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Agitated patients attack us but we are always on guard — Psychiatrists

Agitated patients attack us but we are always on guard — Psychiatrists

Agitated patients attack us but we are always on guard — Psychiatrists image
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A psychiatric nurse, Miss Busola Alao (pseudonym), couldn’t imagine what hit her the three times she was attacked by her patients. Now in a top position in her career, Alao still bears scars of the injuries arising from the encounters.

She disclosed that the first experience occurred while she was a student nurse. Alao said, “I have been attacked thrice by patients.  The first one was when I was a student.  We were on clinical posting; I was posted to a male ward. I went to the ward to check a male patient. Immediately he sighted me, he started shouting, “This is my girlfriend. I was brought to the hospital because of you. They lied that I am not feeling fine and brought me here. Why did they send you to look for me here?”

Alao added that she could hardly ponder on what he was saying when he suddenly grabbed her since she was already near him.

She said, “While I was still trying to figure out what the problem was, he attacked me from behind and held me telling me he missed me and wanted to kiss me. On seeing what was happening, the senior colleagues came to my rescue and separated us. They usually looked for a way to take me away from him.  I was compelled to leave the place immediately. Whenever I entered the ward, he always charged at me. He would become angry and irritated.’’

Alao said she thought the drama ended until she experienced another one when she got full employment.

She stated, “I was off the day the patient was admitted. The patient was a student from one of the private universities in Nigeria. He was admitted for mental behavioural disorder due to multiple substance abuses.  The ritual is that when one resumes duty, one has to greet the patients’ one after another to familiarise with them and for them to know the next nurse for the shift.  He was grossly psychotic (he hears voices in his head). He was confined to a bed so that he doesn’t injure himself or attack other patients. I was attending to the patients on the third bed.  To my surprise, he jumped from his bed nearby and grabbed me from behind. He held me tightly to himself. In fact, I forgot that I am a psychiatric nurse and started to cry. He tore my uniform.”

The psychiatrist said colleagues who were around including some patients fast recovering rushed to rescue her from the patient who she said tugged at the torn uniform like a leech on its host. Alao noted that the incident didn’t stop her from continuing with her work that day. (adsbygoogle = window.adsbygoogle || []).push({});

She added, “I was taken home by the supervisory nurse. I changed my dress and returned to work. Of course, I was already disturbed and scared throughout my day at work that day. I was a newly employed nurse then and hadn’t developed enough capacity for such experiences.’’

The psychiatric nurse also said she experienced a similar situation after over 10 years experience in the profession, stating that no skill could prevent such an incident especially when the patient showed no symptoms of violent behaviours.

She said, “The last I am still suffering from was one of my rehab experiences with a patient that was going into epileptic crisis. I was at the facility for like six years and I never saw her go through such.  When I noticed that she was about to make something we call an epileptic cry.

“As a psychiatric nurse, once one hears a patient make an epileptic cry, one must rush to where the patient is to make sure the patient doesn’t get injured by creating a comfortable environment for him or her.  Immediately I got to where she was, I removed the locker beside her, unzipped her and loosened the neck button, so she doesn’t get choked.  While trying to make her comfortable even if she was going to get epileptic so that she doesn’t injure herself.  She just grabbed my hand and twisted it to the back. She was so strong that my hand got fractured. The other health workers came to my aid but my hand was already fractured.’’

Patients’ daring attacks on therapists

Like Alao, Dr Ibironke Thomas said that she was also attacked in her early days as a psychiatrist.

She said, “I was undergoing residency training in Benin, Edo State, then. I was having a conversation in the hospital corridor with someone when out of nowhere this female patient rushed at me and hit me in the abdomen. Those on that wing came out and I still remember how it felt. “

Thomas said she later learnt that the patient was known to the hospital, had a relapse and her relatives who brought her to the hospital were waiting to collect her card when she attacked her.

She said she found out that the patient attacked her as revenge for admitting her the previous time she visited the hospital with her relatives. “I later discovered that I had admitted her in the last admission, so she came for me to get revenge for hospitalising her the last time she came to the hospital,” she explained.

The psychiatrist further said immediately her relatives restrained her, noting though she was in pain, they had to assure her family members that she was getting better.

According to Dr Adeoye Oyewole, psychiatric patients exhibit violence. Many of them who exhibit violence are those with substance abuse, disorders, maniacs and people with an organic brain disease like those who have had a brain injury.

Adeoye said he had once been attacked by a psychotic patient, adding that he was at alert being aware of the patient’s record.

