Incident Report

Many years ago, in a place I cannot name, I witnessed an event that left an indelible cynicism, a swath of imperishable gray on my do-gooder soul. It was a financially difficult time for the treatment program where I worked, a facility I melodramatically nicknamed the “Annex of Hell”.  (In retrospect, lobby or waiting room of Hell might have been a more appropriate label.)  Referrals had declined precipitously, and there was talk of layoffs, beginning with the line staff—often single mothers who worked the hardest, endured the riskiest assignments, and had the least choice in the matter.  Being a clinician, I was somewhat insulated from this anxiety, but not insensitive to the fact that morale was terrible.

The owner decided to open a new service line, in part to take advantage of overcrowding in local jails and prisons, and also to attract lucrative patients that other rehabilitation centers would quail at having on their premises.  Here was an opportunity for the company to re-position itself in the market for increasingly scarce, but well-paying long term patients.    

The “neurobehavioral unit” was opened in the fall of that year, and my employer rapidly proceeded to concentrate all of the most difficult and violent patients in the program on the floor where I worked.  The best I can say is that all tedium in the workplace soon vanished—it was never, ever dull.  Safety required constant vigilance, and the ever present threat of workplace violence led many of us to recalibrate our expectations about what constitutes normal human behavior—downwards, that is.   It was around this time that I began drinking more enthusiastically, though not at work, where it would have done the most good.

Our first new referral to the unit, a man I will call ‘R’, arrived in midwinter.  R had incurred a head injury from a recent motor vehicle accident, which established the pretext for his admission.  But it was obvious within moments that whatever impairments he experienced from the brain injury were insignificant aside his long history of violence and criminality—from which his family suffered far more than him.  He arrived with his wife and two teenaged children, but escorted by two of our stronger male staff.  This was an emergency admission, not the more leisurely referral from an acute care hospital or psychiatry office we were accustomed to.  The ugly discoloration on the right side of the wife’s face was beginning to dissipate; his children stood well beyond arm’s length of him.  He was a monster and a terror. 

R was a large man, slightly balding, a bit pudgy, but dense with muscle and rage.  Perhaps he had worked as a mason or in construction.  R was coming here against his will.  Jail, and likely prison, were the only other options he had.  He screamed at his wife, blaming her for his incarceration.  His face reddened and swelled visibly .  She shrank back as if about to be struck.  One of the admissions staff took her and the children into another office, out of his sight.  She and her family were still terrified, wondering whether they had done the right thing.  Our largest line staff guided R forcefully to the west wing, where he was classified an “elopement risk”.

R attempted to escape just a few hours later.  I heard yelling and thumping and down the hall I saw a pile of staff bodies squirming on top of a bulky heaving form on the floor.  One of the staff told me they had him under control, which seemed true from what I could see.  I may have made a crack about having to file another incident report that day.  As usual, it had been very eventful during the shift.

The next morning our boss let us know that something had gone terribly wrong on the west wing the previous night.  R had been physically restrained two more times, and had almost made it out the front door on his second attempt at escape.  He had been taken down by several staff, but in the middle of the “behavioral event” he stopped breathing.  The evening staff attempted CPR until the ambulance came and took him to the hospital. R died there just a few hours later.  Because of the emergency admission, we had not yet received the medical records that described his serious cardiac problems and precautions.

The rest of the day was a flurry of meetings, hallway conversations and phone calls to our corporate attorneys.  Our administrative team was able to precisely formulate a response to awkward questions about what to tell the other families whose loved ones were in our facility, how we should inform staff, and most awkward of all: how to explain the event to the other patients.  Staff were encouraged to continue their regular routines—to ‘keep calm and carry on’ as we might say lately.  The psychologists made themselves available to the rest of us if we needed to talk.  But we were mostly concerned about the handful of staff members who had inadvertently caused the death of R, believing that they were keeping him and his family safe, at least for a while.

Weeks went by, and then our boss came into the office one morning, looking visibly more relaxed than he had for a long time.  There would be no legal action; the family had no interest in filing a lawsuit. Staff had followed protocol. There were no criminal charges being contemplated. The program was even likely to achieve full re-accreditation following an audit later in the year.  (We might need to review our procedures that pertained to physical restraint of patients.)  We had dodged a bullet.  Eventually, the “neurobehavioral unit” became a strategic success, and the treatment program has since quadrupled in size and become a major player in the industry.

But R’s miserable death and the suffering of his family left a lasting impression on me, one that altered my perceptions of the nature of rehabilitation.  The owner of what I flippantly thought of as the Annex of Hell was a sincere and deeply religious gentleman.  He believed that in some way his treatment program was chosen by God to effect positive change in the world.  This is not an uncommon attitude at all in the world of private rehabilitation, where entrepreneurs blend compassion and inspiration with ambition and opportunism.  My view of the Almighty’s involvement in the field of rehabilitation is considerably more jaded and nuanced at this point in my career:  R’s death is not the worst thing I have seen as I look back over the years.   

In retrospect, it is striking how the event occurred at an intersection of ambition and tragedy, of the program’s hope for the future, and the desperation of a single family.  Sometimes it is easier to believe we are all part of a much larger process—justice? Fate? Salvation?—that involves us in actions that seem inadvertent to us at the time.  Was R’s death just an accident, devoid of meaning?  Or was our terrible incompetence with R in fact the remedy for his tormented family, and their liberation?