When patients abuse emergency department workers

There are few professional careers centered around protecting and caring for others that garner so much verbal and physical abuse than a career in emergency medicine.  Mental health workers, police, fire, and EMS personnel are the other fields that come to mind when I think of a service that “helps” people yet gets abuse dished upon them on nearly a daily basis.

A 2006 survey of emergency nurses showed that 25% of nurses “seldom” or “never” feel safe at work.  The emergency department has the highest volume of reported cases of abuse of any segment of the healthcare setting.   It is generally accepted that the abuses are significantly under-reported because this abuse is just considered part of the job.  I know that I and most of my co-workers never report the abuse that we receive.

From first-hand experience in our high patient volume emergency department, I can tell you that it is nearly daily that I am verbally abused by at least one patient, sometimes more.  Attempts at physical abuse come less frequently but not infrequently.  Patient’s have attempted to hit, kick, bite, scratch, and spit.  By far, the vast majority of cases of verbal and physical abuse come from the drug and alcohol intoxicated, the psychiatrically impaired, and the demented.

Incidents of physical abuse are more common than you might think.  In various surveys, the level of verbal abuse and threats against emergency department healthcare workers seems consistently high.  I did not find one where that rate was less than 60%.  But more surprising was the rate of physical abuse.  Reported physical abuse occurs in a widely varying but nonetheless high rate somewhere in between 25% and 57% of respondents to these surveys.  In one study of 242 employees there were 329 reported cases of verbal and/or physical assault.  Most of which went unreported to hospital or emergency department administration.

I have witnessed a physician colleague of mine get pummeled by a patient for no apparent reason,  I have seen multiple nurses go out of work due to injuries suffered at the hands of patients.  And I have even seen a patient attempt to start the emergency department on fire by lighting up the hospital bedsheets.

A recent harm threat that I received was from a gentleman who after stating “you will see what it is like to be in pain” stood at the nurses desk and whispered to me as he pointed toward the exit door: “I will be waiting for you outside after your shift ends.”

From 1980 -1989, 22 physicians were killed while at work.  More recently in November 2013, a Dr. Stephen Larson was shot and killed by a man disgruntled about the care his mother received.  And in December 2013 a urologist in Nevada was killed by one of his patients and one of the other physicians in the office was critically wounded.

But what I want to talk about are the patients who are nice as can be when sober, mean as can be when not.  My general line of thought is that I am perfectly ok with mild to moderate drug and alcohol use.  But if you end up in the emergency department, and sometimes multiple times, due to your drug and/or alcohol use, then it is obvious(to me) that you are doing something wrong.

I am usually quite disturbed by the intoxicated patient who comes in tied down to the stretcher, using all sorts of profanity, spitting, and trying to swing at nearly anyone who gets within an untied-arms reach.  Then, miraculously, hours later they are sweet as pie.  Often quite apologetic for their behavior and sometimes telling me about their family and asking when they can be released because they have to be at work in a few hours.

How is it that these normally good people, turn so ugly with drugs or alcohol?  I know that drugs and alcohol change your perception, change emotions, disinhibit people, and alter impulse control.  I usually forgive the young teenager who went a bit overboard with their experimentation.  But adults whom I know have been down this path before.  They are not so easy to understand.

I recently watched a TED talk by Philip Zimbardo about the “Psychology of Evil.”  In that episode, Mr. Zimbardo stated that there are true “bad apples,” but these true sociopaths only make up less than 1% of the population.  There are also “bad apple barrels,” which would be the environment or conditions that the people are under that make them do things that they normally would not do.  And finally, there are “bad apple barrel makers,” which would be the system that allows the bad environment to exist.  This system could be a family, a business, or a government that allows, promotes, or creates the conditions that lead to a bad environment and bad behavior.

So when it comes to this completely inappropriate behavior that occurs with drugs and alcohol, I understand that most of these people are not actually bad people.  Many are in a bad environment that induces such behavior.  But if the behavior is induced purely by the environment of being marinated in drugs or alcohol, then it seems that this environment needs to change.

I am not suggesting a prohibition-like state by any means. That would be addressing the apple barrel makers.  While I think improved enforcement and education for sober driving and “healthy” substance use is warranted, what I am suggesting is some personal responsibility to fix the bad apple barrel — to address the circumstances.

As I mentioned, if you are ending up in emergency rooms due to drug and alcohol use, you are doing something very wrong.

Jonathon Savage is an emergency physician who blogs at Medical Mojo.

