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