He said, “I have been attacked before during my junior residency training and there is what we call levels of dangerousness. We are often proactive towards handling a patient brought from home who has a history of attacking people or threatening to kill. Some of the patients are usually paranoid.

“I was attacked by a patient who thought I was the one his family always used to arrest him every time they wanted to deal with him. On that day, I sensed that he was going to get violent, so I was always on the alert whenever I was in the ward.

“He charged from the bed and attempted to hit me. Because I was already on alert, immediately, he attempted to hit me, I dodged the punch. Those in the ward came to help me and we sedated him. There was a time a chief medical director in Akure, Ondo State was attacked by a patient who almost killed him.’’

For Dr Olayinka Atilola, the closest encounter he had with a patient was when he suffered a needle injury. The patient refused to be injected by him and during the struggling, he was pierced by the needle.

He said, “Yes, there is an occupational hazard and one of them is that your patient might turn on you.  The highest attack I received from a patient is a needle prick. “

Similarly, Dr Kafayah Ogunsola also said that she had been attacked by a patient but refused to narrate the experience.

She said, “Patients attacking their caregivers happens and it has happened to me before but I won’t share the details because it’s not something I want in the public space.  It was well managed when it occurred and that was it. It’s one of the occupational hazards for psychiatric workers but we try as much as possible to ensure that such things don’t recur.”

However, one of those who slightly missed death by a whisker when attacked by a patient admitted to the hospital is the Chief Medical Director, Ondo State Neuro-Psychiatric Specialist Hospital, Akure, Dr Akinwumi Akinloye.

The President, National Association of Resident Doctors chapter in the hospital, Dr Jeje Oyetayo, said that doctors embarked on an indefinite strike after the last attacks on two female doctors at the outpatient unit of the hospital in June.

Oyetayo said, “Patients have attacked doctors many times at the hospital and we don’t have trained security agents to address it. But the last one was on June 5; two female doctors were attacked such that consultants were called to help them. The patient took an iron rod and started running around with it and there were no security officials. Patients get violent occasionally but the norm is that there should be security officers to disarm them.”

Attacks on psychiatrists not peculiar to Nigeria

 Attacks on psychiatrists by their patients aren’t peculiar to Nigeria. There have been cases when such happened in advanced countries. In Dallas, Texas, the United States, a 55-year-old psychiatric patient killed a physician. A police statement noted that Cason was a patient at Timberlawn Hospital when he became agitated in a hospital corridor after being told that he would be transferred to another facility.

Dr Ruth Mardock, who worked at the hospital, walked around the corner and found herself standing in front of Cason, who tackled her and caused her head to slam on the hard floor.  Mardock, who lost consciousness, died at a hospital and the charge against Cason was upgraded from aggravated assault to manslaughter.

In Korea, in August 2020, a patient also killed a doctor. About 20 months after, patients stabbed a psychiatrist, Professor Lim Se-won, to death at Kangbuk Samsung Hospital in Seoul.

Hectic workload

Thomas said that the issue of doctors leaving the country was critical. She stated, “A large number of our colleagues have also travelled out of the country. The brain drain cuts across, only that it’s not as hectic in the private sector. As a consultant, I can determine my schedule.  I am no longer in public practice. At the moment, I work as a consultant in a private setting. The workload was hectic when I was in residency but now I am a consultant. But that doesn’t mean I am oblivious of what’s happening in that public sector.  From my colleagues, I hear that there is depletion of experienced hands in the field and it affects the patients.’’

She added, “The World Health Organisation recommends one psychiatrist to 100 patients per country but because of the brain drain and all that we go through, we can’t meet up the standard.”

During the celebration of World Mental Health Day, Chairman of the Nigerian Medical Association, Kwara State branch, Baba Issa, said only 350 psychiatrists specialising in mental health were currently serving 200 million people in Nigeria.

Currently, there are eight federal neuropsychiatry hospitals across the country and psychiatric hospitals are in Anambra, Akwa Ibom, Sokoto, Kano, Oyo, Osun, Rivers, Cross River, Kwara, Plateau, Kaduna, Enugu, Ekiti, Ekiti, Ondo, Delta, Niger and Ogun states including the Federal Capital Territory, Abuja. Besides, there are state-owned psychiatric hospitals in Adamawa, Bauchi, Benue, Edo and Oyo states among others.

Adeoye explained that many psychiatric doctors, especially young ones, leave the country upon completion of their studies due to poor remuneration.

