Charles C. Anderson's Blog

DISCOURAGED ABOUT THE FIGHT AGAINST HEALTHACARE VIOLENCE

You may have noticed that I don’t post very often on my healthcare blog anymore, http://thefirsttosayno.wordpress.com. I have concluded that I have done all that one male emergency physician can do to support healthcare workers who are not ready to fight for their own safety in the healthcare workplace.

I know a few very dedicated activist nurses in healthcare violence, but they are mostly retired. How else could they be vocal about emergency department violence? Few employers would tolerate an activist nurse, someone who demanded measures like armed security guards, controlled visitation, mandatory reporting of abuse, and mandatory responses to abuse. However, neither the rank and file emergency nurse nor nationwide nursing organizations are willing to go to the mat over healthcare violence at this time. Emergency nurses will fill out violence and abuse surveys and go to healthcare violence workshops, but they have too much to lose to stand up in their own departments and scream, “I’m sick of being abused and I’m not going to take it anymore.”

Like the rape victim, the emergency nurse knows that complaining about an assault by a patient will bring her own behavior into question. “And what did you do, Nurse Ratchett, to provoke this man into slapping you?” Think about it.  Would you report a patient who slapped you, or groped you, or spit on you, or verbally abused you?

By their nature emergency nurses are long-suffering, compassionate, very slow to complain, and exceptionally tolerant of abusive patients.  God love them for these qualities. It is this very tolerance of abuse that is standing in the way.  Abusive patients are usually repeaters. They know that no matter what they do or say to a nurse, the hospital is not going to support the nurse.

Some nurses in a few states have tried to approach the problem legally. If abuse of a healthcare worker were a felony, they reasoned, then abusers would take notice and change their behavior. Wrong. I couldn’t find a single patient prosecuted as a felon in Virginia under this law. Nice try, but the nurse is still in the position of dealing with an unsympathetic administrator, who wants to go to his grave without suing any patients. Any nurse who announces that she wants to sue a patient will likely be victimized twice. And she could be labeled a trouble maker.

The same dilemma faces a nursing department head. If she supports prosecution of an abusive patient, her job could be in danger. Those nurses who have climbed the ladder of success into administration or who have been elected president of a state or national nursing organization know that being an obnoxious activist against healthcare violence will likely damage their successful careers. The problem requires being obnoxious. Such a person would need to be a warrior.  Besides ruffling feathers in her own hospital, she would need to take on some of the most powerful corporate lobbies and government agencies, including the American Hospital Association (AHA), the Joint Commission on the Accreditation of Hospital Organizations (JCAHO), the Centers for Medicare and Medicaid Services (CMS), and Occupational Safety and Health Administration (OSHA). These organizations could have acted to protect healthcare employees years ago, but only the squeaky wheel gets oiled in Washington.  Nurses don’t squeak, and they suffer for it.

AHA, representing hospitals, does not want to spend money on full-time armed security in EDs. Hospital administrators don’t want ED patients to feel like the ED is a dangerous place, despite the fact that it is the most dangerous workplace in America. Lost in this upside down thinking is the first principle of crowd control–the highly visible presence of armed security prevents violence and abuse.

I went to a large summit conference on healthcare violence. All the speakers were from the organizations listed above. They were all friends and obviously scratched each other’s back. AHA didn’t want any government agency requiring them to spend money.  In many cases the same people sit on government agencies and private hospital boards. The summit ended with no action plan. Same old. Same old.

To their credit a few large hospital corporations have placed security guards in their emergency departments. Thank you. Thank you. I’m curious. If guards prevent violence against their employees, why wouldn’t guards prevent violence in other departments?  Too simple, I guess. Often a hospital will wait until a disaster occurs in the emergency department to hire full-time security. So sad.  Do not assume that US hospitals are any more prepared for a violent crowd than they are for Ebola.

