriend with whom he lived. He said he managed well for a while but that life began to unravel and he lost the job, the boyfriend and the friends. Eric told of how he would go to bars and use drugs like ecstasy with his friends. He also regaled of how he would go to car dealerships and drive off with cars under the pretext of wanting to take them out for a test ride. He had had a few car accidents and was also in trouble with the law as a result. Eric would retell these stories like a kid talking about going to a baseball game. He seemed to not see the problem with this kind of behavior, "I really did not think it would be such a big deal." It was unclear when, but at some point prior to admission Eric had seen a psychiatrist and was given a diagnosis of bipolar and was placed on disability. The psychiatric department at the Brigham could not distinguish between what was a psychiatric issue and what was related to a brain injury. Nevertheless, our plan of care was the same: keep Eric safe and continue to provide an environment conducive to his emotional growth.
Eventually Eric improved and we eliminated the one-to-one sitter. However, shortly after this Eric was discovered missing from his room causing panic to ensue among the staff. It was winter and Eric had no clothes except for his hospital Johnny! What would happen to him? We all worried so much. Finally the Boston police contacted us. A nurse who detained him until the police could arrive discovered Eric at Spaulding Hospital. He was brought back to the Brigham and Women's Hospital. It was not clear why he left. He felt so sorry to have disappointed us. He was also sad to be back on one-to-one sitters. The psychiatrist deemed him to be incompetent. His family was contacted in Arizona to seek guardianship. They had never been to see him in the weeks following his accident. The staff was all looking forward to meeting them. Eric was ambivalent as he said his father and he had a history of a strained relationship. He was looking forward to seeing his little sister who was 16 years old and his mom. On the day that Eric's family came, we were quite surprised with the brevity of their visit. In fact his dad stayed outside the room much of the visit talking sports with one of the staff. Occasionally he would yell into the room to Eric and mockingly say, "So where are all your friends now?" The mom sat passively and let her husband, Eric's step dad, do all the talking. I felt as if Eric was just so alone in the world. The psychiatrist was interested in the parents being Eric's guardian. The nursing staff felt very strongly that Eric's family would not necessarily be the best advocates for Eric, due to the dad's hostility and the mom's passivity. We advocated for Eric and the psychiatrist and the court listened. Eric's mom and a neutral lawyer were given guardianship over Eric. This was thought to be best in Eric's best interest, as the lawyer would prevent the stepfather's negative influence over Eric's mom.
The disability payments afforded Eric the opportunity to live in his rooming house. As Eric began to clear mentally, he began to panic about losing his housing, as he could not pay his rent. Eric was desperately afraid of becoming homeless and with good reason. Prior to getting this room, Eric had been briefly homeless and dreaded being in that position again. Eric suffered from anxiety attacks and providing emotional support was a huge part of our plan of care. Eric was very social and enjoyed spending time with the staff. As Eric's stay was prolonged due to the guardianship issues and later placement issues, the nurses became very much like family to Eric. Eric was with us for weeks. He turned 24 while on our unit and celebrated Christmas. The staff provided celebrations for Eric, which included clothing and various gifts. Eric was delighted. Although he developed therapeutic relationships with staff, Eric longed to be discharged from the hospital so he could live independently. Even though he had progressed to the point where he was able to be trusted not to run from the hospital, it was clear that he would require additional support more than his current situation could provide. I made phone calls to agencies that Eric thought could help him such as day programs in the Lowell area but it was determined that Eric would require a great deal more supervision and support that these provided. Since it was unclear how much of his issues were related to brain injury versus psychiatric diagnoses, he was in a gray zone in terms of what community agency could best provide him with support. Finally, an MRI was completed (Eric had previously been unable to tolerate this procedure). The MRI found extensive axonial brain injury most likely as a result of traumatic brain injury. This was a sad but important finding, as Eric would now quality for placement in a head injury program. Eric was discharged from Brigham and Women's Hospital on Feb. 1, 2006, to a new home with a foster parent for people who suffer from brain injuries. He would have his own room and would live with this woman for several months until he was able to transition to independent living. Eric was excited about the prospect of starting a new life. "I was crazy before, I am much better now," he said. Even though we did not think Eric would jump out of the moving van this time, we were not taking any chances. I accompanied him in the chair car to his new destination to ensure that he had a smooth transition. I began this journey with Eric when I first admitted him five months previously, and I was happy to have closure with him in this way. I felt his story illustrates the difference nurses can make in the life of a person. Eric arrived to us with a body broken that we quickly helped mend, however long after the cuts and bruises had healed Eric continued to endure the silent pain of a person suffering from mental illness and debilitating brain injury. The nurses worked as a team to provide Eric with the tools to help him heal both physically and gain the emotional strength to return to his life. Weeks after his discharge, Eric returned to visit the staff. He reported that he was enjoying his foster home and he was feeling a lot more positive about his life than he had in a long time.