Charles C. Anderson's Blog, page 4

VIOLENCE IN HEALTHCARE SUMMIT

The Emergency Nurses Association is sponsoring a summit on violence in healthcare in Chicago June 22. I’m going. Hope to see you there.

LET’S END ALCOHOLIC DIPLOMATIC IMMUNITY

In my novel about patient violence toward ED personnel, “The First To Say No,” there is an alcoholic character named Jack Hopkins.  He has a large role in the book, but his most profound statement is, “People think drunks are stupid.”  This observation could shed some light on our current ED violence problem.

As passionately as I feel that every ED must have a physical barrier to weapons and armed, certified security, solving the weapons problem will do little to ameliorate our problem with alcoholics.  God Bless all of you who work in neighborhoods where the same alcoholics do not muck up the emergency department every night, but I have not been so fortunate.  We must confront this hard-core group that is disruptive, sleeps in a stretcher in your treatment area, compounds the nurse’s work, commonly acts out-of-control, and enjoys the status of diplomatic immunity for bad behavior.  The answer is to provide consistent consequences for bad behavior, the exact opposite to what most hospitals do.

If you follow this blog you know by now that the chief drivers for violence in the ED over the last decade are the number of alcohol, drug related, and mental illness related patients we see.  These numbers rise in a parallel line with the number of violent incidents.

ED physicians find that it is impossible to discharge these patients before morning, or until they feel like leaving.  They will just walk around the hospital and register again if it is too uncomfortable outside. They have no interest in detox, just shelter on their terms.  The homeless shelter has those ridiculous rules about being unable to drink in your bed and being in bed by midnight. But in the ED nurses wait on you hand and foot, especially if you call 911.  These patients, like Jack Hopkins, have figured out how the system works, and are taking full advantage of it.

The professional alcoholic has learned that he can yell at anyone he likes, anytime he likes. He can kick, punch, slap, grope, bite, and spit without any concern about consequences. He can throw his urinal at anyone who passes by or urinate in the floor when he feels the urge. This is what I call diplomatic immunity.  There is no legal basis for different laws outside and inside a hospital. It is a byproduct of EMTALA and fear of litigation.  If an out-of-control alcoholic actually hurts a hospital employee, these wily academy award nominees will immediately have a seizure, or chest pain, or shortness of breath.  “We can’t take him like this,” the officer will say.  “Call us back when you have all the medical problems sorted out.”

Sometimes it appears that EMTALA and the hospital administrator’s fear of litigation have handed the keys to the ED over to the alcoholics.  These are the same patients who are involved in such a disproportionate number of our violent incidents.  Nurses often feel that reporting an assault by any  patient will be used to call their own behavior into question.  It reminds me why so many rapes go unreported.  The victim must defend herself as if she provoked the assault.  Nursing supervisors, policemen, and administrators have all preached the doctrine that alcoholics are patients, and thus, not responsible for what they do.  This is clearly a double standard.  There is no alcoholic diplomatic immunity for a DUI.

If a nurse works in an ED that does not have an armed, certified security guard, she is easy prey to this kind of patient.  She has little or no recourse.  She is told that she can’t use her fists to defend herself.  She can be fired for helping another nurse who is being attacked.  She cannot use any available potential weapon to protect herself, because objects cannot be used to strike a patient. By the time a violence response team arrives, the assault is usually over.  The hospital does not want the reputation of suing patients and they don’t want to pay for uniformed, armed guards 24/7.  Something has got to give here if we intend to have any staffing in emergency departments in the future.

Unfortunately, Jack Hopkins and his friends know the law.  EMTALA gave them incredible benefits but no responsibilities whatsoever.  Most important, it provided no consequences for bad behavior.  Our nation just can’t seem to understand that any law that facilitates self-destructive behavior will encourage more of it.  EMTALA solved the dumping of indigent patients on a county hospital but replaced it with dumping of alcoholics and mental health patients with diplomatic immunity on every ED.  Each time funding is cut for mental health or addiction, the result is more violent prone patients being brought to the ED.

You would think that agencies like OSHA or JCAHO would make some definitive rules about how an employee can protect herself from violent patients, or at least insist on armed security guards.  After all, they have access to the same statistics about healthcare violence that I do.  So far, in my view, neither has provided anything useful.  The hospitals that have metal detectors and armed, uniformed security hire them because they know that they work, they care about their workforce, and they have already reached the conclusion through a bad experience that nothing else works.

OSHA will say that the employer must provide a safe workplace, but they generally leave the details up to the individual hospital.  In the last JCAHO inspection of the ED I witnessed about a year ago, the group of inspectors did not ask one question about how we managed violence.  This was an inner-city hospital.  They concluded that we needed to move our copy machine 25 yards down the hall, away from everyone who needed it, into a closet.  This one edict increased the work load of everyone in the department; often left the reception desk and nurse’s station unmanned, and accomplished nothing. Any agency that doesn’t have the guts to come on the night shift is worthless, in my view.

I wanted to scream in their faces, “This ED is one of the most dangerous workplaces in our city.  We have no security guards who can touch out-of-control-patients.  We are told that we cannot defend ourselves or our colleagues without being charged with assault, and your response is to screw around with the location of our copy machine!  To show our disgust with your priorities we will wait until you are gone and put the copy machine back where it belongs.”  I didn’t say it. I wasn’t quite ready to retire.  My point is that security in the workplace should be the first priority of these agencies. Otherwise, they are about as useful as a termite inspection on Mount Everest.

Why is it that an alcoholic can commit an offense outside the hospital and be charged and convicted, despite the fact that he is intoxicated, but when he gets in the ED he can destroy our equipment, assault us, and verbally abuse us with impunity and immunity?  This is what Jack Hopkins and millions of other alcoholics already know.  They are drunk.  But they are not stupid.  From my own thirty eight years of experience, when intoxicated people know that there are consequences to bad behavior, they do not misbehave. This is why the presence of an armed, uniformed security guard in the emergency department is so important.  Those of you who have it take it for granted.  Those of us that have nothing but elderly, unarmed flashlight transporters are at risk of serious injury on every shift.

Today there are practically no consequences to misbehavior in some EDs.  The leather restraints we hide from JCAHO are often all we have that is effective for the out-of-control patient who won’t stay in bed or hold still long enough to take vital signs, give chemical restraints safely, or do an accucheck.  I wonder how many people from OSHA or JCAHO have been in a fight where the other guy can do anything he likes to them, including throw the monitors at them and swing IV poles, but they must wait on the unarmed response team.  In many hospitals, no one but a certified, armed security guard can apply the necessary force without fear of litigation. Those of us who do not have this off-duty policeman are still wrestling in the floor with needles in our hand, just like we did forty years ago.  This is a failure of OSHA and JCAHO.

