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Eluveitie
08-05-2016, 01:48 PM
I have a character who tries to escape from the hospital after being critically wounded.

Scenario:

A young man is found with a knife wound to the stomach and is taken to the hospital. He has no identification on him and there are no witnesses to verify his identity. No one steps forward to claim him. When he regains consciousness after surgery, he becomes extremely agitated and tries to remove the IV tube, electrodes, etc, ignoring all attempts to calm him. He attacks any nurses/doctors who try to get close to him. He is physically fit and has former tactical training, so he poses a high threat to the people around him. He basically lashes out like a rabid dog.

How would a patient like this be treated? Would he get tazed or pepper sprayed? Would he be sedated and/or put in physical restraints? If so, what medications would be used and what sort of physical restraints are we talking about here?

mirandashell
08-05-2016, 02:55 PM
Where is this set?

Eluveitie
08-05-2016, 03:13 PM
Where is this set?

Present day America.

mirandashell
08-05-2016, 04:39 PM
I kind of assumed that much! :D

I meant more like is it in a small Midwest town with a cottage hospital and 3 police officers or in the middle of New York with loads of security and a lot of experience with violent patients.

Eluveitie
08-05-2016, 04:48 PM
I kind of assumed that much! :D

I meant more like is it in a small Midwest town with a cottage hospital and 3 police officers or in the middle of New York with loads of security and a lot of experience with violent patients.

Lol, oh. That makes sense. It takes place in Albany, New York.

Maryn
08-05-2016, 05:24 PM
Albany's a big enough city to have security in hospitals and cops who can get there quickly. I have no actual experience in this, but I find it implausible that a patient recently out of surgery would be pepper sprayed or tazed. (Haha, I wrote taxed. Which is worse?) I suspect the hospital administrator would order everyone out of the room unless the patient were harming himself.

Within ten minutes or so, police, security, and orderlies (sometimes big guys who can easily move patients) would create an overwhelming force in sheer numbers. Your trained guy can't take out fifteen or twenty men acting in concert. They'll rush him, hold him down (and try not to break his stitches), until someone can administer a syringe of something that will knock him out very quickly. He will be in restraints from that point forward, the way violent criminals might be.

GeorgeK
08-05-2016, 05:35 PM
1: After surgery he won't be waking up in the ER. He'd be in a room, possibly private or semi-private. There might be the old style wards somewhere but I've not seen one since probably the 80's.

2: I don't care what his tactical training is. If they had to do a laparotomy to fix internal injuries then he's not going to be up to fighting. He won't be up to eating. He might not even be up to walking to the bathroom. Any attempt will be met with severe pain and nausea. If he tries, there's also a good chance that he's going to dehiss the wound.

3: Most likely if he actually by some miracle or alien technology/physiology could attack, people would likely just get out of his way. "Hey Dude, there's the door. We were just trying to help. You don't want help, fine, just leave. See the exit sign?"

There is a chance that a security guard might try to crack him in the head with a nightstick, flashlight or shoot him. I've not worked in Albany but in major city trauma centers often security guards are armed. They are also likely to respond to violence with violence. But if someone is just scared and agitated, typically the guards will try to stand down and let the staff calm the patient.

GeorgeK
08-05-2016, 05:37 PM
Albany's a big enough city to have security in hospitals and cops who can get there quickly. I have no actual experience in this, but I find it implausible that a patient recently out of surgery would be pepper sprayed or tazed. (Haha, I wrote taxed. Which is worse?) I suspect the hospital administrator would order everyone out of the room unless the patient were harming himself.

Within ten minutes or so, police, security, and orderlies (sometimes big guys who can easily move patients) would create an overwhelming force in sheer numbers. Your trained guy can't take out fifteen or twenty men acting in concert. They'll rush him, hold him down (and try not to break his stitches), until someone can administer a syringe of something that will knock him out very quickly. He will be in restraints from that point forward, the way violent criminals might be.

The crux in this situation is that they are post op and a mattress tackle is probably going to split open the wound. I've never seen this be a significant issue on a surgical floor because being post op is sort of its own restraints.

The exception is ICU psychosis which has always been verbal abuse rather than physical except for the stray black eye, but that's not the same as going into hand to hand combat, again because of the pain of being post op and the thing to do there is basically stop any meds that you can, get them in a dark room and let them sleep. IT takes usually 3 days for ICU psychosis to resolve.