So, getting back to discouragement. As much as I would like to have been a champion of abused nurses, the nurses themselves are not ready for the fight that is necessary.  They are concerned about being abused, but not enough to demand change as a group.  At times I have gotten 15,000 hits per day on this blog. I have railed about all of the contributors to healthcare violence.  I have offered plans of action. I have shared my personal experiences. I have appeared on radio shows and written editorials on healthcare violence. At this time, nurses cannot agree to work as a group. They cannot compromise among themselves or agree on their goals. In small groups, they will accomplish little.

It is impossible for me to go to my contacts in the House of Representatives and the Senate without some endorsement from nursing organizations.  I’m thinking that emergency nurses need a charismatic female national leader who is willing to stand up and fight the AHA lobby and the do-nothing-constructive government agencies regardless of the personal cost. Women who have actually been abused are probably more persuasive than an old man like me in a skirt.

I really do care about the safety of all healthcare workers, but especially ED nurses and EMS workers. I worked 38 years with them. My observations were that ED nurses and EMS workers were treated miserably by many patients and that they were usually not supported by anyone when they were abused.  Unfortunately, too many ED nurses and EMS personnel would rather leave their jobs than fight for a safe workplace.  Those who stay see themselves as caregivers, not inclined to buck the system, put their own job in jeopardy, or draw attention to themselves.  They have kids at home to feed. And so they suffer on–EMS workers, nurses, and nurse’s aides. I tried. I did my best. I really don’t know if I made any difference in the big picture. Emergency nurses and EMS, God Bless you everyone.

IMPLEMENTING LASTING DETERRENTS TO HEALTHCARE VIOLENCE

 

PART II OF AN INTERVIEW WITH JEANNE WHITE TUESDAY APRIL 15, 2014

FEATURING SHEILA WILSON, R.N., MPH AND CHARLES C. ANDERSON, M.D., FACP, FACEP

This is a thirty minute segment that completes this presentation.  To listen click this URL.

http://tinyurl.com/mcntwok

The initial 60 minute segment on healthcare violence, which aired on April 11, can be found at http://thefirsttosayno.wordpress.com

 

Charles C. Anderson M.D. FACP, FACEP

http://www.amazon.com/author/thrillerguy

 

PWR INTERVIEW ON HEALTHCARE VIOLENCE

PWR INTERVIEW FRIDAY APRIL 11, 2014 ON HEALTHCARE VIOLENCE with LILLIAN CAULDWELL

Sheila Wilson, RN, CEN, MPH and I had a nice 60 minute interview with Lillian Cauldwell on PWR Internet Radio on Friday, April 11, 2014.  Lillian claims to have 10 million worldwide listeners. The subject was healthcare violence. We were able to define the nature of this problem well. We were invited to return next Wednesday at 2:00 PM to discuss remedies.  Click on this link to hear Friday’s entire broadcast:

 

https://www.pwrnetworkllc.org/cauldwell-20140411/

Charles C. Anderson M.D. FACP, FACEP

http://www.amazon.com/author/thrillerguy

 

 

 

MY HEALTHCARE VIOLENCE INTERVIEW ON BLOG TALK RADIO

LISTEN TO MY INTERVIEW ON HEALTHCARE VIOLENCE ON BLOG TALK RADIO  SUNDAY MARCH 23, 2014

http://www.blogtalkradio.com/webbweaverbooks/2014/03/23/webbweaver-books-proudly-presents-author-charles-c-anderson-1

I WILL BE RETURNING TO THIS SHOW ON MAY 9, 2014

LIVE BLOG TALK RADIO SHOW TOMORROW

 

I will be the featured guest on a 30 minute live blog talk radio show tomorrow, Sunday, March 23, 2014, at 12:00 PM. EST/DST. To listen to this interview go to http://blogtalkradio.com/webbweaverbooks.  I will be talking about healthcare violence, as well as my novels.  I will read about 10 pages from The Farm, and field questions from listeners.  This web site is a great place for anyone who likes to read.  Hundreds of authors have recorded interviews on file. You can find podcasts on almost any subject by some of the most interesting and qualified speakers in the country. Webb Weaver Reviews has been recognized for the past three years as one of the top 15 book review blogs in the world by Predators & Editors.  Due to questions, sometimes these interviews last longer than thirty minutes.  In any case the entire interview will be available at this web site indefinitely. If you go to the web site today, you will see an announcement of my interview. Make this site a favorite and you’ll be ready to listen with one click tomorrow.