How much longer do you think ED nurses will be willing to work in this environment, for any amount of money?  I have successfully kept two of my own children and two of my nieces from following in my footsteps into emergency medicine.  I felt that the working conditions were intolerable and that there was insufficient support for those who took the greatest risks every shift.  In fact, instead of decompressing the ED, hospitals are boarding more and more admitted patients all night, making the night nurse’s job even more difficult, and increasing her chances of being injured.

I was blessed to be six feet four and 235 pounds.  At least it used to be a blessing. I make no apologies to anyone for the times I have had to make up my own rules in order to protect someone else or myself in the ED.  I didn’t start fights.  I tried not to provoke people.  But eight years in the military taught me that he who hesitates is lost.  Especially toward the end of my career, when losing my job would not have been a hardship to me, I worked nights in an inner city hospital with no security. Flashlights and jingling keys don’t count as security.  In any case, I never hesitated to take an out-of-control patient to the floor.  The out-of-control behavior ended quickly because I had been trained how to do this job.  Guess what?  Out-of-control patients respect strength and consistency.  Their behavior around me often improved dramatically, both acutely and in future visits. Some alcoholics came to the ED ambulance entrance and looked in to be sure I wasn’t on duty before walking down the street and dialing 911 from a bar.  I found that drug seekers also quickly learned that I was not going to be their pusher. Those that supposedly were unable to control their behavior learned new behavior.  Imagine that.

I admit that I am an anachronism.  I never bought into the Press Ganey philosophy.  I do not believe that an emergency physician’s chief goal should be to satisfy patients or make them happy.  I’m glad when they do leave smiling, but my job is to do what is best for the patient, whether they like it or not.  The patient always has the right to refuse care, but he does not have the right to order his own drug therapy.   I refused to feed narcotics to addicts just to make them happy, even if it provoked an incident of patient yelling and complaining and my Press Ganey scores went down.

Show me where JCAHO or OSHA has recommended specific legislation protecting nurses, physically and legally. These efforts have generally come from the nurses.  Show me any official government document that describes what a nurse can and cannot do to save her own life or that of her colleague.  I believe it is time to face the reality that government agencies and administrators do not have employee safety as a priority.  Their priority is the safety of the patient with diplomatic immunity and pumping up those Press Ganey scores.

Let’s face the cold, hard truth.  Many administrators would prefer that you were beaten to a pulp than his hospital be sued for assault.  They still think that Jack is stupid, and cannot control his behavior.  Jack gladly takes advantage of this.  The approach of the administrator is very pragmatic.  When an ED employee gets whacked in the head with an IV pole, the nursing supervisor will pull someone from another part of the hospital and throw them in the lion’s den.

Good luck with your lawsuit, if you are the victim.  It is unlikely that you will see anyone from your hospital at your table if there is a trial.  If you pursue the assault on your own, most likely the patient will accept a plea bargain and get no punishment at all.  Do you see why the armed, certified security guard stationed permanently in the ED is essential?

Patient violence must be met immediately by someone who has no fear of being fired for taking the offender to the floor and handcuffing him if necessary.  This is called consequences to bad behavior.  It works.  The very presence of the officer helps maintain order.  Other patients, families, and visitors appreciate the protection.  Anyone who puts the least amount of thought into how we teach children, and horses, and dogs should be able to comprehend why potentially violent patients act out.  All of us, people and animals, learn by testing limits.  If no limits are applied or enforced, the person or the animal will act out of control.  No visible armed, uniformed security in the ED means no limits to many of our potentially violent patients.  Providing no consequences to bad behavior guarantees more bad behavior.

While I am thankful for the contribution of violence response teams, most violent events are over by the time the team arrives to the ED.  Statistics have yet to support the concept that violence teams make a difference in the number of ED assaults or their outcome.  They are certainly necessary on the floors and units upstairs.  The major weakness of this approach to violence is that the team is invisible until an alarm is pushed.  To maintain order in the ED there must be a constant, serious, armed officer already there.

Pretending that a man who hit you over the head with a monitor did not hit you over the head with a monitor because he was drunk, when you have blood streaming down your face and a huge hematoma and laceration in your scalp, is your hospital conferring diplomatic immunity on the patient.  Since he is intoxicated, he is free to abuse anyone he likes.  Jack isn’t stupid.  Mr. Administrator, OSHA, and JCAHO are stupid.  If we continue to tolerate abuse without armed, uniformed guards, just to increase hospital profits, we are stupid.  In the words of Forrest Gump, “Stupid is as stupid does.”

I feel that hospital employees must continue to seek specific laws from our state legislatures which protect us from administrators, government agencies, and violent patients.  Sometimes it is hard to say which of these three do the most harm.  In the climate of violence we have today, if you are still working in a hospital without armed, uniformed security in the ED, and you are injured by a patient in the ED, I recommend that you sue your hospital, which repeatedly exposed you to violent people without adequate security.

You owe these hospitals nothing for their failure to protect you.  If this hospital discriminates against you for being assaulted, or interferes with your seeking employment elsewhere, sue them again. I realize that this may sound over the top to those of you who have not been a victim. I’m sure that there are still many nurses who consider themselves as part of a hospital team.  Where I grew up, team members didn’t look the other way and cry, “Diplomatic Immunity” when one of the members of their team was getting beat up.

How do you get rid of alcoholic diplomatic immunity?  Answer:  Stop being stupid.  Provide consistent consequences to bad behavior.  For example, I have successfully stopped sprees of every night ED visits by the same alcoholic by admitting the patient by judicial order to a cooperative internist or hospitalist. The catch is that he has to stay in the hospital at least three days, during which time he will likely withdraw from alcohol.  The important thing is that he can’t leave.  Even though he does not remember everything that happened to him when he is discharged, he will remember that he was denied alcohol when he was hospitalized and once he came, he could not leave.  He has a new incentive not to come back intoxicated in an ambulance.

While this is a very useful technique, the ED physician must have the cooperation of the hospital.  The hospital must be compelled to admit the patient upstairs to a bed, not board him in the ED.  Adult protective services or social services may be required to get the judicial order.  Usually, once withdrawal begins, you no longer need a judicial order.  The patient has a physical reason to be in the hospital until his vital signs are stable.  As a physician I can defend this management.  I am helping him whether he likes it or not.  I am taking him out of the driver’s seat, rather than just facilitating his self-destructive lifestyle one more night.  I am keeping him out of the ED for several days.  Less alcoholics, less potential for violence and more beds for other patients.

The patient is discharged after his period of withdrawal and referred for out patient follow up.  Will he actually follow up?  I am not an optimist here, but I feel that breaking his cycle of intoxication at least gives him a chance at sobriety.  Letting him leave every morning does not provide any consequences to bad behavior, and does nothing to help him.