He said, “Many of the doctors have left the country due to poor remuneration and standard of living.  I doubt if we are up to 200,000 anymore.  And we have a population of over 200 million. You can see the ratio. Many young doctors have all left the country and one of the factors that make it easy for a psychiatrist to travel is the fact that it’s easier to practice psychiatry in any part of the world. Unlike other medical practices where one would be required to take a number of professional exams, psychiatry is the practice anywhere in the world. For instance, if I want to practice psychiatry in the United Kingdom, after practising as a junior psychiatrist for like two years, I would become a full psychiatrist. It doesn’t happen in any other practice.”

Ogunsola also lamented that the number of psychiatrists in the country were reducing by the day. She said, “If we are to examine the ratio of psychiatrists that we have with the ratio of population, we can say that the workload is definitely much.  The recent data on the population of psychiatrists in Nigeria is between 250 and 300.

“The numbers are frequently fluctuating because many doctors are travelling out of the country. Despite the brain drain, many of our doctors are still leaving the country.  And you expect that one in three or four Nigerians has emotional sickness. So, we are talking about 50-60 million people.

She said being a worker in the private sector, she determined her work conditions and fees, adding that countries where her colleagues moved to offered them good opportunities.

Ogunsola said, “Other countries that are welcoming psychiatric doctors from Nigeria and other places are those who appreciate mental health. We continue to lose our best hands to countries that have robust mental health practice. If Nigeria is just opening up to mental health cases, it means it has a lot of catching up to do.”

Rising mental health cases

Adeoye told our correspondent that mental health issues were on the rise especially psychosis cases. He stated that quite many people were mentally ill due to several reasons, ranging from economic to gender-based violence, among others.

He said, “Our hospitals are always filled. This population is not part of those who seek alternative caregivers such as traditionalists, pastors, prophets, Islamic clerics and others.’’

According to the Nigerian Ministry of Health, at least three in 10 Nigerians suffer from a mental illness that often goes untreated due to the country’s lack of mental health care system.

The WHO 2018 Global Health Observatory data repository records an estimated 17 suicides per 100,000 people across Nigeria, ranking seventh in Africa behind Zimbabwe with 19 suicides per 100,000 people.

“I see about four or five new cases during consultations. And you know that for Nigerians to have brought their loved ones to the hospital, it means that the patients must have wreaked some havoc,” Adeoye stated.

Adeoye stated that the government should intervene in the mental health practice as it was fast becoming a scourge.

He added, “Gender-based violence is also a cause of the increase in mental health issues. Marriage is an emotional relationship. A person could be in the house paranoid and be keeping a knife for months. A person could be pricked in the house and keep piling up the hurt for months. Marriage can emotionally sap a person, a partner could offend and refuse to apologise and each time such a person sees the partner, the person is angry. Before you know it, the ‘I am going to hurt you back’ thing becomes a mental illness. And that is why we see cases of people stabbing, hurting or killing their spouses.

“The government needs to do something about this psychosis. In the ward, we can manage such patients but imagine those who walk around the streets like they are normal.  Innocent helpless people could be attacked by those people.

“Imagine psychotic people charging at old people or little children that cannot run. There are many such cases that do not get reported. It’s an issue the government needs to look into.  The norm is that there should be trained personnel that can disarm them.”

Ogunsola believed that mental health cases weren’t necessarily increasing, noting that the surge was an offshoot of the increase in awareness of mental health issues.

She stated, “The cases could seem like they are increasing because there is awareness and more people are getting aware. It’s probably because our people are now more aware. The more people become aware of it, the more the conversations around it. Many people can connect and relate to the issues.

“Also, there is the possibility that there are a lot of events precipitating mental health issues. There is a downturn in the economy; the rising cost of things, insecurity, and social violence, among others.  All these can trigger new cases of emotional disorder.”

She added that there was also poor access to mental health care and people deny being mentally ill and seeking treatment in religious homes or from traditionalists.

“There is also a breakdown in family structure. When people are ill, there is no family support of rallying around them to ensure they are fine.  Mental cases have always been there, it’s not a new diagnosis, and it’s been since the era of the Aro community,” Ogunsola stated.

Handling aggressive patients

Adeoye said one of the reasons patients attacked caregivers was because sometimes family members who brought them to the hospital didn’t fully disclose their conditions.