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  • Rob Burnside

    An interesting piece, but incomplete. You could have, and perhaps should have, made mention of “legitimate” misbehavior in emergency department patients. Throughout my career, I was slugged by more geriatric hyperglycemics than I care to remember, I chased a significant number of head trauma patients down the road, and I was verbally abused by many a manic bi-polar type-1 who either forgot to take his lithium, thought he didn’t need to take it, or simply couldn’t afford it. And that’s just for starters. I used to fantasize about a triage nurse armed with nitrous oxide–what a difference it would make!

    It’s a safe (and prudent) assumption that every conscious ED patient is already agitated to some degree on arrival. Once there, a long wait for treatment will only make things worse. The bottom line: a substantial amount of patient misbehavior comes with the territory. Perspective ED workers need to know this up front, and should try to avoid taking any of it personally. When you get to this point, it’s time for a break.

    • Jonathon Savage

      I agree with you. There are many legitimate reasons why patients become frustrated and occasionally agitated.

      I find that most staff members do not take these situations personally but try to work with the patients through their frustrations and attempt to address the focus of that frustration. The under-reporting is a direct result of not taking it personally and considering it part of the job.

      Unfortunately, I do not think there is much training in residency programs or nursing/physician assistant that directly speaks to de-escalation in these situations.

      • Rob Burnside

        It’s a shame about the lack of realistic training, Dr. Savage. There never was any, actually, but that’s no reason why it can’t change., or shouldn’t. Maybe you can do something about it.

        Part of the problem, in my opinion, lies with health care administration–staffing. It’s an issue everywhere, but the ED, as you know so well, is totally unlike any other healthcare setting. You and your colleagues should re-write the book, and get the staffing levels you need for your own safety. This will benefit patients and staff alike. I’d also like to see the sabbatical concept become reality for all ED workers. Otherwise, your careers (and perhaps your lives) will be cut short by the long-term effects of excess cortisol production. Finally, I think it’s important for everyone to realize that stress and revulsion are cumulative rather than episodic. These things are not rites of passage, initiations, or gut-checks–they’re killers. You must do whatever you can to limit exposure, and mitigate it when it occurs.

        If it were up to me, I’d limit shifts to six hours (without corresponding salary reductions) to reduce physical, mental, and emotional exhaustion; institute a sabbatical program for all full-time ED staff; adjust the salary scale to compensate everyone appropriately–the civilian equivalent of military “combat pay;” and offer burned-out staff extra time off and/or rotation to quieter duty elsewhere in the hospital.

  • JR

    The next time you have an addict in your hospital, do not ask “what’s wrong with you?” but instead ask “what HAPPENED to you?”

    80% of people with addictions have suffered from traumatic events, and many do not consciously connect those events with their substance abuse.

    If you are interested in learning how to better serve these patients, look up “trauma informed care.” Research is starting to provide best practices to help these patients but it requires a lot of change to the way health care is delivered.

    • Jonathon Savage

      Thank you for your suggestion regarding “trauma informed care”. I have begun to review the various websites for the National Center for Trauma-Informed Care (NCTIC).

      I do not disagree with your premise one bit that many patients managing substance abuse issues are also managing traumatic events in their lives. But I am not so convinced that attempting to delve deeply into their past by asking “what happened to you?” is the correct management technique during an acute crisis situation. Obviously asking “what’s wrong with you?” is not the correct approach either.

      Substance abuse identification and counseling in the emergency department is under-utilized due to time and finances. Given the support and resources, it would likely be employed way more often.

  • Mengles

    The emergency room is a brave new world for those who work there, doctors and nurses alike. That has to have an effect on one’s psyche. It’s no surprise then that ER doctors burn out at such a high rate.

    • Jonathon Savage

      A 2012 Archives of Internal Medicine survey suggested that US physicians showed signs of burnout at a rate higher than the US general population work-force.

      A 2013 Medscape survey did not provide any rosier results. Emergency physicians and Critical Care docs were at the top of the list. See doctor burnout rates by specialty graphic here: http://www.medscape.com/features/slideshow/lifestyle/2013/public#2

      Dealing with difficult patients was ranked of moderate importance as a reason behind the burnout symptoms. However, there were several others that were ranked higher. See that graphic here:
      http://www.medscape.com/features/slideshow/lifestyle/2013/public#4

  • medicontheedge

    Right on!!! The very same police who arrest a drunk while driving, will refuse to arrest that same drunk who assaults a worker in the ED.
    Infuriating!

    • Kate

      You may be interested in this link: http://news.nurse.com/article/20101122/NJ02/311220003#.UwPTwCheYSV
      While I believe it is the duty of clinicians to have the knowledge & skill to de-escalate & contain agitated patients, when this is impossible with intoxicated patients or patients who are just plain angry, clinicians need to have recourse and administrative leadership that will back them up.