As for physical abuse of employees, each hospital must be held to the same standard.  Organizations of nurses must stand together and demand a zero tolerance policy for abuse.  A mechanism needs to be developed and implemented whereby each hospital must report each incidence of assault just like it must make a record of each transfer.  It should be obligated to participate in assault charges, support its employees in court, and seek a felony conviction.  Every time.  Each incidence of verbal abuse must be met with a summons from the uniformed, armed security officer.  This management establishes consistent consequences for bad behavior.  The patient will likely be less aggressive in the ED in the future.  After all, he’s drunk.  He’s not stupid.

The smart hospital corporation would realize by now that if they stood up for their nurses, advertised improved security in the ED, and guaranteed a zero tolerance policy for abuse, they would attract nurses.

Charles C. Anderson M.D. FACP, FACEP

WHY METAL DETECTORS AND ARMED SECURITY SHOULD BE IN EVERY ED

In 2009 Patricia B. Allen, MBA, RN wrote a superb article on KevinMD.com/blog entitled Violence in the emergency department and how to promote ER safety.  It is perhaps the best summary that I have seen.  She correctly identifies the risk factors for ED violence and even hits one of my favorite bones of contention—the cluelessness of  many hospital administrators regarding the risks that ED employees have and their absence of dialogue with ED employees on the subject of ED violence.

I would like to point out what appears to me to be an important lapse in logic in Ms. Allen’s otherwise excellent summary.  On her first page she makes this statement: “A large number of hospitals and their administrators believe that ‘violence can’t happen here.’ But violence can happen-no matter the size or location of the hospital.  Being unprepared and downplaying the risk places hospitals in an extremely vulnerable position.”

I couldn’t agree more.  As she points out herself, those factors that drive violence are concentrated in every ED.  EMTALA, boarding of admitted patients, closure of psychiatric facilities, and cuts in mental health programs affect every hospital.

Ms. Allen goes on to recommend a 3-step beginning, all of which makes perfect sense until she asks the rhetorical question,” Does your facility warrant the consideration of metal detectors and around-the-clock security?”  She recommends talking to local police about gangs, crime rates, and the hospital’s geographical location, and ends with a most profound conclusion:  “The only failsafe way to eliminate the presence of contraband in the ED is via electronic screening for weapons.”  I agree wholeheartedly with the last sentence.

So where is the breakdown in logic?  It is illogical to say that violence can happen anywhere, no matter what the size of the hospital or its location, and then say that the local police can predict the likelihood of violence from the presence of gangs and the frequency of crimes in the hospital’s geographical location.  First of all neither the presence of gangs nor crime statistics have been cited as predictors or drivers of ED violence.  How many of you ever heard the word “Columbine” before some deranged person decided to shoot students in a classroom there?  My point is that all EDs are at risk because they all are affected by the same drivers of violence.  I believe that all employees deserve to have the same measure of safety in the workplace.  Ms. Allen correctly identifies the only failsafe way to eliminate weapons from the ED.

When Ms. Allen asks the question, “Does your facility warrant consideration of metal detector and around the clock security?” she is making the assumption that someone or some committee can predict the unpredictable–when and where violence will occur.  She has already admitted that violence is unpredictable and that it is not just a problem for large inner city hospitals.  Hospital administrators, boards and corporate executives are no more able to predict the unpredictable than anyone else.  This breakdown in logic allows every hospital to do whatever they feel like doing.  And that is what is happening.

Would you want your wife, or daughter, or sister, or mother to work in the most violent workplace in America with the assurance from the local hospital that, in their opinion, it is less likely that she will be killed there than in some other ED?

There can be no wiggle room for unqualified people to make impossible reassurances to the public and the staff that the local ED is a safe workplace.  We must insist that they all be equally safe with regard to weapons control.

There is another reason why making all EDs weapons safe is the most sensible course.  Homeland Security knows more about metal detectors and armed security than just about anybody, wouldn’t you say?  So far, they have concentrated on securing airports and government buildings.  When we have the next national disaster, either natural or terrorist-inspired, EDs in the disaster area will likely be over-run with patients.  Unfortunately, in the past, when the lights have gone out in America, for any reason, looting and anarchy have started immediately.  The number of people carrying guns has skyrocketed.  Many of these people are carrying guns for protection of themselves or their families.  Wouldn’t it be reasonable for all EDs to prepare for the kinds of common weather disasters that nobody can predict?  Guns must be stopped in every ED at the doors of the hospital or the waiting room. Period.

How can we expect the very people who would have to approve the expenditure of millions of dollars on metal detectors and armed security guards to be able to make an unbiased determination that these measures were necessary, especially given the fact that no one can predict when and where violence will occur?

WHAT DO REVIEWERS OF MY BOOK SAY?

5.0 out of 5 stars Enough Is Enough; You NEED TO Read This Book!, May 13, 2012

By

Glenda A Bixler “Glenda” (Pennsylvania) – See all my reviews (VINE VOICE)

This review is from: The First To Say No (Hardcover)

You may have noticed that, upon reading the first few pages of this book, I stopped and put out an advance notice in my blog and declared it a must-read. I feel even more strongly that it is, now that I’ve finished reading!

I recognize that Dr. Anderson has dramatized his novel by using many samples of what he’s seen as an emergency room doctor, within just one novel. (Or maybe not?) The timing is not important, rather it is the fact that I believe that every shocking example case that he has used is real, in this agonizingly realistic story …

All you have to do is read a newspaper or watch the news! America has become a violent nation! Violence of one type or another happens faster than can be reported!

Dr. Kate Taylor, head of the Emergency Department, in a small Virginia city, had lost her father too early in her life. One of her fondest memories was his walking with her to a local park where a beautiful fountain with fish was her favorite place to spend time with her father, sitting along side, looking down at all the wishes that had been made by visitors throwing in pennies…

Now that park could no longer be used by the town’s residents…

It was filled with drug dealers, prostitutes, and a place where anybody who wandered in might be brutalized or worse. It was owned, now, by the Plagues, a gang of violent criminals…

And they routinely paid off the majority of the police officers to stay away from that once-beautiful park…

Kate Taylor had another memory from that park. When she was 13, a man had tried to rape her there in the park…and he was still trying to hurt her…but, now, as head of the Plagues, he “owned” that park! And the doctor who she had never told she loved, was murdered!

You will start reading this novel as a young doctor is being raped. She has no idea how many have used her, but it was definitely more than one. This is her third gang rape… But, she knew more now, and the man who was raping her did not live after she was through with him… She and the medical emergency worker who now had to talk by holding a finger over a tube in her throat, after she was hurt bringing in a patient, both joined Kate as they began to take back their town!

