In the history of medicine, an invention by country doctor Adam Politzker in 1841 hardly seems worth mentioning. Dr. Politzker, who practiced in the farmlands around Vienna, employed a simple, homemade tool when visiting patients - a small handheld mirror.
Light and easy to use, Dr. Politzker carried it with him always. This little innovation meant any sick man, woman, or child never had to move to a wall-mounted mirror, but instead could remain comfortably seated in a chair or reclining on a bed.
What inspired Dr. Politzker to fashion this portable looking glass? It is theorized that there was a need for it in ear examinations, but if you ask some modern-day emergency physicians, they may suggest it was useful for fulfilling an important clinical function that's still relevant today: the instant self-portrait.
When an intoxicated or otherwise out-of-control patient with a facial laceration wants to leave the emergency department without treatment, Leigh Vinocur, MD, whips out the same kind of reflective glass Dr. Politzker used. Show them the mirror, she advised, because a picture is worth a thousand words, and frankly, such patients don't want words, anyway. In fact, they often get their ideas across in far more brutal ways, as Dr. Vinocur well knows.
As a resident in Detroit several years ago, she had to dodge fisticuffs, knife brandishings, and on one occasion, a chokehold that rendered her completely unable to call for help. It is just much easier to show someone that gash than try to tell them it's the reason they can't go home, she said.
Welcome to the world of emergency medicine in the 21st century, when point-of-care blood sampling and palm-sized imaging technology make reliable bedside diagnosis quick and noninvasive, but patient behavior makes treatment a virtual nightmare, at least in some cases.
I think it really is getting worse. You hear that, and I think it is true, said Dr. Vinocur, a former member of the the American College of Emergency Physicians' committee for violence prevention. I don't really know why [that would be], but I think there has been a rise.
Anecdotal Reports
If anecdotal reports from her colleagues are any indication, that observation is tantamount to fact. From the East Coast to the Pacific Northwest, emergency physicians report being kicked, punched, threatened, and otherwise abused by their patients, thanks to higher substance abuse, lower access to mental health services, and an economy that despite media proclamations seems to be throwing a lot of people out of work.
I thought (emergency medicine) was the place where I could really do some good. - Dr. Leigh Vinocur
Ken Rhee, MD, a co-author of a study on the issue, said part of the reason he got interested in the issue was that, as a young resident, he did all the wrong things. Though his learning curve was limited to only one encounter, the lesson that he could be so mistaken about how to deal with violence left its mark. He now has a list of do's and don'ts for others in the same situation.
In his early experience, Dr. Rhee said he found himself thinking - like any experienced school teacher would - that if you simply exert authority and insist on it, you can win the day. So when he met a belligerent young man handcuffed by one arm to a police officer, he simply employed these methods. I stood over this guy and I told him what he had to do, he recalled. Then, he looked at me, and just went for my throat with his good hand. The policeman had to beat this guy down. I mean, he just had to really deliver some blows to stop it.
Dr. Rhee said he remembers choking, and then thinking, This can't be happening. When it was all over, he thought: Now I don't have to treat this guy just for an overdose, but for injuries he suffered right here.
The incident left such a stark impression that now Dr. Rhee's No. 1 rule for angry patients, even if they seem quite normal initially and their anger appears unjustified, is to do something to alleviate their ire. I mean, if someone has been sitting there, and they are tired of waiting, and they start yelling, 'I need a glass of water,' well, get it for them, he said.
In an investigation about why patients batter their health care providers, Dr. Rhee and former colleagues at the University of California, Davis, Medical Center in Sacramento found that perpetrators who had kicked, punched, grabbed, pushed, or spat on medical staff members were mostly patients on psychiatric or substance abuse retainment (Ann Emerg Med 1993;22[3]:583).
But apart from documenting who was involved in these assaults, something really positive came out of it that Dr. Rhee thinks needs to be restated because it seemed lost in the literature at the time: Most of the situations could easily be anticipated, and thus, arguably, avoided. Looking back, that is what I get out of it. So much was anticipatory, and if you anticipate something, you can deal with it more effectively.
Empathy for the Patient
How? By accommodating the patient's viewpoint. Accommodation occurs when one person actually responds to the plight of another - even if it is unreasonable - and in so doing, accepts the tone of the situation and adjusts the approach to it. This approach includes empathy, respect, genuineness, and validation (Current Thinking and Research in Brief Therapy: Solutions, Strategies, Narratives. The Milton H. Erickson Foundation. 1998, Vol. 2.)
The research helped me understand less invasive approaches to the violent patient. - Dr. Janice Blanchard
Conversely, even simply ignoring the behavior can exacerbate it. There is a kind of 'ramping up' that can go on, Dr. Rhee explained. The signs he spots initially are a loud voice, pacing, gestures consistent with agitation. Not all patients exhibiting this kind of restlessness will want to deck a doctor over some perceived slight or offense, but just taking a step back, being empathic and seeming to listen go a long way to calming them down, he said.