USELESS LAWS

I received a question to this blog recently regarding how many states had felony designation for assault on a healthcare worker.  I’m working on the answer, but I believe this is the wrong question.  A nurse wrote to this blog telling me proudly that in her state it was a felony to assault a healthcare worker.  I checked.  In its first year, not a single person was prosecuted under this law.  That’s been my own experience.  I have NEVER seen anyone prosecuted for assaulting a healthcare worker.  I would be interested to hear from any healthcare worker whose hospital actually assisted them after they were assaulted.  Healthcare workers are under great pressure NOT to press charges against patients.  Police departments are very biased against charges made by emergency nurses. In some cases, the police refuse to come to the emergency department and take a report.  Hospitals do not want to be part of any attempt to prosecute “customers.”  Passing laws making assaults on healthcare workers a felony helps no one.  A useful law would be one that required a hospital to take measured steps against patients who assault employees, and prevented a hospital from punishing any employee who brought charges against a patient.

OUR MASS INCARCERATION OF NON-VIOLENT OFFENDERS IS THE GREATEST POLICY MISTAKE OF THE LAST FORTY YEARS

 

The United States incarcerates more of its citizens per capita than any other nation on earth.  Who are these people and what do they have to do with healthcare violence?  Talking tough on drugs sounded like a good idea back in 1970.  Mandatory minimal sentences were adopted supposedly to frighten drug users into sobriety.  Let’s look at these tough sentences and what they have cost us. Of prisoners serving life sentences without parole in the US, 79% committed a non-violent drug crime.  Minorities have suffered the most from our failed War on Drugs.  Non-violent prisoners are costing U.S. taxpayers over $1.7 billion dollars more than if life without parole were not a sentencing option, according to a report by the American Civil Liberties Union.   Due to mandatory sentencing laws non-violent drug offenders have cost taxpayers over a trillion dollars since the War on Drugs began.

Hundreds of thousands of non-violent drug offenders are serving sentences of twenty years to life for doing what is now legal in Colorado.  Taxpayers are shelling out billions every year to house and feed these non-violent drug offenders, who may be serving incredibly long sentences for mistakes made in their teens and twenties.  The country’s War on Drugs has become a cash cow for the private multibillion dollar prison industry.

Federal and state governments across the nation funnel money into private prisons, which are paid more for longer sentences. The prison industry spends millions of dollars lobbying for even more prisons while their executives are paid like Wall Street tycoons.  There is a long list of industries, institutions, and individuals that profit from our mass incarceration. Every one of these have financial incentives to imprison more people for longer sentences. Include on that list the phone companies that charge astronomical rates for prisoners to call their families, for-profit prison health care providers, commercial food vendors who charge sky high prices in their vending machines, and the powerful correction guards’ unions.

I recently visited a federal minimum security prison.  I was shocked by this experience.  The nice dormitory buildings with semi-private rooms were arranged like a summer camp.  I saw immaculate grounds. There was no barbed wire.  I saw no armed guards. Visitors were allowed to show their driver’s license and spend almost all day Saturday and Sunday with their friends or relatives.  Nobody searched me.  I noted that no one was allowed to bring food.  All food consumed in the large hotel-lobby style visiting area had to come from vending machines.  A sandwich costs $6 from one of these machines. A candy bar costs at least a dollar. Drinks were $2.

I was at this minimum facility on a Saturday and the visiting area was packed.  Every inmate in this particular federal facility was a “white-collar” offender.  I met accountants, lawyers, doctors, and businessmen.  Most of them had been forced to plead guilty to income tax violations.  I didn’t meet a single person who had a trial.  Everybody I talked to was given the choice of pleading guilty to whatever they were charged with or having their families charged as co-conspirators. I asked about their possibility of early parole.  Almost as one person, these inmates stated that their case manager had little reason to get them out early, since the institution would lose money if anyone went home early.