Did you know that medical care workers can be violated by criminals in an emergency room and cannot file criminal charges because it happens during the time the criminals are considered patients? Do you know that since many are homeless as well as criminals, they do not pay…for anything…except their drugs or alcohol…or sex (perhaps)…

The author has retired from his medical career. He may never have become a vigilante, but he has become a whistle-blower… One that I admire greatly for having written this book! If you feel right now that there is NO reason why criminals, drug dealers and prostitutes roam the streets of America’s towns (Note that the homeless are not necessarily included), then I encourage you to support one man’s efforts to reveal what is going on. It may not be so rampant in every town, but I can guarantee you, that similar single incidents are happening everywhere…like I said, just read the news!

This book is not easily read because of the number of violent acts one right after another, although the author has done a wonderful job in writing it as a thriller. I did get bogged down a little with the medical issues terminology that were efficiently described, but that’s my own limitation, not the author’s.

You will be amazed and excited about what a few people, and then a town did! And I would have been in there, in some way, if it happened somewhere near me! Would you? Enough is Enough… Read this book!

GABixlerReviews

5.0 out of 5 stars great bones,May 4, 2012



By
Kathleen McKee (Norfolk, VA, US) – See all my reviews



Amazon Verified Purchase(What’s this?)
This review is from: The First To Say No (Hardcover)
Even if you know nothing about the health care industry, this book will take you on a ride that you won’t let go of until you reach the end. I dare you to read the first two pages and not finish it within two days. It has great bones. All the elements of a story well told. Would love to see this as a movie.

There are eleven reviews of this book on Amazon.com and seven on Barnes and Noble.com

WHY MOST EDs DO NOT HAVE ARMED GUARDS AND METAL DETECTORS

While visiting in New England recently I tried to find out how many local EDs had armed guards and metal detectors. I would say less than one quarter. The one thing these hospitals that have metal detectors and armed guards have in common is that they have already had a violent incident, almost always a shooting incident, in their treatment area or waiting room.

If one or more of your ED physicians or nurses have been gunned down in the ED, or several patients in your waiting room, metal detectors and armed guards are suddenly a no-brainer.  Besides the cost of metal detectors and armed guards, one of the chief reasons that hospitals fight these two things is because they project the idea that the hospital, and specifically the ED, is a dangerous place. Well, the facts can only be suppressed for so long.  Hospitals and EDs are statistically the most dangerous workplaces in this country.  Mull that over for a minute.

I know that you thought those guys catching king crabs in Alaska had the most dangerous job, but it isn’t so.  As I pointed out in a previous post, over 60 per cent of all assaults in the workplace occur in a healthcare setting.  The overwhelming majority of victims are women with nurse’s aides having the highest number of assaults and RNs next.  The ED is the most common site of an assault.  So stop looking down your nose at postal workers.

I visited Washington recently and noted that almost every building was protected by metal detectors and armed guards.  They must know something.  If metal detectors and armed guards were ineffective at making an area secure, then why are they in every airport in the country?  They obviously work.  If the ED is truly the most dangerous workplace in America, why doesn’t every ED already have these proven safety features?

The size of the ED or town does not matter.  Had you ever heard of Columbine before some deranged person decided to start shooting at this school?  My point is that the factors which make EDs so dangerous are everywhere and increasing.  These factors are in every community, and the ED is the final common pathway for everyone with violent behavioral problems.  EMTALA is not going away.  The professional ED patient has been emboldened in his violence toward hospital employees because he knows it is very unlikely that he will be prosecuted.

In Virginia, funding for mental health has undergone drastic cuts, with more cuts planned for the years ahead.  This means more paranoid schizophrenics wandering the streets and ending up waiting for days in the ED for a psych bed to appear in a hospital somewhere in the state.  My personal experience is that most of these potentially violent psych patients leave before a bed is found.  Don’t expect policemen to stop calling a 911 ambulance to bring in every inebriated person on the street. Don’t expect hospitals to stop boarding admitted patients all night in the ED.  Now that drug seakers know that ED physicians will be punished for not making them happy, don’t expect to see less of them.  Press Ganey rules.  Happy patients outrank security.

I have already outlined the advantages of having a certified, armed, uniformed guard on duty.  You would need at least one such guard to legally confiscate a weapon.  Unarmed security guards are of no value if the only person in your ED with a 9 mm pistol is a paranoid schizophrenic.

This brings me to ACEP and ENA. The groups that would seem to gain the most by having armed protection on site do not even list metal detectors or armed guards as one of their priorities in their position papers on violence. Of course, neither administrators nor physicians want to scare patients away by installing devices and personnel that suggest that the ED is a dangerous place.  Those hospitals that have suffered tragic shootings don’t have this objection anymore.  Personally, I believe that patients and staff would feel much safer with metal detectors and armed guards.  I know I would.

The physicians who wrote the 2012 ACEP position paper on violence do not have the advantage that I have.  My 38 years in the pit are over.  These physicians are still employed by somebody who can be punished for taking a position that will cost hospitals millions of dollars.  One of the most ridiculous objections I have seen to having armed guards is fear that someone will take the officer’s gun away from him.  In all of the tragic shootings that I have read about in hospitals, fast-food restaurants, and schools, not a single one of these began by someone taking a gun away from an officer.  Wake up to the fact that guns are easy to come by and it is a given that they are already in your ED.  Criminals don’t need to take guns from officers. They likely have more deadly weapons than the police.

The reason that ACEP and ENA do not have a clear recommendation for metal detectors and armed guards cannot be due to a lack of demonstrated need for security. The number of violent incidents in the ED is accelerating in tandem with the number of alcohol and drug visitors and the number of psych patients. This information is readily available to anyone who has a computer and can spell Google.

Virginia is fortunate in one respect.  Some states have no laws whatsoever protecting healthcare workers. What Virginia has going for it is a law regarding armed, certified, uniformed security guards. In Virginia, and in some other states, these guards have all of the powers of a policeman in the area they are hired to protect. They can hand out a summons on the spot if a patient slapped a nurse. They can arrest people. They have the same “limited immunity” to touch people that policemen have.

Every indicator we have says that violence will get worse in our EDs. Is it a  question of how much blood is required in the floor for us to come together and make this a priority? Virginia Tech didn’t think they needed armed guards. Columbine didn’t think they needed armed guards. Each time I hear of another shootout it is clearer to me that this is a national problem.

Think about it this way. There may be as many as five or six semiautomatic pistols in the pockets of people in your emergency department, but none in the hands of anyone on your side. It only takes one pistol with a 13-15 round clip in the hand of one paranoid schizophrenic to murder your entire staff, simply because he is tired of waiting.  Currently, most hospitals are buzzing this fellow right through the key pad entry into the treatment area without searching him or making him walk through a metal detector.

Anyone who has worked in a metropolitan area has probably experienced just how fragile our system of emergency departments are.  An entire city with five or six hospitals can be brought to its knees by as few as 50 trauma patients.  We are woefully unprepared for the disaster that dumps hundreds or even thousands at our doorstep.   One of the first things that will happen in a mass casualty disaster–hurricane, power grid loss for any reason, flood, biological or nuclear accident or terrorist attack—is a run on the ED.