Mattress Tackles were interesting when I had to respond to those on the psych floor (not post op). As Maryn said, you got a half dozen or more guys holding mattresses in front of them and they pin the patient to the wall, fish out a limb somewhere and give them a nice shot of...it's been a while, if I remember it was thorazine, phenergan and meperidine.

I remember the first one the best. After a few minutes I commented, "He's gone limp." Then Joe said, "Nope, He's faking it. We're going by the clock. Keep him pinned a full 15 minutes."

That said, I don't know what they actually are allowed to do now. There are now rules about both physical and chemical restraints.

MDSchafer
08-05-2016, 06:53 PM
I have a character who tries to escape from the hospital after being critically wounded.

Scenario:

A young man is found with a knife wound to the stomach and is taken to the hospital. He has no identification on him and there are no witnesses to verify his identity. No one steps forward to claim him. When he regains consciousness after surgery, he becomes extremely agitated and tries to remove the IV tube, electrodes, etc, ignoring all attempts to calm him. He attacks any nurses/doctors who try to get close to him. He is physically fit and has former tactical training, so he poses a high threat to the people around him. He basically lashes out like a rabid dog.

How would a patient like this be treated? Would he get tazed or pepper sprayed? Would he be sedated and/or put in physical restraints? If so, what medications would be used and what sort of physical restraints are we talking about here?

If he's waking up in the PACU and becomes agitated as he's coming out of anesthesia the first step is soft wrist restraints, and most of the time they work. Coming out of anesthesia isn't like opening your eyes, it's a slow process and typically you can get restraints on someone before they're fully with it.

If the guy is getting physical beyond the RN's ability to control the next step is to call security. The bigger the hospital better trained the security is at descolating situations and physically controlling a patient. You would never use pepper spray on patient in a hospital because it can touch off respiratory distress in nearby patients. If he physically assaults someone the staff can always call the local PD and press charges, although typically nurses don't press charges because we just assume that patients physically assaulting us is part of the job.

If the guy is in charge of his mental faculties and insisting upon leaving, and the doctor doesn't want to place him on a short term legal hold we'll hand them the Against Medical Advice papers and let them walk out.

MaeZe
08-05-2016, 07:33 PM
What MDSchafer said above.

You don't mention he was arrested. If a patient is not under arrest, no one stops them from leaving the hospital. We try to get you to sign a form you are leaving against medical advice, but if you don't sign it, no one stops you from walking out the door. It's not legal to stop you.

If on the other hand, a patient wakes up confused and starts ripping lines out, a code for physical assistance is called and a bunch of people show up to restrain the patient.

But no one would restrain a person who was clear headed and just chose to leave.

If you were under arrest, it depends on the nature of the crime. A minor offense like drunk and disorderly, the police wouldn't stick around if the patient needed to be admitted, but they would wait for the patient to be treated, then take them off to jail. If it were for a serious crime, the patient would be handcuffed to the bed and the cop would be with him except during surgery.

If a patient assaults the hospital staff, we call the cops just like anyone else would. I've never seen hospital security do much in the way of physically fighting a patient or a visitor. They may help restrain someone, but they are more like mall security, they'll tell people to leave, they'll respond and look official. But they don't typically carry guns or handcuffs.

Maryn
08-05-2016, 08:44 PM
(Good, I was hoping people with actual medical knowledge and experience would show up.)

Eluveitie
08-05-2016, 09:56 PM
Fantastic answers! Thank you, everyone! Your responses really gave me a good picture of what happens in this kind of situation. GeorgeK, I've never heard of a mattress tackle before, so that was fascinating to hear about.

To clarify, the character is a person of interest in a homicide. The police aren't sure whether he's a victim or the culprit. In a case like this, do you think that he would be treated like a suspect and handcuffed to the bed, Maeze?

jclarkdawe
08-05-2016, 10:00 PM
If he has a knife wound, the police will be notified as soon as that fact is ascertained. A police officer would be sent as soon as possible with instructions to interview him as soon as the doctor lets them.

From the police point of view, you don't know whether this is an accident or intentional. You don't know whether he is the victim or the one doing the assault. You don't know whether there are other injured and/or dead people out there that the police have not found. Until the police get this situation straightened out, he isn't going anywhere. As soon as his behavior becomes questionable, the police officer will place him in protective custody, and the soft restraints will go on. If the police officer has problems restraining him (see George's answer above about why they won't have any problems restraining him), reinforcements will be called.

