ED nurses cope with unpredictable, violent patients on methamphetamine

Patients are often combative, may have life-threatening conditions

A patient in extremely poor health comes in with severe chemical burns and many underlying medical conditions. That same patient refuses to comply with discharge instructions and is capable of assaulting and threatening ED staff at a moment’s notice.

These are the challenges of caring for a patient abusing methamphetamines (meth) in the ED. Emergency nurses interviewed by ED Nursing report dramatic surges in these cases.

"The amount of patients we are seeing for meth-related visits has been steadily increasing over the last several years," reports Ken Lanphear, RN, BSN, ED nurse at Borgess Medical Center in Kalamazoo, MI. "Of course, this can be probably said about every ED in the country."

Meth-related ED visits increased 54% between 1995 and 2002, according to a report from the Drug Abuse Warning Network, and comprised 42,538 ED visits occurring in the last six months of 2003.1,2

University of Colorado Hospital’s ED sees about 10 meth patients a month, and they often have suicide attempts, adverse reactions, or overdoses, reports Molly A. Evans, RN, manager of the ED. "We see many more that present with dental problems, skin abscesses, anxiety, heart palpitations, and other associated problems."

St. Joseph’s Hospital and Candler Hospital, both based in Savannah, GA, are each seeing at least one meth case a month in their EDs, reports Michael McCumber, director of emergency services. "The biggest challenge comes from patients who are violent or aggressive," he adds. "They may need to be sedated."

Meth patients use more resources and have a longer length of stay than other ED patients, according to Wayne T. Watson, MSN, RN, operations director of the intensive medicine clinical program for Salt Lake City-based Intermountain Healthcare, which has 19 EDs. "Often these patients require intense critical care and life-saving testing and procedures," says Watson. "Dealing with their agitation and hallucinations may be difficult."

The smallest rural EDs in the system see two to four meth patients each year, the community EDs see five to 10, and the largest urban ED sees 20 to 25 per month, says Watson. "The challenges for a rural ED can be greater because of limited staff, hospital services, and other resources," he notes.

Some of the EDs have developed specific protocols and training to deal with the surge in meth patients, reports Watson. "Our pediatric hospital also has put a specific protocol in place to deal with children who are exposed to meth by their parents in their homes," he adds.

4 tips to follow

Consider the following items when caring for meth patients:

• Patients may have unrelated health care needs.

Meth abusers are very neglectful of their health and often have a variety of medical problems, says Lanphear. "So if they do come to the ED for other health care needs, they are invariably much worse and more difficult to treat," he says.

Arranging care from visiting nurses isn’t possible as the patient usually won’t want someone coming into their home and patients usually won’t follow discharge instructions, adds Lanphear.

ED nurses gave one meth patient intravenous pain medications for severe abdominal pain, and he was diagnosed with a kidney infection. Because the patient felt better, he refused to be hospitalized and was sent home on oral antibiotics — only to return to the ED four days later. "His infection had gotten much worse, and he was almost in sepsis," says Lanphear. "When asked if he had been taking his antibiotics, his reply was, I forgot.’"

Remember that meth patients are dealing with an addiction and often are unemployed without social support, says Evans. "Often they have alienated their family or friends," she says. "Frequently they don’t follow up with care instructions, which many times leads to their medical condition worsening."

Bring in social services and case management to help with referrals, Evans suggests.

Patients may be violent.

Recently, a combative meth patient brought to the ED at LDS Hospital in Salt Lake City kicked a police officer in the chest and knocked him to the ground, says Watson. "The patient was verbally abusive and totally out of control, hitting, trying to bite, and kicking," he says. Watson says an experienced ED nurse caring for that patient said, "At that moment, I thought I was going to die."

It took a team of eight ED staff members to control the patient and place an intravenous line to medicate him, says Watson. "This brought him under control and allowed us to further care for him," he says.

When two meth patients were brought by police to a Savannah ED, it took multiple staff members along with police to get them into a room, says McCumber. "At that point [lorazepam] was given to sedate them. There had to be multiple doses given," he recalls. "The staff was at risk because these patients were completely irrational and had no pain factors to help restrain them."