Under these circumstances, any person who owns a gun is likely to have it in his pocket.  Wouldn’t you have your gun to protect your family if there was no power and anarchy ruled the streets?  If we do not have metal detectors and armed guards already in place, who is going to protect the healthcare workers under these kinds of circumstances?  How many employees would leave the relative safety of their own homes to go to an unsecured area full of desperate people? A hospital can call in extra security, but it can’t install metal detectors or hire certified armed guards in an hour.

I believe that hospitals throughout the country that do not install metal detectors and hire 24/7 armed, uniform guards are in a precarious legal situation, much worse than Virginia Tech.  If Virginia Tech can successfully be sued for inadequate security measures, how can a hospital, a place that concentrates violent people, possibly avoid being prosecuted for not providing adequate security when the inevitable tragedy occurs?  The risks are clear and accelerating.  The consequences of lack of action are clear.  Has someone made the financial decision that it would be cheaper to pay the claims to the families of dead patients, employees, and visitors than take appropriate security measures?

I believe that the American College of Emergency Physicians may also be liable for their inaction.  Who else should better understand the risks?  At the very least they should change their position statement to reflect reality.  They should be out front leading the fight for adequate security in every ED.

I feel that the Emergency Nurses Association must stand up for itself and be clear about what it wants.  There are people who want to help you.  But if you can’t make up your mind whether you want metal detectors and armed, certified security guards protecting you 24/7, you should expect that your situation will not improve.  The vague recommendations of ACEP and ENA about violence in the ED have been ineffective.  ED violence is getting further and further out of control.  The factors that drive ED violence are accelerating.  ACEP and ENA have played right into the hands of the hospital corporations, who don’t want to spend the money anyway.

For once, can’t we act before another senseless death occurs in our emergency departments?

Charles C. Anderson M.D. FACP, FACEP

LAWYERS HAVE MADE US AFRAID TO DEFEND OURSELVES OR OUR COLLEAGUES

Many of the legal issues that healthcare workers have regarding defending themselves would be ameliorated by having a certified, armed, security officer in the department.  This officer has essentially the same ability to interrupt fights, write summons, and perform arrests as a regular police officer.  An unarmed security guard is usually afraid to touch a patient and cannot arrest anyone.  In my experience, these guards have been useless when a violent person needed to be taken to the ground and hand-cuffed.  They don’t even carry handcuffs.

There will always be times when a patient will lash out from his stretcher and injure an employee. Whenever this kind of attack can be ended by backing out of the room, that is the best course.  Sure, you’re disappointed that the patient broke your nose, but vengeance cannot be the reason we use our fists and hands.  The certified, armed security guard can issue the patient a summons or even arrest him.  If at any time a confrontation can be diffused without touching a patient, I would certainly recommend that approach.

I have heard several lectures about how it is usually possible to diffuse violent situations without use of force.  Usually doesn’t do anything for the minority who need aggressive action immediately to stay alive.  If there is no one in mortal danger, by all means try to calm the patient and get him under control without a physical confrontation.  Often a new face will calm an enraged patient. If there is no one in eminent danger, I recommend waiting on the rest of the support team.  Hopefully you have one.  It would be better if you had the armed, uniformed security guard as well.

One of the most frightening situations that do not involve weapons is the patient who is out of bed and is attacking a member of the staff.  In my view, when a patient steps out of bed and attacks someone, any attempt that you make to keep him from hurting others should not result in a charge against you, no matter which of your own extremities are required to end the assault.

Our hospitals refuse to state clearly that everyone has the right to defend themselves.   Self defense is a cornerstone of our legal system.  Part of your job cannot be a punching bag. There is a big difference between using your fists to “get your licks in” and using your fists only to defend and immobilize.  When help arrives in the form of enough people to restrain this individual, then the employee should disengage to have his own injuries evaluated.

It would be nice if assaults were easy to predict and always responded to the same simple methods to regain control.  This is not reality. Action Teams and Code Atlas teams are very important, but the employee may be dead when the team gets there if the employee cannot defend himself and those around him will not help him due to fear of being charged with a crime or fired by their employer.  Violence in the ED is usually sudden and unpredictable.  Often, the response must be instantaneous, or the results may be disastrous.

Let me give you an example that occurred to me.  An HIV positive patient was having her blood drawn by a nurse from a triple-lumen central line that I had inserted.  I had used lidocaine and the procedure went smoothly.  The nurse drew two ten milliliter samples of blood and was in the process of transferring the blood to lab tubes.  The patient grabbed one of the syringes from the Mayo stand and the needle cap fell off.  With her left hand the patient put her arm around the nurse’s neck.  She held the needle to the nurse’s neck.  My best recollection is that she wanted Dilaudid.

I did not want to leave the room and besides, I did not have access to the PIXUS machine anyway.  I did not think that I could reach across the patient’s body to her hand.  I felt that I was just as likely to cause her to plunge the needle into the nurse’s neck or into my hand if I tried. What would you do?

I hit her in the face with my fist, as hard as I could.  I still had two pairs of size eight and a half gloves on.  I felt her facial bones collapse. That was not my intention, but I did not want her half awake.  The syringe fell to the floor and the nurse was unharmed.  I feel that my actions were justified.  Neither of us documented the incident.  We knew what the Monday morning quarterbacks would say.  I felt certain I would be fired.  As it turned out, after her head CT scan, the patient couldn’t recall how she was injured.  My point is, anyone should be able to take reasonable steps to defend himself or his colleagues from mortal danger, including using his fists, if that is the only weapon available.

Of course, the very person who will not hire a certified, armed guard to protect you will be the first one to recommend that you be fired for striking a patient. Concierges, metal detectors, and armed, certified security guards in the ED are no-brainers—perfect for the tools the average administrator has.  Legislators will have to grapple with other ideas that I LIKE:

(1) A healthcare employee cannot be fired or reprimanded for reporting an assault by a patient.

(2) A healthcare worker cannot be charged with a crime for using reasonable force to protect himself from harm by an out-of-control patient.  In all cases where possible the employee will disengage from the patient and back out of the room.

(3) If a healthcare employee cannot disengage from a violent patient, and he feels that his life is in danger, he can use any reasonable force to separate himself from the patient without being charged with a crime.

(4) Any healthcare worker may come to the aid of another healthcare worker who is being assaulted by a patient.  The good Samaritan healthcare worker may use any reasonable force to rescue the assaulted employee, and may not be charged with any crime, even if he must hit the patient to rescue the assaulted colleague.

I welcome your comments on these ideas, which will no doubt be controversial, especially for someone who has never had to fight for his life in the floor of an ED or the back of an ambulance.