In Albany, for a knife victim with no history, my guess is a tox screen will be done ASAP. One is so the doctors know what drugs he has on board, the second to predict future behavior in the next 24 - 48 hours. There are a few drugs that could still be in his system that would explain this type of behavior. If the tox screen comes back positive for those drugs, he'll be in restraints even before he wakes up.

Jim Clark-Dawe

jclarkdawe
08-05-2016, 10:03 PM
Eluveitie gave some additional information while I was writing. If he's a person of interest in a homicide, he'll be in soft restraints prior to waking up. In Albany, he'd be moved into the prison ward as soon as possible. At least a couple of cops will be with him throughout the operation (though not in the operating room) and afterwards.

Jim Clark-Dawe

MaeZe
08-05-2016, 10:12 PM
Fantastic answers! Thank you, everyone! Your responses really gave me a good picture of what happens in this kind of situation. GeorgeK, I've never heard of a mattress tackle before, so that was fascinating to hear about.

To clarify, the character is a person of interest in a homicide. The police aren't sure whether he's a victim or the culprit. In a case like this, do you think that he would be treated like a suspect and handcuffed to the bed, Maeze?

Nope. It's like any suspect, until you are arrested, you are free. And if arrested the police have a limited amount of time to charge the person. Then on the first court day (if the charge didn't have automatic bail) you get arraigned and the judge sets bail.

I'm always amazed at how police sometimes leave a suspect, even one that has been charged, on their own in the hospital. Sometimes I have to track a discharged patient down, and despite charges, the hospital has discharged the person. If the person has been admitted to a psych hospital I have to get a public health officer to find the guy, even the cops are not allowed know where the patient, a suspect who has been charged, went. It's bizarre.

State laws may vary. In addition, depending on the facility, jail heath varies from large jails that have fully staffed infirmaries to those which use the local ED to provide medical care to prisoners.

For serious crimes suspected, but charges not made, the police would probably not expect the patient with serious knife wounds to be sneaking out of the hospital any time soon. They would likely want to interview the suspect as soon as he was awake after the surgery. But I've seen people leave, especially after drug ODs. They wake up, you can't stop them from leaving unless it was a suicide attempt. In that case there will be a mental health officer with the authority to order a three-day eval on a locked psych unit. Longer than three days and a court must order it.

MaeZe
08-05-2016, 10:16 PM
Eluveitie gave some additional information while I was writing. If he's a person of interest in a homicide, he'll be in soft restraints prior to waking up. In Albany, he'd be moved into the prison ward as soon as possible. At least a couple of cops will be with him throughout the operation (though not in the operating room) and afterwards.

Jim Clark-Dawe

So NY laws must differ from WA State. But I'm curious how "a person of interest" translates into a person that would be taken into custody?

MaeZe
08-05-2016, 10:23 PM
If he has a knife wound, the police will be notified as soon as that fact is ascertained. A police officer would be sent as soon as possible with instructions to interview him as soon as the doctor lets them. Yes, gun shot wounds and knife wounds that resulted from an assault require reporting here too.


From the police point of view, you don't know whether this is an accident or intentional. You don't know whether he is the victim or the one doing the assault. You don't know whether there are other injured and/or dead people out there that the police have not found. Until the police get this situation straightened out, he isn't going anywhere. As soon as his behavior becomes questionable, the police officer will place him in protective custody, and the soft restraints will go on. If the police officer has problems restraining him (see George's answer above about why they won't have any problems restraining him), reinforcements will be called.

In Albany, for a knife victim with no history, my guess is a tox screen will be done ASAP. One is so the doctors know what drugs he has on board, the second to predict future behavior in the next 24 - 48 hours. There are a few drugs that could still be in his system that would explain this type of behavior. If the tox screen comes back positive for those drugs, he'll be in restraints even before he wakes up.

Jim Clark-DaweCurrent HIPAA laws make it illegal for the hospital to tell the police anything about the tox screen results. And that is a federal law.

HIPPA (https://healdove.com/health-care-industry/HIPAA-Protection-of-Patient-Privacy)
What are the rules about disclosing personal information?