I left this facility wondering why any of these people were incarcerated.  How could they pay the back taxes and fines they owed if they were not working? By the time they got out, many would be unemployable.  Back home, their families were struggling from day-to-day. What a terrible waste of educated people.

If a person is not a flight risk and is non-violent, what purpose is served by incarcerating him for long periods of time? We seem to have lost all perspective of what it means to deprive someone of their personal liberty for even a year. With mandatory minimum sentencing laws, judges have lost the ability to hand down reasonable sentences, while prosecutors have enormous discretion in determining how long an individual goes to prison.  Drug offenders often get 5-10 mandatory extra years because they were caught with a certain number of ounces of a drug.

How effective has mass incarceration been? Despite the fact that we incarcerate more people per capita, and give out much harsher sentences than nearly all developed countries, this incarceration has not resulted in lower crime rates than our peers’.  We incarcerate 173 times more inmates with life sentences without parole than the United Kingdom. Only two European countries even imprison offenders without parole. Our imprisoned citizens have no voice.  No one is handing out millions to politicians to get them out of jail and into drug treatment programs or back to work.

The War on Drugs has been the greatest failure of policy in this country over the last forty years. Millions of young men have lost the best years of their life for a mistake they made at age 19-30.  At the same time we were dumping the paranoid schizophrenics out into the street and closing mental health facilities, we were spending trillions to house non-violent offenders without mental illness.  Our emergency departments are the destination of last resort for the mentally ill, but we have nowhere to send them.

I’m not implying that all mentally ill patients are violent, or that they should replace the non-violent inmates in institutions.  I’m saying we wasted trillions of dollars that could have been spent on the treatment of mental illness and drug dependence.  Most of the perpetrators of the notorious mass shootings we hear so much about not only had a history of mental illness, they had no access to mental health services when they were in crisis.

A logical solution would be to declare the War on Drugs a failure and to dismantle the prison industry that thrives on the incarceration of non-violent people.  Non-violent IRS offenders have little reason to be in jail at all.  So many small businessmen are forced to choose between sending tax payments to the IRS and paying their employees.  By the time their businesses fail, they owe more taxes than they can ever pay.  I believe that long sentences for IRS offenders are primarily for the intimidation of other taxpayers.

Rapidly moving mentally ill patients from emergency departments to mental health evaluation and treatment facilities would decompress all emergency departments and lessen the risk of violence in emergency departments.  There is enough money wasted on the incarceration of non-violent people in this country to fund a uniformed armed guard in every emergency department in the country, to fund the implementation of every known environmental preventive violence measure in every emergency department, to fund the evaluation and treatment of the mentally ill, and to fund drug treatment centers.  We have invested in punishment instead of rehabilitation and prevention.

I know you have heard this before, but we need to think of it again in the context of mass incarceration of non-violent people.  A definition of insanity is to continue to do the same thing and expect different results. I didn’t think that I agreed with Mr. Eric Holder on anything, until I heard him say that the mass incarceration of non-violent Americans was a tragedy.  Sometimes sanity comes from the most unlikely source, in this case, the Attorney General of the United States.

AN AGENDA FOR CHANGE IN HEALTHCARE VIOLENCE

Improving the sad state of physical and verbal abuse toward emergency nurses and other healthcare employees will require the combined efforts of legislators, hospital administrators, government agencies, nursing organizations, and emergency physician organizations.   We all find it easier to point out what is wrong than to develop a consensus for change.  Powerful lobbies will oppose anything that costs money.  Therefore, we must have some data and rationale to justify the recommendations we make.

The first step in understanding physical and verbal abuse in emergency departments has already been taken.  In 2011 the Emergency Nurses Association published a landmark study that clearly defined the scope of the problem.  We know approximately how many emergency department nurses suffer which kind of abuse.  We know what environmental measures are used by hospitals to control physical and verbal abuse.