TWO GOALS WE MUST STRIVE FOR TO TURN THE TIDE

It would be nice if America was not a violent country that led the world in non-war-related homicides, year after year. It would be nice if we didn’t live in such a culture of violence that it is nearly impossible to turn on the news without seeing or hearing about a murder.  We are bombarded with a steady stream of shows and movies about murder. In many American cities, at least one person is murdered every single day.  Americans are always shocked at the latest school shoot-out, postal shoot-out, or fast-food shoot-out, but these events are not rare.

During my training at Grady Hospital in Atlanta I encountered a significant number of Israeli surgical residents.  I asked them how they ended up in the United States.  They answered, “At home we see a fair amount of Arab-Israeli violence, but most of it is blunt trauma from explosions.  Here in America, in every big city, somebody gets shot or stabbed several times a day.  It’s a good place to learn about penetrating wounds to the chest and abdomen.”

And it was.  In a typical 24-hour trauma shift one could expect six or eight penetrating wounds (knife or gun) that required major surgery.  The surgical side of the ED had four operating rooms, fully equipped with IVs hanging. There was a long hall outside with a rail for handcuffing less injured warriors.  This is where I learned about managing a whole lot of potentially violent people. Outside the ambulance entrance to the ED rows of people sat on the rails and watched for their relatives and friends to come in.

The crowd was controlled by the presence of armed, serious, uniformed officers who could use any measure necessary to control an individual who was out of control.  They carried sprays, billy clubs, and yes, guns.  They carried radios to call for help.  They did not place themselves in positions where their guns could be taken from them.  They did not use their guns to threaten people.  They carried their weapons to respond to people who were carrying guns or knives and to protect the employees.  I thought they did a great job.  I witnessed one prolonged shootout inside the department between the police and the Black Panthers.

I received further education in control of potentially violent people in the military.  One armed marine stood at the ambulatory door of the emergency department.  Again, the principle of showing force prevented violence.  For most people the mere presence of that marine kept them under control.

I know what you’re thinking.  We’re too civilized in our hospital to need billy clubs, pepper spray, and armed guards.  Haven’t been out much lately, have you? If metal detectors were not an effective means of keeping weapons out of an area Homeland Security would not have them in every airport in the country.  We are not talking about controlling violence in band practice or at Wal-Mart.  We’re talking about controlling violence in a place that collects sociopaths, homicidal schizophrenics, freaked out druggies, angry victims looking to get even, relatives looking to get even, gangs looking to get even, and intoxicated folks who are completely unpredictable.  These patients are bunched into small spaces and feel they have no privacy. They must wait in uncomfortable beds for hours to days because the administrator does not want to spend the money on appropriate staffing upstairs. Meanwhile this administrator wants all the patient’s friends and relatives to have the freedom to move in and out of the treatment area without passing through a metal detector. He doesn’t want a uniformed officer to frighten anyone.

May I ask you a question?  What purpose does key pad entry to the treatment area serve if those people entering do not pass through a metal detector?  In the first 6 months that a Detroit hospital had a metal detector between their treatment area and waiting area, they confiscated 33 guns and 1,234 knives.  In Los Angeles doctors discovered that 25 % of male trauma patients had weapons on them upon arrival and 31% of females were armed.

Whether you like guns or hate guns, if your psychotic patient has one and no one else in your hospital does, he can kill a room full of people before help arrives. There is a big difference between a security guard who is armed and one who is not.  In Virginia, certified security guards who are armed have essentially the same powers that a policeman has within the territory they are hired to protect.  They have the same limited immunity that a police officer has when he touches a person.  It is very unusual for a policeman to be charged with assault in the line of duty.

As long as the officer is not behaving like the officers who assaulted Rodney King, the judge will give little weight to the violent patient’s complaint of “police brutality”.  A certified armed security guard can arrest a violent or out of control patient for a misdemeanor or a felony.  He can pursue a fleeing perpetrator.  He can pass out summons to court.  He can legally handcuff you.  In short, he can protect you without fear of being sued.

On the other hand, the unarmed security guard may be able to pick up a couple of cupcakes from the cafeteria for you, but he can’t do squat to protect you.  He won’t take someone to the ground and handcuff him.  He carries no weapon in a place that is full of armed and potentially violent people.  Off-duty police officers make excellent security guards for the ED, for obvious reasons.

I would like to repeat something.  Until a person experiences deadly violence they have no idea of their vulnerability.  I recall how difficult it was for me as an intern to accept that a certain number of people in almost every metropolitan bar go there to watch potential victims drink alcohol.  They quietly sip their drink and watch for loud voices, laughter, unsteadiness, or drowsiness.  They wait for one of these people to leave alone.  Usually within a half a block from the bar the intoxicated person is beaten to a pulp in the face and head.  The sociopath who does the beating doesn’t even know his victim.  He doesn’t want the intoxicated victim’s wallet.  He just enjoys beating other human beings senseless.  I have repaired hundreds of such head wounds.  So what’s my point?  My point is that the ED is far more dangerous than a bar and it caters to these sociopaths.   If you are not willing to admit the presence of evil among your typical ED patients and visitors, God go with you.  I hope He’s armed.

In summary, in my view the two most important things that ENA should lobby for are metal detectors at every interface that the public has with the ED and armed, uniformed officers who cannot leave the ED while on duty.  I applaud the efforts of ENA to demand stronger penalties for people who abuse them.  I will repeat my basic question.  Would you rather sit through two years of court hearings that end in a plea bargaining or would you rather be protected from this person and never get assaulted?

Stay tuned for my next post on fear of litigation, and how it contributes to violence in the healthcare workplace.

Charles C. Anderson M.D. FACP, FACEP

HOW HOSPITAL ADMINISTRATORS CONTRIBUTE TO ED VIOLENCE

I have had a close working relationship with six hospital administrators, close enough to figure out some of the things that make them tick.  The easiest administrator to deal with is not the CEO of a hospital that is part of a large hospital corporation.  The corporate administrator is a puppet.  He wants only two things from the ED– happy patients and getting paid.  After all, this is a big part of how he is judged by his corporation.

The administrator in an independent hospital is more likely to care about his employees, to institute policies that protect them, and stand behind the ED staff.  He is accountable only to a local board, to which he can justify measures to protect employees. Let’s examine a couple of examples where administrators undermine their own ED.

Corporate CEOs in hospital chains are competing with their colleagues in other hospitals.  In their race to keep their Press Ganey scores up, increase revenue, and capture as much market share as possible, the corporate administrator often makes promises to the public that the staff in their ED cannot keep.  Have you noticed the battle of the billboards, where each hospital administrator tries to outdo his competitors by promising that a patient will be seen in his ED even before he take his clothes off.  They have reduced themselves to competing over the number of minutes before a patient is greeted by a physician.  Somebody forgot that our mission is to provide the best care possible for each patient and to concentrate on the sickest people first.