Under HIPAA, personal healthcare information can be released to law enforcement without patient permission under certain circumstances. These include:

Court orders and subpoenas
Identifying suspects, witnesses, or missing persons
Reporting about victims of crime, neglect, or abuse

For any other uses, an authorization form must be signed by the patient prior to the release of information. There is special protection for:

Psychotherapy notes
Drug and alcohol abuse treatment records
Research records
Communicable disease information
HIV/AIDS status
Genetic testing
Evaluation and treatment of mental health disorders
Mental illness medical records have additional safeguards under the law and are treated differently from other types of medical records.

And it is against the law to restrain a patient except for patient safety, which you have to clearly show in your documentation, unless there is a court order.

The hospital is not a de facto jail. Only court ordered psych patients are locked up under the supervision of medical staff.

ironmikezero
08-05-2016, 10:53 PM
Custody makes a difference. An arrested person is in custody pending an appearance before a court. A person of interest is not in custody. A hospital patient is in custody if under arrest; a law enforcement presence will be on the scene. A hospital patient deemed a person of interest is not in custody, however law enforcement personnel may be present in furtherance of an investigation.

A person of interest can be taken into custody pursuant to a material witness warrant (rare circumstances, indeed); otherwise, a person's participation in protective custody is voluntary.

Custody has logistic considerations few folks are aware of . . . like the medical bills. In the US, an indigent person in custody is entitled to reasonable (non-elective) medical care while in custody. If hospitalized, the LE agency having legal custody may be responsible for those bills (typically at negotiated Medicare rates)--that means the taxpayers are ultimately paying the bills. Generally speaking, LE agencies will, whenever possible and pragmatic, postpone executing an arrest warrant until after the subject patient is discharged from the medical facility. This does not mean the patient would not be subject to close surveillance pending that discharge.

MaeZe
08-05-2016, 11:00 PM
... Generally speaking, LE agencies will, whenever possible and pragmatic, postpone executing an arrest warrant until after the subject patient is discharged from the medical facility. This does not mean the patient would not be subject to close surveillance pending that discharge.Oh, that explains the patients charged (most commonly with assault) but whom are not in custody. Interesting. There is actually a reason the police don't seem concerned the hospital will discharge the patient.

jclarkdawe
08-05-2016, 11:45 PM
IronMike forgot about protective custody, which could also be used here if he's a danger to himself. Removing IVs would be viewed as a danger to yourself, especially as it is going to be questionable whether you're in the right frame of mind. New York is also great at an arrest and then drop the charges a few hours later. New York is not viewed as a defense favorable state. It really depends upon how much of a person of interest the person is and what's the story involved in the homicide. My guess is that the police would get a judge to issue a material witness warrant while he's being operated on. In New York, this isn't hard to get.

Drug and alcohol treatment records can't be released, subject to a lot of work on a warrant. Results of a tox screen, however, are not either drug or alcohol treatment records and can be released. If the hospital wants to be a pain, a search warrant is easily acquired for this. This is part of a standard homicide investigation in this type of fact pattern.

Problem for the hospital here is that you've got a guy suspected of killing someone. You don't know what way they're going to explode when they become conscious. Easier to restrain than to deal with the consequences. If he went down swinging before the surgery, which would be my guess, you've got to figure that's going to happen afterwards. He either lied to the admission/ER people, or he came in on an ambulance. If he's lying, you don't know what he's going to do when he sees a police officer in the room.

In this sort of scenario, he would be a suspect and not a person of interest. The police are unlikely to know what's going on and they're going to be cautious until they get the story straight. In New York, the view tends to be go overboard in the beginning and back down as the situation develops.

Albany is not as tough as New York City, but it's a tough city. It's got some serious crime levels and some aggressive policing. They'll infringe on your rights to the point where a judge might get upset. New York judges don't get upset at much. In New York you'll see a lot of aggressive approaches in the beginning of the case. However, some of this depends upon what happened with the homicide. But I'm working on the presumption that the police still have little clue what happened.

Jim Clark-Dawe

MaeZe
08-06-2016, 12:25 AM
Restraining a confused patient is not "protective custody".

Understanding Patient Restraints: a Hospital's Decision to Use Restraints (http://corporate.findlaw.com/law-library/understanding-patient-restraints-a-hospital-s-decision-to-use.html)
A hospital may be sued for negligence for not taking adequate precautions to protect impaired, elderly, incapacitated or unstable patients. On the other hand, hospitals also have been sued for false imprisonment when patients were restrained against their wishes.