The ENA study listed these preventive environmental measures with the utilization in their sample of departments—-bullet-proof glass 10.0%, chemical restraints 74.3%, enclosed nurses’ station 11.4%, handcuffs 20.0%, limits on number of visitor 62.0%, lock box/safe for cash 61.6%, locked treatment room 24.7%, locked /coded ED entries 80.6%, Mace 9.5%, mirrors to show hidden spaces 29.9%, panic button/silent alarm 73.6%, personal belongings search 53.3%, physical/leather restraints 88.0%, pseudonym to call a code 77.5%, security batons 14.6%, security cameras 85.3%, security signage 42.4%, visitor tag/badge 44.4%, and well-lit areas in the ED 91%. Metal detectors were not mentioned.

An attempt was made in this study to associate various environmental measures with the occurrence of physical and verbal violence. I would like to underscore that an association of an environmental measure with physical or verbal abuse does not imply a causal relationship, only a co-existent relationship.  If only 10 per cent of hospitals have bullet-proof glass, 11 per cent have enclosed nurses stations, and 10 per cent use MACE, this utilization may be too small to draw conclusions.  A true test of efficacy of any environmental measure must include physical and verbal abuse statistics before and after a measure is implemented. This ENA study was not designed to test the efficacy of environmental measures.  It was a surveillance study.

Panic buttons/silent alarms were associated with lower physical violence rates while the presence of an enclosed nurses’ station, locked/coded ED entry, security signage and well-lit areas were associated with significantly lower verbal abuse rates.

Perhaps the most important relationship noted in this study was the relationship between physical violence, population density, and the size of emergency departments.

Physical violence rates tended to increase as population density increased, rising from rural (9.1%) to large urban (14.8%) settings with middling rates in suburban and small urban settings. The rate was significantly above average in large urban settings (OR=1.45, pThe larger the department, the greater need for preventive environmental measures.  Larger departments are in areas of higher population density.

Thus, it makes sense that Level I Trauma centers need almost every type of environmental control measure, while lesser measures are required in smaller emergency departments associated with a lower population density.  This is a very important observation to those of us working for change.  Our goal isn’t to force expensive measures onto small hospitals that are unlikely to benefit from those environmental measures.  Every emergency department does not need bullet proof glass and a metal detector.  I would argue that every department does need on-site uniformed, armed security.  Physical violence can occur in any size department and muscle may be required to contain it.

In the study, hospital-employed, police/sheriff, campus police, and private security were all associated with a higher odds of physical violence.   This is not a causal relationship.  It is a co-existent relationship.  More baby carriages are found where there are more babies, but baby carriages do not cause babies.  Hospitals with the most violence are likely to have the most security.

I am sure that some people will read the association of human security personnel and violence and conclude that having armed security results in more violence.  The idea that not having an armed security person in an emergency department will lessen the chance of violence is foolish and not supported by this ENA study or any other study.  Most mass shootings occur in gun-free zones.  The first principle of crowd control is a credible show of force.  Vladimir Putin has just shown us an example of this principle in the Winter Olympics.  The only way to test the validity of uniformed, armed security as a violence prevention measure is to compare statistics before and after such security is implemented.

An important step in the arduous task of addressing ED violence is to establish some rational framework for recommending environmental security measures.   Each measure should be proposed in light of what we know about the relationship of size of a department to the threat of physical and verbal violence.  All environmental measures could be divided into:

1. Measures every hospital must comply with.

2. Measures that apply to departments with less than 20,000 visits/year.

3. Measures that apply to departments with 20,000-40,000 visits/year.

4. Measures that apply to departments with greater than 40,000 visits and/or have trauma center

designation.

5. Measures for pediatric emergency only departments reflecting their diminished risk of violence.

These are just examples.  We must start somewhere. Let’s glean some other insight from the ENA Study.

Since panic button/silent alarms are clearly associated with lower physical violence rates, then every emergency department should be using them, not 74%.  Since the presence of an enclosed nurses’ stations, locked/coded ED entry, security signage and well-lit areas are associated with significantly lower verbal abuse rates, every emergency department should be using them, not 11.4%, 27%, 42%, and 91%, respectively.