The ED is not a cattle drive or a theme park.  Its purpose is not to entertain you or make you happy. Its purpose is not to leave you satisfied. Its purpose is to deliver the most appropriate care to each patient, as quickly as possible given the overall requirements of the sickest patients. When patients are given impossible promises and told that they are entitled to satisfaction they frequently become angry when they find that the waiting room is packed and they have to wait a half hour.  The average ED patient is not known for his patience.  He is noted for being demanding.  Guess who is teaching him this?  So the administrator sets up a confrontation between the ED staff, who are working as fast as they can, and the patient and family, who actually believe the billboards.

The best solutions to most ED problems have been known for decades. They are just trampled by the desire to make more money. One good answer to diffusing potential violence is a dedicated concierge whose only job is to advise patients and families about the progress of their relative or how long it will be until they are seen and why.  Hospital administrators do not want to waste money on concierges any more than they do on adequate security.  It’s always about money.

I was so happy when Virginia developed the first prescription monitoring program.  At last doctors could track drug seekers from pharmacy to pharmacy.  We did not have to make an educated guess who was a drug seeker.  We could have the data in front of us before we confronted the patient.  Guess what?  Administrators have no interest whatsoever in the fight against prescription drug abuse, even though more people kill themselves from prescription drugs than heroin and cocaine combined.  Remember, they want happy patients who pay their bills.  The administrator does not care if you give the drug seeker 40 tablets of Dilaudid as long as he leaves happy with a smile on his face.  He will be given a survey as he leaves and a follow up call later to make sure he was satisfied with the service from his pusher.  Press Ganey calls this measuring quality of care.

I always take a nurse into the room with me when I talk to someone about their overuse of drugs, usually narcotics.  I want double documentation that the patient was properly informed, that he was referred to a pain management specialist, or to his private doctor, or to drug rehab.  It doesn’t matter where he is referred.  He will be angry.  He was promised a happy visit to the theme park and now he has to leave without the prescription he came for.  He is not satisfied.

Again, the administrator has promised a service that I cannot deliver. I have a moral obligation to do the right thing for each patient, even if he doesn’t like my treatment.  Thus, the ED physician has a difficult choice.  He can generate great Press Ganey scores and turn out happy patients with no personal concern for the harm he is doing, or he can stand his ground, be branded as a trouble maker by the administrator, and generate confrontations where he is the most at risk.  Are you beginning to understand why we are not making any progress in the prescription drug epidemic?  Ideally, the uniformed police officer should accompany the ED physician into the room and escort the patient off of the premises. When a patient is in withdrawal and wants only one thing, he can turn violent in a heartbeat.  The officer by your side is an effective tool.  But the real culprit is the administrator.  He is the one who is inviting the drug seeker to keep coming and to expect to go away happy.  If these drug seekers were disappointed regularly, and the administrator stood behind you and what you were trying to do, they would not come back.

I have some more bad news for those of you who thought the administrator cared about best practices for common diseases.  You know, all that stuff you spend hours learning in CME courses.  If you have a determined mom who wants antibiotics for her kid’s cold, it is not in your best interest to try to educate the mother.  Mom’s own doctor and other ED physicians have so thoroughly indoctrinated her that all URIs require a visit to the doctor and an antibiotic that your attempts at education will only produce another unhappy patient.  And, of course, producing happy paying patients is the administrator’s priority, not providing care based on best practices.

Press Ganey scores have proven that doctors who pass out more drugs get higher scores.  The administrator and the patient want you to order as many tests and X-rays as possible. It doesn’t matter that the patient doesn’t need them.  Press Ganey measures satisfaction, not quality of care.  If mom thinks junior needs an X-ray, and that is why she came, then you, the physician, are trapped.  The hospital makes money on the tests you order.  This is why it does not bother the administrator that the same alcoholic gets 25 head CTs per month for evaluation of altered mental status. Each physician is judged by the amount of money he can generate per patient and the number of patients he can satisfy.  What does this have to do with quality of care?

Many of the basic safety measures that are unavailable in many EDs are missing simply because they cost money.  Three uniformed off-duty cops per day cost money.  Metal detectors cost money.  Your safety as an ED employee is not as important to Mr. Administrator as saving that money.  Having officers interferes with the administrator’s view of the ED as a theme park.  So do metal detectors.  One of the problems with the average administrator is that he has never experienced the emotional trauma of a sudden, unexpected shooting or stabbing of a real person, someone he cared about, right in front of him. He is under the same illusion as the administration at Virginia Tech—“That couldn’t happen here.”

I have been in the ED or trauma center on six occasions when bullets were flying.  I have seen five people killed in the ED with guns and two shot in their beds on floors upstairs.  I have seen a nurse stabbed in the parking lot and a physician’s brain turned to hamburger with a baseball bat just outside the ambulance entrance. Let me tell you what I have learned. If your uniformed officer is not in the ED when these events start, he is useless.  If he is not armed, in some fashion, he is useless.  Having a team that responds to “Code Atlas” is too little, too late for the type of patients that EMTALA has herded into our EDs.  The pen on all those policies for response to violence has not been mightier than the sword in my 38 years of experience.  You can write all of the policies you want, but if you do not have a weapon that you can access in a few seconds, you have no chance to prevent further tragedy.

Think about it.  The average fight is over in less than 30 seconds, usually in half that time.  It doesn’t take long to pull a knife or shoot a gun. If you believe that no one in your waiting room has a loaded gun or a knife, you are a fool. Sociopaths and deranged schizophrenics do not care about policies. They can clear out your waiting room for no other reason than they are tired of waiting.  I guarantee that you will never forget it.

I spent the greater part of my career working the night shift in large hospitals.  That is one of the reasons that I am more attuned to the potential for sudden violence.  Most of the very worst tragedies I have seen occurred at night.  The only good thing about nights is that the administrator is not around to babble on about satisfaction surveys from a group of patients who are intoxicated, psychotic, drug seeking, and drug abusing.  I have never figured out how those comatose, septic nursing home patients filled out their surveys, but I appreciated them.

What is the point of having uniformed guards, or any security guards, or any action team, if no one is allowed to touch the patient?  In a subsequent post, I will discuss the effect of fear of litigation on violence in the ED and how this constant over-concern with being sued prevents us from giving any useful guidelines to our own employees.  Many employees feel that anything they do to help a colleague who is under attack will result in being fired.  They are often right.

I just finished reading the position statement of the Emergency Nurses Association on violence in the emergency setting.  I was shocked at the list of generic recommendations.  Even the ENA does not demand uniformed, armed (in some fashion) officers.  They do not specify concierges. They do not ask for relief from charges of assault if they are forced to come to the aid of a colleague. They do not ask to be able to defend themselves without fear of being charged with a crime.  They do not provide the specifics that are necessary to take to the legislature.

I still contend that it is better to prevent an assault than respond to one.  Preventing assaults requires a constant show of credible force.  Administrators are standing in the way of this with their emphasis on satisfaction, speed, and theme park environments.