He said, “Many things can cause it (attack by patients)such as the level of gravity. For instance, in the case of what happened to the CMD at Akure, it’s possible that he was not probably briefed about the patient’s condition. A patient can come in calm and quiet but could have caused some havoc at home. An inexperienced doctor or a doctor who was not properly briefed may get attacked.”

He said the rule is that when patients come into the hospital, they strip them of anything that can harm or hurt others. He added, “We don’t see our patients as dangerous. Even when you walk on the street, and you see a mentally ill patient, we try to assess them to know if the person is dangerous or armed? That’s why when patients are brought into a hospital, we check and strip them of any harmful objects.  We don’t let them come in with a bag.’’

Adeoye noted that with adequate experience, a psychiatrist would know if a patient was  dangerous, adding that as a rule, when a person becomes violent, such a patient gets sedated.

According to Ogunsola, there is a hazard attached to every occupation and one of the occupational hazards for mental health workers is physical aggression from patients.

She stated, “There are different things to consider for a patient to be aggressive. It could be that the patient is into substance abuse or psychotic by hearing voices in command hallucinations that can order him or her to do certain things. Sometimes, a patient may not be happy about being admitted. But the good thing is that we have ways of calming patients before it escalates. But in certain situations, due to certain human errors or things beyond one’s control, certain things can happen.

Alao said there could be a pointer to an aggressive patient and the caregiver ought to be proactive after detecting that.

She said, “We have different kinds of techniques. There are situations where one is unaware that the patient will attack one like in a case where the patients attack psychiatrists from the back. When a patient is too demanding, be on the alert because that patient is prone to violence. She or he may come up with anything.  When a friendly patient suddenly becomes hostile, one must be careful around such a patient. Also, if a patient becomes unnecessarily irritable, the patient will likely become violent.”

Alao said the standard practice is organising training for health caregivers on how to prepare for danger.

She said, “We organise training for psychiatrists on how to prepare for danger. There is something we call the breakthrough technique. We do the training once in six to eight months.  If a patient holds you tightly from the front, there are techniques to use in such situations such that you won’t injure yourself and the patient. Also, if the patient is lying on you as a female, there are ways to go about it to push away the patient and call for help.

“There are cases of extremity like a patient grabbing your breast from behind. The first thing that you will feel is fear because of the situation. In my last experience, it caught me unawares because I was trying to help the patient. There will always be such a situation.”

Bursting myths about mental health

There are myths and misconceptions regarding mental health and mentally ill people.  According to experts, it’s not true that people will run mad when a mentally ill person bites them, neither is epilepsy contracted through saliva.

Alao said, “It’s not true that when a mentally ill person bites you, you’d get infected. The same with epilepsy; it’s a mental health disorder. There is no transmission from saliva. When you see an epileptic person, what you need to do is to help them not to swallow the saliva. When the patient is having seizures, there is something called teeth wedging. You need to help them with a spatula so that while they are wedging the teeth, they don’t cut off their tongue in the process. I have helped an epileptic person in the market. The saliva does not in any way transfer epilepsy.”

Thomas also said that mental illness is not transmitted through teeth bites. She said, “It’s not true that if a mad person bites you, you’d run mad. There is no way such sickness gets transmitted through body fluid. I would be worried about tetanus, bacterial infection and others for such transmission.’’ According to her, the popular belief that mentally ill people attack caregivers is a myth. She said, “The majority of patients with mental health cases are actually not violent.’’

On his part, Atilola said during his career, he witnessed more attacks in the general ward than in the psychiatric ward.

He said, “I witnessed more attacks in the general ward more than in the psychiatry ward. In my place of work, we are trying to pass a law against the physical abuse of health workers and that is due to the incidents in the general ward such as accidents, emergency wards and others. Psychiatry patients are not as violent as people think.”

Thomas also said that sleep could not be used to measure the wellness of a mentally ill person.

She said, “Generally, sleep is one of the biological activities that are part of the rhythm of our lives. We sleep because the system needs to rest. Sleep is often one of the things usually affected when people are having psychological problems.  It’s a common symptom even in cases of stress burn out and things that are not even psychiatric disorders.”

Thomas said when she was attacked by a patient, it turned out good as she later developed a cordial relationship with the patient after she became well.

She added, “Patients in psychiatry also get well after treating them for a while. We treat them for a while, they get better and we discharge them. Like the case of the patient who hit me in the stomach. She later got well and she turned out to be a totally pleasant lady.  In the end, when she felt better, she apologised to me that she didn’t know she did that. It was her brothers that told her.’’ Thomas said the patient then in an altered mental state did what she never intended to do.

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