In the ENA study, higher commitment to violence mitigation from hospital administration and ED management and the presence of reporting policies (especially zero-tolerance policies) were associated with a lower odds of physical violence and verbal abuse. Specifically, hospitals with no reporting policy had an 18.3% physical violence rate, hospitals with a non-zero tolerance reporting policy had a 13.7% physical violence rate, and the lowest rate was in settings with a zero-tolerance reporting policy (9.1%). Nurses whose hospital administration (OR = 0.81) and ED management (OR = 0.77) were committed to workplace violence control were less likely to experience workplace violence. This level of commitment and policy must be made mandatory for all hospital administrations and ED managers. 

The majority of the participants who were victims of workplace violence did not file a formal event report for the physical violence (65.6%) or the verbal abuse (86.1%). Of the emergency nurses who indicated experiencing physical violence, almost half (46.7%) reported that no action was taken against the perpetrator as a result of the violence, and less (20.4%) reported that the perpetrator was given a warning. When asked about the hospital’s response/recommendation to the nurse, nearly three-quarters of nurses (71.8%) stated that the hospital gave them no response concerning the physical violence they experienced. Similarly, half (49.7%) of the nurses who indicated being victims of verbal abuse responded that no action was taken against the perpetrator(s), and just over a quarter (28.5%) reported that the perpetrator was given a warning. In regard to the hospitals’ responses to the nurses who experienced verbal abuse, more than three-quarters (80.6%) indicated that the hospital gave them no response.

This is outrageous. Hospitals must be held accountable for protecting their employees—physically, emotionally, and legally.  They must be forced, even if kicking and screaming, to support injured employees and prosecute physical and verbal abusers.  Every verbal abuser should receive a minimum of a letter from the hospital outlining the zero tolerance policy. Hospital administration must be judged by standards of compliance.

DUI offenders are not excused for their behavior or the injuries they cause because they are intoxicated. Calling a violent intoxicated person a “customer” while not providing basic human rights and legal rights to your own employees is disgusting.

I feel that it is long past time for healthcare to give up the ridiculous “customer” model.  We take care of patients, not customers.  Patients are frightened, sick, injured, vulnerable, and sometimes under the influence of drugs and alcohol. Some are seeking drugs. They are not coming to us to buy hamburgers. The customer model is an affront to both patients and caregivers.  Our goal as caregivers is to provide the most compassionate and appropriate care possible—-not to boost Press Ganey scores for an administrator.

My parents taught me to do the right thing, not the thing that pleases. We should never expect that doing the right thing will always please, or that pleasing somebody represents quality care.  So many of our necessary procedures cause pain.  Buying a hamburger does not cause pain.  Customers are always right.  Patients know what hurts.

Press Ganey scores need to be trashed.  This crude club was based on the false analogy of patients to customers and the false concept that pleasing a patient represented quality care.  Don’t you think that the failure of administrators to support their own abused employees is related to their view that patients are customers?  I do.

I welcome your comments.  My next post will address how environmental measures and changes in the management of the mentally ill can be paid for.

Charles C. Anderson M.D., FACP, FACEP

EFFECTIVELY RESTRAINING PATIENTS

One factor that contributes to violence and poor outcomes among critically ill patients and out-of-control emergency departments is a failure to restrain patients effectively. Accrediting organizations emphasize that the use of restraints is to be considered a last resort—to be employed only when all other methods of preventing injury to the patient or others have failed.  JCAHO goes so far as to say that using restraints represents a failure of management in psychiatric patients. There are people out there who believe that all restraints violate constitutional rights.  To comply with JCAHO a clinician appears obligated to defer his clinical judgment and experience regarding what will work and what will not to waste time on ineffective methods.

To please JCAHO many hospitals have removed leather restraints from the ED, or greatly restrict their use.  In some EDs, the leather restraints are locked up or otherwise made inaccessible by requiring a nursing supervisor’s presence or approval. Yep, we’ve got effective restraints. Nope, we can’t use them. In some EDs, nurses are required to use ineffective gauze before using leather restraints. Documentation of the use of restraints has become so onerous that the paperwork alone discourages their use. Well-intentioned people are making it difficult to use effective restraints when they are needed the most.  This may force the clinician to use even more risky methods of gaining control of a deteriorating patient—paralyzing and intubating the patient.

