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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