    • NormRx

      The state makes money off of a DUI conviction, they do not make any money off of an assault in the ED.

      • T H

        In CA, anyone arrested will be back on the street before the deputies can finish the paperwork because of jail and prison overcrowding.

  • medicontheedge

    If hospitals had to report assaults on staff as a specific occurrence for OSHA, you would see a huge uptick in the numbers. As of now, they are grouped in with all the work related injuries, so are hidden in the stats.

    • Jonathon Savage

      The bit that I was able to pull from the Bureau of Labor Statistics did separate out the health care service industry. But in any case, the incidents are mostly under-reported and the overall problem seems to take a back-burner to all of the other myriad issues that are being dealt with.

      Patient safety appropriately has the spotlight currently. This is deserved and necessary. But a little more public light needed to be shed onto the issue to health care worker abuse as I do not think it gets much attention.

  • querywoman

    I understand what you are talking about; however, I will take this opportunity to put in a plug for the rights of people with skin disease. I get abused all over the place for my skin disease. That includes nondoctors who think my derm is a quack and that they can prescribe better.
    I was recently in the ER with apparently flu and, then, a few days later, pneumonia. My skin lesions were noticed. I told all they are a form of atopic eczema, yet every turn I heard about, “scratching.”
    Skin patients need the medicos to shut up about scratching and treat us!

    • DoubtfulGuest

      Good point, querywoman. I experienced something similar, although not in the ED. It amazes me how easily they attribute skin diseases to patient behavior. I had shingles, seemingly twice over several months during a very stressful period. I had been wrongly accused of malingering and was going without needed care for my mitochondrial disease. Finally near the end one of my doctors recognized it as zoster. But for about nine months, they attributed the rather painful lesions (I had nerve pain in my face) to young female patient, “excoriations”, psych problems, bad person, blah blah blah. I’m sorry this is an ongoing problem for you and probably worse. The disgust and negative judgment on doctors’ parts is really hard to take.

      • querywoman

        I have been dismissed as a delusional fruitcake in the past. I have a decent dermatologist now.
        It’s atopic dermatitis/eczema and it slowly peels off, with treatment.
        Yesterday, I saw a woman on the bus, who I know has umpteen health problems, who plainly stated she’d been picking at the skin on her hands. Her fingers and hands were swollen in a way that mine is not.

  • buzzkillersmith

    Good Ted talk. Thanks for the link.

    ER is a tough job for a lot of reasons, and this is just one more. I don’t know how you all do it.

    • Jonathon Savage

      Thank you. It truly is a very rewarding and dare I say “fun” job. All types of patients from all walks of life with all types of medical conditions makes for a never boring, ever challenging career.

  • Jonathon Savage

    You never forget experiences like that. The intent behind my blog was simply to highlight the high rate of such violence and the effect it can have on providing quality of care because incidents such as yours can affect your interactions with and care of other patients. I am sure that you, like many, have carried on with your job and do it well but it can affect your performance and job-satisfaction.

    The Bureau of Labor Statistics gave a rate of 9.3 violent assaults/10K workers while at work for individuals in the healthcare services industry vs 2/10K for individuals in the private sector. And again, this is likely a low number due to under-reporting.

  • Jonathon Savage

    I have known staff members to file charges for assault, but I can count on one hand how many I have known that have taken the incident that far.

    I agree with Kate’s comment that clinicians should be given the knowledge and skill-set to learn to de-escalate a situation. There should be administrative support for these incidents that exists more than just on some piece of paper filed away somewhere.

    OSHA guidelines for preventing workforce violence for health care and social service workers state:
    “At a minimum, workplace violence prevention programs should:
    Create and disseminate a clear policy of zero tolerance for workplace violence, verbal and nonverbal threats and related actions. Ensure that managers, supervisors, coworkers, clients, patients and visitors know about this policy.”

    See below for more on the full guidelines:
    https://www.osha.gov/Publications/OSHA3148/osha3148.html

    Since the guidelines are just guidelines, the degree of implementation of them is likely immensely variable.

  • querywoman

    Who is the “he” who spoke the truth? I don’t care what doctors think of me. I just fire them and get another now.
    My skin goes through stages where the process peels down, then nodules or lesions come to the surface.

    It looks worse until the scabs fall off. Then I get accused of “picking at it.”

    Thanks to the wonders of modern photography, I take pictures as it progresses and that helps me to prove what’s going on.
    Skin disease is real and worthy of treatment.