I recently read an article which stated that intubated patients who were restrained were statistically more likely to extubate themselves than non-restrained patients.  No mention was made of how the patient was restrained or how the endotracheal tube was stabilized or what the mental status of the patient was.  As a critical care specialist directing multiple respiratory ICUs, I have intubated and ventilated more than 1000 patients.  When leather restraints are applied properly, endotracheal tubes are stabilized properly, and the patient is immobilized and properly sedated, it is nearly impossible for a ventilated patient to extubate himself. There is an association between episodes of physical violence and applying restraints (ENA 2011 Emergency Department Violence Surveillance Study).  I wonder whether this association is due to lacking effective restraints, a lack of training applying restraints, or a lack of help from an officer.

I have been called to ICUs hundreds of times to re-insert an endotracheal tube after patient self-extubation. Almost without exception, the patient’s hands were not immobilized to the hand rail as far away from the endotracheal tube as possible, or the tube was secured improperly, or the patient was not sedated properly.  It is possible for a patient to slide down in his bed such that he can bring the endotracheal tube to his restrained hands, but if the hands are fully extended at his side, this maneuver is very difficult, and triggers alarms.  A posey will keep the patient from sitting up or sliding down. Almost all patients on ventilators do better with sedation, and all patients on ventilators should have cameras monitored outside the room. My point is that there is a lot of BS out there regarding physical restraints—mostly from people who have little, if any, clinical background. In their ideal minds, clinicians should be able to use drugs and soothing voices on out-of-control hypotensive patients with no IV.

The most bothersome side effect of restricting the use of effective restraints is the negative consequences.  The folks who make the rules are not responsible for the negative consequences. Their agenda is to minimize the use of restraints. Lost in this agenda is the harm done when critically ill patients pull out their only IV, their central lines, their chest tubes, and their endotracheal tubes. At night, there may not be anyone in the hospital capable of replacing these devices. Not every ED physician can run upstairs and re-insert a central line or an endotracheal tube in a massively obese patient in respiratory distress. Often these central lines were inserted by ultrasound, unavailable at night.  When an obese patient with respiratory distress rips out the only IV and endotracheal tube, re-intubating in the sitting position without sedation and paralysis requires uncommon skill and experience.

I’ve never lost a patient due to too many restraints, but I have seen multiple deaths due to failure to restrain a patient properly.  How many well-meaning JCAHO experts have witnessed a patient bleed to death or have a cardiac arrest where the event was triggered by the patient’s own actions combined with a failure to properly restrain?

I would like to recommend the best emergency department violence study I’ve seen—The Emergency Nurses Association’s November 2011 Emergency Department Violence Surveillance Study.  This is an excellent summary of the scope of the problem.  I am going to use some of this data to fashion a logical plan of action in a subsequent post.

 

 

 

A PERFECT STORM FOR HEALTHCARE VIOLENCE

 

Recently a visitor to this blog asked about the title of one of my novels, also the title of this blog, The First To Say No.  An explanation is reasonable. Throughout my 38-year career I collected the details of the most violent incidents I had witnessed in an emergency department or trauma center. All of the characters in my novel The First To Say No represent real patients, real doctors, real EMS personnel, and real nurses with different names. Not a single character in this book is fabricated. Old nursing buddies call me to say they remember my characters.

The only thing fabricated in this novel is the plot.  I organized my most infamous patients into a gang.  This gang tormented the employees of an inner city hospital emergency department. After being repeatedly assaulted, groped, raped, and otherwise abused, the nurses, female physicians, and EMS personnel cook up a plan for vigilante justice.  I certainly do not advocate vigilante justice.  However, if you have already been a victim, and no one is protecting you, and no one will stand up for you after you are assaulted, and you are punished for not adopting the notion that part of your job is to be a victim—desperate things can and do happen.