Potentially violent meth patients must be continuously observed, and the room has to be made safe says McCumber. "Everything is removed from the room, including all equipment, cables, and blood tubes. This is to protect the patient as well as the staff," he says.

Meth patients’ personal belongings are removed, and the patients are placed in paper scrubs with direct observation by security or a member of the ED staff, says McCumber.

Patients may have life-threatening conditions.

Patients may have other drugs on board, notes McCumber. According to a report from the Rockville, MD-based Drug Abuse Warning Network (DAWN), more than 60% of ED visits for meth also involved other substances, such as cocaine or alcohol.1

Assess the patient’s heart rate and rhythm, hypertension, and respiratory rate; look for signs of difficulty breathing; and perform a neurological check by assessing for jerking, blurred vision, confusion, or convulsions, says Watson.

Patients also need psychological screening for hallucinations, anxiety, paranoia, and potential violence, adds Watson. "Many of our EDs have specially trained crisis workers who carry out an initial psychological assessment if the patient is able to talk and reason, which many are not," he explains. "If not, the psychological examination is completed later as an inpatient."

Protection of the patient’s airway is the single most important thing to consider, says McCumber. "More severe cases may require placing the patient on a ventilator and medicating to elevate or lower blood pressure," he adds.

• Be ready for patients with severe chemical burns.

"We see a lot of people who are burned or injured while cooking meth," says Dawn Klenck, RN, clinical educator for the ED at Deaconess Hospital in Evansville, IN. "The problem is that they always tell a different story and lie about their injuries, so we play a guessing game in how we treat them. We usually have that gut feeling when they are not being truthful."

Individuals with "meth-making" chemicals on them, such as anhydrous ammonia, need to be decontaminated prior to entering the ED, says Klenck. "The chemicals they use to cook meth with are very toxic," she says.

If exposed to the chemicals used to make meth, the patient’s clothing must be removed and bagged, and the patient has to be showered, says Lanphear. "Remarkably, thus far, we haven’t had to decontaminate any patient from a meth lab explosion. But we expect this could happen at any time," he says.

References

  1. Substance Abuse & Mental Health Services Administration, Office of Applied Studies, 2003: Emergency Department Trends from Drug Abuse Warning Network, Final Estimates 1995-2005. DAWN Series D-24, DHHS Publication No. 03-3780; Rockville, MD.
  2. Substance Abuse & Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2003: Estimates of drug-related emergency department visits. DAWN Series D-26, DHHS Publication No. 04-3972. Rockville, MD; 2004.

Sources/Resource

For more information about caring for meth patients in the ED, contact:

  • Molly A. Evans, RN, Manager, Emergency Department, University of Colorado Hospital, 4200 E. Ninth Ave., Denver, CO 80262. Telephone: (303) 372-6595. Molly.Evans@uch.edu.
  • Dawn Klenck, RN, Clinical Educator, Emergency Department, Deaconess Hospital, 600 Mary St., Evansville, IN 47747. Telephone: (812) 450-2035. Fax: (812) 450-3099. E-mail: dawn_klenck@deaconess.com.
  • Ken Lanphear, RN, BSN, Emergency Department, Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49048 Telephone: (269) 226-7000. E-mail: KenLanphear@borgess.com.
  • Michael W. McCumber, RN, Director of Emergency Services, St. Joseph’s/Candler, 11705 Mercy Blvd., Savannah, GA 31419. Telephone: (912) 819-6039. Fax: (912) 691-9096. E-mail: mccumberm@sjchs.org.
  • Wayne T. Watson, MSN, RN, Operations Director, Intensive Medicine Clinical Program, Intermountain Healthcare, 36 S. State St., Salt Lake City, UT 84111. Telephone: (801) 442-3109. E-mail: wayne.watson@intermountainmail.org.

To obtain a protocol to help children found in drug-exposed settings, go to the Utah Drug Endangered Children Alliance web site (www.utahdecalliance.org.) Click on "Utah’s Medical Protocol" and then "LEVEL 2 Best Practice Guidelines for Medical Evaluations of Children Found in Drug Exposed Settings."