WE ARE JUST GETTING STARTED
There are times when a situation seems so hopeless that you are tempted to just walk away. Violence toward healthcare workers does not seem to incite urgency or enthusiasm from nurses, emergency physicians, JCAHO, CMS, or the nameless congressional committee supposedly working on “Healthcare Violence.” After more than a decade of rising violence focused in emergency departments none of these groups have come forth with any recommendations for minimum standards of security for every emergency department. This is pathetic, with all due respect to those who have good ideas but never open their mouths. I’m sure that there are some nice people in all of these organizations, but the facts speak for themselves.
The recent meeting of the Emergency Nurses Association in Chicago could have been a wonderful opportunity to develop consensus and an action plan. Instead we heard a conglomeration of speakers, most of whom were not brave enough to endorse anything. I didn’t think that the architect or the non-clinical speakers added anything useful. We had a colorful speaker show nurses how to deflect the forearm of a man pointing a gun at them, but no one wanted to talk about how this armed man got into the emergency department to start with. Not one minute was spent on what the nurse was supposed to do with this man after his forearm was deflected. This is not education. It is an invitation to disaster. Having a military background, I found it tragic to watch. Any man who has a gun in his dominant hand will not be disarmed by deflecting his forearm. If you are not trained to follow up on your split second advantage, this man is likely to bring the gun over the top of the extended arm of the nurse, and, well, God help her. She has now provoked him.
I am hopeful that no one bought into these simplistic maneuvers. This is not how to teach self-defense. It takes months of training and one-on-one practice against other professionals to hope to disarm an attacker without getting killed. It is not prudent for any nurse who watched a child’s play demonstration one time to go back home and attempt any of the maneuvers illustrated. This man had some good advice about giving angry people their space, but he seemed to be under the impression that doctors and nurses could develop black belt skills in karate by watching a demonstration. From my viewpoint, almost all of the speakers’ time was wasted because there were no priorities set at the beginning of this meeting. What we needed were speakers who had analyzed our major risks for violence and had a plan of action that they were willing to defend to the audience. It is okay to have two speakers who disagree, but each must have the courage to defend his position.
The second major flaw in the program was the failure to outline what was necessary to make each kind of change. Some problems can be solved locally by changes in hospital policy. As I noted in my last post, no one even brought up the subject of boarding admitting patients. I’ll bet there was not a nurse there who wouldn’t agree that this practice is bad for the admitted patient, bad for the incoming ED patients, and bad for the ED staff. It is dangerous for everybody and plays a critical role in ED violence, which mostly occurs on evenings and nights. It contributes to that critical mass that often results in a violent outburst from someone who is tired of waiting for the nurse’s attention. It is disappointing that not one nurse could be found who was willing to endorse the obvious.
No act of congress is necessary to hire real, armed, certified security officers. Just like metal detectors, these issues should have been debated by experienced clinicians in front of us. If no one can find a medical director of an inner-city ED who doesn’t endorse these security measures, that should tell the audience something. Your comfort with no security may simply be a function of the neighborhood your hospital is located. Wouldn’t it be prudent to invite someone who sees a gun-shot wound every day? This type of debate gives the audience a chance to weigh issues properly, not come and go with the same old biases.
I thought that the man from JCAHO was a joke. He was incredibly unprepared. He was supposed to be working with a congressional committee, CMS, nursing organizations, and physician organizations on healthcare violence. He couldn’t think of the name of the committee or the name of anyone on the committee. He had no advice regarding consensus, or any information to give us about what members of this committee thought or what information they had or where they got it. We would not even have known about the committee if someone had not pressed him as to why JCAHO and CMS had done nothing so far about a problem getting progressively worse for ten years. This man embarrassed the federal government, if that is possible.
With all of these highly trained and experienced nurses present, there were no surveys to determine who supported what. There was no objective information collected to correlate attitudes toward individual security measures and the amount of violence in a given ED. There was no survey asking the attendees to rate the priority of their issues or their degree of support for each type of response. We wasted all that knowledge and experience. Only one speaker was willing to make a recommendation, the security expert. He suggested that we start by getting uniformed officers in every ED. This was an achievable goal that did not require a congressional committee. This man understood that the most effective way to avoid out-of-control behavior is a consistent show of credible force. Sadly, no one picked up on his theme.