As for a dangerous patient, if you have someone like a person wonked out on PCP, or a delusional patient trying to bite or punch the nurses, yes, we will use the leather restraints.

But a bad guy in his right mind, the hospital is not threat to that person. If they want to walk out, we let them. If the police think they may want to arrest the person for murder, there's a good chance they will leave an officer there.

ironmikezero
08-06-2016, 01:18 AM
To help clarify the "protective custody" thing . . . Jim does make a good point about subjects/patients whose observed or anticipated behavior may constitute a danger to themselves or others; they may find themselves held (possibly restrained) for a period of (psychiatric/psychological) observation/evaluation (typically 72 hours, beyond which a court is almost always involved). While such is considered "protective custody" in some jurisdictions, that terminology is not in ubiquitous use in all jurisdictions. I don't know what nomenclature might be appropriate in Albany, NY. Nonetheless, the effect is the same--three days of confinement and observation.

There are, of course, jurisdictional variations of the theme . . . What does your story need?

jclarkdawe
08-06-2016, 01:18 AM
I'm sorry I wasn't clearer. This would not be the hospital taking custody, it would be the police. Entirely different set of rules. If the guy is in his right mind, the police would probably threaten arrest if he doesn't talk to them. You can always arrest and drop charges.

Jim Clark-Dawe

MaeZe
08-06-2016, 01:32 AM
...they may find themselves held (possibly restrained) for a period of (psychiatric/psychological) observation/evaluation (typically 72 hours, beyond which a court is almost always involved)....Just one nitpick, a 72 hour hold for psych eval has to be ordered (in this state anyway) by an MHP (Mental Health Professional) or a physician. I see in CA the police can also authorize a 72 hour hold for psych reasons. It's governed by state law. When a 72 hour hold is ordered it is almost never on a general hospital ward. The patient would go to an inpatient psych hospital.

I'm trying to point out that hospitals are not jails, and health care workers are not police and we take that very seriously.

If the police want this guy in custody, an officer would be assigned to stay with him and regular shift changes would occur with officers staying round the clock.

MDSchafer
08-06-2016, 06:31 AM
Yeah, I can't resist, but this happens.


https://www.youtube.com/watch?v=dYBeMer1te4&feature=youtu.be

jclarkdawe
08-06-2016, 07:05 AM
I'm definitely not saying that hospital workers would be responsible for this guy. If the police want this guy, and I'm guessing they would, they've got to use their manpower to make it happen.

In the Northeast, the police have the ability to put someone who is severely under the influence into protective custody until they sober up. This is very different from the 72 hour hold. New York has been known to be creative about this statute. New York is a creative state for holding people.

Jim Clark-Dawe

MaeZe
08-06-2016, 07:28 AM
Yeah, I can't resist, but this happens.


https://www.youtube.com/watch?v=dYBeMer1te4&feature=youtu.be

That is funny in so many ways. :roll:

Eluveitie
08-06-2016, 01:38 PM
Thank you, everyone. I didn't realize how complicated something like this really is in real life. It's interesting to read about all the procedures and how it differs per jurisdiction.

Do you think that the situation would be different for a minor (the character in question is 17, but because he doesn't have any ID, I guess that would be rather difficult to tell)? He isn't under the influence of anything, but he's not in the right state of mind. He also knows that if he stays in the hospital, the same people who killed the other victim will kill him, too, but he can't go to the police.

mirandashell
08-06-2016, 03:13 PM
That is funny in so many ways. :roll:

I love the comment underneath about haldol darts.

MDSchafer
08-07-2016, 12:14 AM
I love the comment underneath about haldol darts.

I had a nursing instructor who was a pysch nurse in California during the 70s, and she always used to say, "I could hit a moving hippy with needle full of diazepam from across a crowded room."

MaeZe
08-07-2016, 01:23 AM
Thank you, everyone. I didn't realize how complicated something like this really is in real life. It's interesting to read about all the procedures and how it differs per jurisdiction.

Do you think that the situation would be different for a minor (the character in question is 17, but because he doesn't have any ID, I guess that would be rather difficult to tell)? He isn't under the influence of anything, but he's not in the right state of mind. He also knows that if he stays in the hospital, the same people who killed the other victim will kill him, too, but he can't go to the police.