I never purposefully injured a patient, with four exceptions—all involving assaults on nurses while I was on duty.  I’m recently retired. I could never admit hitting a patient while employed. I’ll bet I’m not the only physician who was forced to take desperate measures due to a lack of security.  I’m not a violent person.  I was never successfully sued by anyone during my career.  To my knowledge, no one ever complained that I mistreated any patient.

If you have never worked in the pit all night without a net, don’t bore me with your opinion regarding protecting healthcare workers. You have not been forced to paralyze and intubate hundreds of out-of-control trauma patients just to keep them in the bed.  Many of these patients could have been managed more safely without paralyzing them.  Because of the ban on leather restraints, I had to take personal and professional risks and the patient had to assume the risk that I could not intubate him after he was paralyzed.  Fortunately, airway management was my specialty, the result of a critical care medicine fellowship.  I do resent being put in this position by non-clinicians who are clueless.

If you have never been a victim, you may have difficulty imagining the anger, resentment, and frustration that so many healthcare workers feel today.  Many of those who comment on my blog posts have left the emergency department in mid-career. My introduction to violence in healthcare came as an Emory University medical student, working in Grady Hospital in Atlanta.  I can recall working on five or six GSW patients in one shift.  I remember being sent to the surgical emergency department in the early 1970s to suture.  A downtown shootout between Black Panthers and Atlanta police spilled into the surgical emergency department, where I cowered behind the long wooden desk, listening to gunshots, bullets pinging off of mayo stands, splintering wood, and screaming. Officers, doctors, nurses, patients, and friends of patients struggled in the floor. A riot broke out.

Anyone who worked at Grady Hospital in the early 1970s would recall the gallery of people who sat on the railing and watched the ambulances roll into “the Gradies.”  These people could rush in behind a stretcher at any time.  They did that day. A lady sat in a booth and pointed stretchers toward the right, the medical emergency department, or the left, the surgical emergency department.  Behind this booth was a long hall with a sturdy bar attached to it.  Injured prisoners and potentially violent patients were handcuffed to this bar pending evaluation, usually accompanied by an officer. These extra policemen prevented a massacre that day, the first time I heard gunshots inside an emergency department.  In those days a policeman could not drop off a violent person and leave.  A patient who abused any healthcare worker was dealt with by a uniformed officer immediately. Nurses didn’t feel victimized.

Today, abusive patients know that we can’t fight back. They know we can’t refuse to evaluate them for alcohol intoxication every night.  They know that we can’t force them to leave.  They know we can’t tie them up. They know they can spit on us, bite us, hit us, and kick us with impunity. They know that the ED physician must give them the narcotics they crave, or they can cause trouble for him.

Today, policemen drop violent, abusive, psychotic, and intoxicated patients into emergency departments where there is no security whatsoever. A single out-of-control patient can gobble up the entire staff, making it difficult to care of the non-violent. Security personnel are no longer in uniform.  They are no longer armed.  They are often hiding somewhere watching a bank of cameras. Even if a security guard responds to your call, he is afraid to touch any patient. Less than five per cent of emergency departments have armed security, bullet-proof glass, and metal detectors.  Very sad.  Hospitals don’t spend this kind of money until after a tragedy.

Code Atlas is a cruel joke—too little, too late, armed with nothing. The administrators babble on about “customers” and Press Ganey scores. JCAHO says that leather restraints are cruel, unnecessary, and illegal. Administrators don’t seem to see any connection between higher Press Ganey scores and feeding and attracting drug abusers to the ED.  Families are allowed to roam in and out of the treatment area without regard to the level of chaos or the number of weapons in their pockets.

This is a perfect storm for healthcare violence. You don’t think there are many healthcare workers concerned about their lives?  Over 15,000 people viewed one post I made on this blog a week ago. Over 10,000 hits a day is not unusual.

I was so glad when my daughter decided to be a physical therapist.  I feared for her life as a nurse.  I advised my own son not to follow in my footsteps. He went to dental school.  Thank God.