One of the most important issues that we face is our chief defense mechanism—DENIAL. If most nurses in attendance really believed that their department was susceptible to a Columbine-type incident, they would not be taking the risks they do so calmly. In February 2010 a gunman marched into a trauma room at a North Carolina hospital and opened fire. Another man in Georgia walked right in and killed one of his mother’s nurses and another employee. Last year a gunman shot an ED physician at Johns Hopkins and then killed himself and his mother. Those who give no priority to making emergency departments free of weapons and do not think that they need armed security are in denial. For a fresh look at the consequences of denial, consider what happened to the Republicans last week.
I was not in favor of Obamacare, mostly because it was enacted by legislators from one party who admitted that they hadn’t even read it. Suffice to say, our government is so dysfunctional that we have sunk to unbelievable lows. “We have to pass it in order to find out what’s in it.”
Having said that, my hat is off to you, Mr. Obama. You may have created a nightmare for us, our children, and our grandchildren, but that remains to be seen. You will certainly increase the number of patients in the emergency departments in our country. But I’m giving you credit for recognizing the vulnerability of denial. You have accomplished something momentous against overwhelming odds in an arena that has taken down many a warrior. You have done what no other president or party has been able to do since LBJ. The Republicans were in denial. They had legions of lobbyists and obstructionists that had held back change for decades. Republicans were so sure that they could defeat Obamacare that they didn’t bother to negotiate or compromise. They were so arrogant that they misjudged the President and the Chief Justice of the Supreme Court.
There is an important lesson here. It is about setting priorities and leaving denial behind. Both Mr. Obama and Mr. Roberts knew that the universal mandate was the key to the entire bill. They both had the guts to go for it. I believe that nurses can impact the plague of healthcare violence, but only if they show more organization, ingenuity, and backbone. This is not an issue where everyone is going to agree on everything. However, if nurses do not agree on something soon, they face a frightful future in the ED.
I can’t supply nursing leadership. Perhaps the nursing community is not the right tool. I’m a physician. The emergency physician organizations are capable of making wonderful lists of problems and possibilities, but so far they have been incapable of endorsing anything definitive or showing the resolve to buck the system. I realize that both nursing and physician groups have political issues to worry about. That’s why I feel that I can help. I don’t care who is insulted by my remarks. Nobody can fire me and no one can convince me that what I am doing is wasted effort.
My next stop is Homeland Security. I’m going to keep knocking on their door until somebody responds. I have already contacted them. You never know when you will run into someone sensible and honest in the government. It’s possible. The little guy can win. If healthcare workers are unable to come up with any consensus or action plan, perhaps someone at Homeland Security will understand the connection between natural disasters, terrorist disasters, and the need for security at the local emergency department when the lights go out. You might be surprised at what powers Homeland Security has. As Mr. Obama and Mr. Roberts just illustrated, there is more than one way to win.
While I’m in Washington I’m going to visit the senators and congressmen from my home state of Virginia. I’m going to find out who is on this congressional committee. I want to testify before this group. I’m not going to stop pointing fingers and calling people out until I see results. There are certainly more diplomatic physicians with better qualifications than mine. But they don’t have the time I do and they still have political risks. I loved my career. I have been director of three emergency departments, two trauma centers, nine EMS agencies, and one intensive care unit. I have developed and directed city-wide and regional-wide EMS systems. I have been elected President of the Medical Staff twice. I have personally designed two emergency departments and three urgent care centers. I have worked in Atlanta, Washington D.C., and Richmond, Virginia. In the last thirty-eight years I have seen it all and done it all in the pit. These congressmen need a dose of reality.
I’ve been assaulted several times and intervened in the assault of several nurses. I make no apologies for doing what a security officer should have been doing. While I took no pleasure in it, I have rendered several violent patients unconscious with my fists, metal bedpans, and infusion pumps. I think that God made me a big man for a reason. In each case, I felt that my actions were the quickest way I could stop the patient from killing the nurse. I don’t care whether you approve or disapprove of my actions. The nurses were grateful.
The best qualification I have for this job is that I have been working in the ED when gang members emptied their weapons into the surgical emergency department, killing my friends, patients, other gang members, policemen, and nurses. This occurred forty years ago while I was a medical student. I have survived several other ED shootings. There has been no significant improvement in the security in most emergency departments during my career. In fact, in many ways, ED employees are even more vulnerable.
I’m afraid that for some of you reading this post, who like the status quo; I’m what you call a troublemaker. Stay tuned.
Charles C. Anderson M.D. FACP, FACEP