The hospital ED can treat minors without parental consent in an emergency. If the character lies about his age, consent would be moot. The laws governing false imprisonment would apply equally to a minor unless you are talking about a young child in which case safety would give cause to hold the child there. If the parent of the 17 yr old said, please restrain my child, the hospital could legally do so. (State laws differ here, you'd need to check. For example some states, no longer require an older teen runaway be returned home.)

Again, consider the police and the hospital separately. Hospitals are not an extension of the police. And with HIPAA, it became even more so. The police were livid tox screens were no longer free warrantless information. The ED grapevine (my word for it) was a common source of information prior to that.

I, as a medical provider, don't have police authority anymore than police have the authority to write medical orders. It's also not my job to solve crimes, my duty is to the patient perhaps along the line of a lawyer's duty to their client, guilty or not.

Susannah Shepherd
08-07-2016, 03:41 AM
The hospital ED can treat minors without parental consent in an emergency. If the character lies about his age, consent would be moot.

Do all jurisdictions have the same rules about the age at which a minor can give consent for their own medical treatment? I remember my parents freaking out when I was allowed to sign consent forms for urgent surgery when I was 13, but staff told them that they'd talked to me and assessed that I was capable of understanding what I was signing (correctly so, I was pretty mature for my age). This wasn't in the USA though; I live somewhere with far less complex legal liability issues.

jclarkdawe
08-07-2016, 04:46 AM
Do all jurisdictions have the same rules about the age at which a minor can give consent for their own medical treatment? I remember my parents freaking out when I was allowed to sign consent forms for urgent surgery when I was 13, but staff told them that they'd talked to me and assessed that I was capable of understanding what I was signing (correctly so, I was pretty mature for my age). This wasn't in the USA though; I live somewhere with far less complex legal liability issues.

No, lots of differences between jurisdictions. As a basic rule, in the US a child reaches the age of majority at 18, but there's all sorts of exceptions and differences between the individual states.

Jim Clark-Dawe

MaeZe
08-07-2016, 05:04 AM
Do all jurisdictions have the same rules about the age at which a minor can give consent for their own medical treatment? I remember my parents freaking out when I was allowed to sign consent forms for urgent surgery when I was 13, but staff told them that they'd talked to me and assessed that I was capable of understanding what I was signing (correctly so, I was pretty mature for my age). This wasn't in the USA though; I live somewhere with far less complex legal liability issues.

I was referring to emergency care which can be given if the parents, or next of kin if the patient is mentally incapacitated, cannot be found. Urgent care is another matter. They would try to reach the parents. In this state at 14 you can legally consent to birth control, STD testing, and treatment without the parent's involvement. But you could not consent to an unrelated medical treatment, for example, a vaccination.

My brother thinks it's outrageous that a 14 yr old need not get parental consent in many states for an abortion. He thinks it's akin to consent for an elective surgery and it annoys him that his parental authority is usurped.

But 18 is an arbitrary social division as well. It's all about one's mindset.

MDSchafer
08-07-2016, 05:51 AM
No, lots of differences between jurisdictions. As a basic rule, in the US a child reaches the age of majority at 18, but there's all sorts of exceptions and differences between the individual states.

Jim Clark-Dawe

Yeah, it can a get incredibly complicated in Georgia, for example. This is all theoretical, but I'm sure could/has happened. In Georgia boys can marry at 16. So if a 16 year-old-boy gets married to a 20 year old Jehovah Witness who determines if the boy gets blood should he need it and unable to given consent himself? A judge, and good luck to her.

WeaselFire
08-08-2016, 06:57 AM
Lol, oh. That makes sense. It takes place in Albany, New York.

In Albany, he'd be at Albany Med. He would be in leather restraints and there would likely be a guard posted, police department, not hospital. He would be in one of the private ICU rooms, coded entry and exit. No ID and no verification of ID is treated as one of the highest security risks, especially in light of terror attacks.

Second, the medical issues won't have him up and fighting in a short time frame. He'll be on an IV with a narcotic drip, kept in a twilight state of anesthesia. If he does manage to get up, he's going to need serious medical attention shortly due to the damage he does to himself.

So, start with what you need him to do or be able to do, then write the circumstances that allow that.

Jeff