In summary, hospital administrators are one of the chief barriers to having a safe workplace in the ED.  They put their money into television sets, security cameras, lights, and policies.  Happy patients and paying patients.  These are some of the reasons you are being assaulted.  I pray that no nurse ever has to look down at her dead colleague in the floor of the ED before insisting on protection in specific terms.

EMTALA: THE DEVIL NEVER ANTICIPATED THE DETAILS

The most important factor responsible for violence in the ED today is a law passed in 1986 called EMTALA (Emergency Medical Transfeer and Labor Act).  The original purpose of the law was to prevent one hospital from referring or transferring indigent patients to another hospital solely for financial reasons.  For that reason it was referred to at the time as an “anti-dumping” law.

Most federal laws operate under the principle of unintended results.  I do not believe that the legislators who drafted this law realized that it would put healthcare workers, particularly ED nurses, in grave danger.  The law stated that any patient could go to an ED any time he wanted to, 24/7, as many times a day as he liked, and that he had to be re-evaluated each time he presented.  No money was provided to fund all this extra care, nor were patients given any responsibilities for this extraordinary access to medical care.

At approximately the same time our federal government decided that most paranoid schizophrenics with a history of violence could live on their own, with minimal supervision. Psychiatric institutions and hospital psychiatric beds decreased due to lack of funding. This theory, that a person who has been violent in the past will take the anti-psychotic medications prescribed for him regularly, has turned out to be a farce.  The most common reason for a schizophrenic to require hospitalization is non-compliance with medications.

From the time that EMTALA was enacted, violence against healthcare workers has steadily climbed.  Climbing parallel to the number of assaults in the ED is the number of drug and alcohol related incidents in the ED.  In fact, from 2005 to 2008, only three years, the number of violent incidents related to drugs and alcohol increased from 1.6 million to 2 million.  Policemen discovered that they no longer had to take responsibility for street drunks, whether they were violent or not.  In the metropolitan area I worked in for the past ten years it is standard practice for a policeman to ask the drunk if he wants to go to jail or to the emergency room.  Duh.

Can you imagine the same street drunk calling 911 for 30 consecutive nights at 11:00 PM for an ambulance ride to the emergency room, where he could sleep (hopefully) in a climate controlled atmosphere.  This is not uncomon.  He cannot be discharged alone while intoxicated and he has no friends who can drive. The ED physician is forced to work this patient up for altered mental status every night, spending thousaands of dollars per night, usually paid for by taxpayers.

As the economy faltered, mental health facilities closed, addiction programs lost funding, and the “drunk tank” at the police station was decommissioned. The ED became the final common pathway for every unsolvable social and behavioral problem in America.  EDs are precluded by this law from turning anyone away, no matter how abusive he is, no matter how many times he has assaulted a member of the ED staff before.  Given the frequency with which each alcoholic appears, and the demanding nature of many of them, it is not hard to imagine how friction could develop when the same patient urinates next to the bed every night or gropes the female employees regularly.

The number of psychiatric beds has shrunk to the point that multiple suicidal and homicidal patients must sit on a stretcher in the ED for entire shifts, sometimes two shifts, before a bed is found in a psychiatric hospital.  Even if you had fairly normal coping skills I challenge you to lie on any ED stretcher for 8-24 hours.  If you weren’t crazy before…Should we be surprised that these patients decompensate under these conditions and lash out at ED employees? The majority of patients waiting on a psychiatric bed just walk out of the ED.  That’s right. And no one is going to lay a hand on them for fear of being charged with something themselves.

On the night shift in an inner city hospital a good description of the nurses’s job is “a waitress in Hell.” No matter how much compassion you start out with, how long would you want to work in a cauldron of intoxicated, belligerant, uncooperative, psychotic, or violent patients?  Keep in mind that these patients are taking up a disproportionate amount of nursing time, leaving less time to see new patients and real emergencies.

Nothing in the EMTALA law and no other law requires a hospital to protect its own employees.  You would think that this would be a given.  It’s not.  Certainly there are a few hospitals that are beginning to offer support and some protection to ED employees, but these are in the minority.  I am saving a special post about hospital administrators, and what they care about, but let me make it clear that they are not concerned about the safety of ED employees.

One of the first things I learned about controlling a large number of potentially violent patients was to maintain a constant show of force to meet any threat.  Instead of posting off-duty uniformed policemen in the ED, most hospitals employ non-uniformed women or non-uniformed elderly males, who spend their time walking the halls and watching cameras.  Most are specifically instructed not to touch patients.  The hospital is more concerned about being sued than it is about the nurse’s face being smeared into the floor.  They don’t want the ED to look like an “armed camp”.  They dislike metal detectors, even though they produce outrageous numbers of weapons on patients and visitors when they are employed.  ED employees are told that they cannot strike back or defend themselves with fists.  Under no circumstance are they allowed to hit a patient.

Let me digress here a moment on the subject of hitting patients.  Now that I am retired I can freely confess that I have rendered four patients unconscious with a blow to the head during my 38 year career.  In each case, the patient was strangling a nurse (2) or on top of her, beating her repeatedly (2) with his fists.  Thankfully all four incidents occurred in a closed room.  I was really sorry to see those big heavy bed pans retired.  In each case, the nurse thanked me, we hugged, and I ordered a head CT on the patient.  None of these four suffered significant injuries.  We offerred up our middle fingers to the administrator and added head injury to the patient’s problem list.  God knows how these guys get injured.  I would do it again.  And I would get fired if caught.

Back to uniformed officers. Without a symbol of authority and a non-verbal message that there will be consequences to unacceptable behavior, there is little to constrain patients with a tendency toward violence.  They know that the laws that apply outside the ED do not apply inside the ED. They know that they can slap, punch, kick, grope, scratch, spit, and throw urine and feces at ED employees with impunity.  The administrator insists that they are patients, and that they are “sick.”  Thus, it is permissible for them to exhibit bad behavior.

It is my own position that no illness, no fever, no amount of pain, no amount of intoxication, no altered  mental status from any drug, and no degree of impatience gives anyone the right to assault a nurse, or any other healthcare worker.  DUIs are not excused from their behavior because they are drunk.

In summary, EMTALA has herded the most violent, mentally ill, intoxicated, drug-seeking, and drug abusing people on this planet into our EDs, and given them a green card to assault us without consequences.  Should it be surprising that assaults abound?  Since no protection is given to the ED employees, is it surprising that they are being abused at an alarming rate?

At the presnt time there has been some headway in legislatures establishing some type of punishment for assaulting a healthcare worker.  In some states it is already a felony.  Let me ask you? Would you rather be beaten up and then go to hearings for two years before the perpetrator makes a plea bargain, or would you rather have some protection, and never get assaulted in the first place?