This kind of approach can be dramatically beneficial for older patients who suffer memory lapses. They get angry because they are confused, Dr. Rhee said. Research shows that patients with multiple medical problems, life-shortening conditions, or dementia may find routine screening tests more burdensome than younger patients (J Amer Geriatric Soc 2003;51:270). The situation needs to be taken into account by emergency medical staff who consider such tests just part of the drill.
Past studies also have shown that a linguistic adjustment can be made with such patients. A French study showed that politicians could still win over their listeners if they were personally appealing and remained vague with audiences who held contrary political views. Conversely, listener loyalty diminished if they were starkly clear in their positions, especially when those positions that clashed with their audience, (Euro J Social Psych 2002;32:343).
Smart nurses and other savvy personnel are good at this, even though they are not official politicians. They tend not to impose their thinking on a patient who is upset or demanding. Instead, they simply offer something to let a patient know, no matter how cantankerous she seems to be, that they are there for them. Offering a cup of coffee or a more comfortable spot to sit makes someone feel like they are being cared for, regardless of the circumstances they have found themselves in, Dr. Rhee pointed out.
If anecdotal reports from EPs are any indication, violence against ED staff is rising
It sounds like a cliche, but bringing a snack item makes someone your friend because food is such a strong symbol of kind intent in so many societies, he said.
Though there is quite of bit of evidence about violent patients, most of it comes from the psychiatric literature. In fact, violence in the emergency department is a problem that is poorly documented, inadequately researched, and often not managed optimally, according to a review article on the topic. The article noted, however, that there has been a 10 percent annual rise in the number of psychiatric emergencies as well as an increase in violence in society in general (Emerg Med Clin NA 1999;17[3]:717).
Emergency physicians are traditionally not adept at addressing the issue of violence in the ED setting, according to the article, which also asserts: Many doctors are simply in denial of the threat of violence in the ED because of fear or a feeling of lack of control. As a result, most residencies do not offer formal violence training programs that teach physicians how to both recognize and manage the violent patient.
Variables of Violence
The authors of the article, Janice Blanchard, MD, and Kevin Curtis, MD, found the emergency department was the most common hospital location for physical assaults, and that the only variables that correlated with increased incidence of violent behavior were male gender and a history of drug or alcohol abuse.
The research helped me understand proper techniques for restraint, less invasive approaches to the violent patient, as well as what steps an emergency department should take to protect its staff from a potentially violent situation, Dr. Blanchard said.
(I)f you anticipate something, you can deal with it more effectively. - Dr. Ken Rhee
Dr. Blanchard, an assistant professor in the department of emergency medicine at George Washington University, said she tries to pass these lessons to residents. She and her co-author noted in the article that several other publications have suggested an exacerbating role in the ED, thanks to long waits and the 24-hour policy, which mixes all segments of society.
Dr. Vinocur, who served on ACEP's violence prevention committee, said she believes emergency medicine goes a long way to prepare its residents for dealing with the problems of potentially violent patients. Most residencies offer training in a community-based hospital and an inner-city one, she said. Studies have shown that these kinds of settings differ in the experiences they provide, and that the inner-city populations consistently pose more challenges (J Urban Health [Bulletin of the New York Academy of Medicine] 2002;79[2]:173).
Dr. Vinocur urged all emergency physicians to learn their own hospital policies on violence. Know your protocols, she stressed. When she was a resident in Detroit, the big urban center where she was trained had a police substation in it. Nonetheless, she still suffered her share of physical and verbal abuse, and she stressed that while some patients can be talked down, it isn't possible for others.
In the choking incident that left her gasping for breath, she had just resuscitated the patient, only to have him wake up and grab her in a fit of rage. I was the nearest person to him, she said. The x-ray technician standing behind her had to forcibly pull the man off, and security showed up in time to keep him off, she recalled.
Dr. Rhee, who suffered a similar occurrence, said those encounters are rare. He noted, however, that the anger that can spring from grief is much more common. He recalled a man who had punched a hole in the wall after a family member died. The emergency medicine staff, rather than considering the man an immediate risk, simply summoned a woman who had a lost a son and who had agreed to talk to anyone who had a deep personal reaction to a loved one's death.
I remember how she listened to him, and told him she had lost her son. And then, this man, he just sat down and started crying, Dr. Rhee said. Both Dr. Rhee and Dr. Vinocur explained that such moments reinforce their commitment to the specialty, not weaken it.
I left a surgical subspecialty to go into emergency medicine even after the choking incident. I thought it was the place where I could really do some good, said Dr. Vinocur.
EPs are being kicked, punched, and threatened by patients due to higher substance abuse, lower access to mental health services, and a poor economy
Dr. Rhee agreed, recalling that one man's anger escalated into rage when he visited the emergency department after a hunting accident. He started waving his gun around, an act that frightened everyone but his wife, who was quickly called to the scene.
Without any hesitation, she ordered him to disarm. You idiot, what do you think you're doing? she yelled at him, as he was waving and shouting. Now put that gun away! Right now!
The man meekly did so. Well, I wouldn't go eye-to-eye with a guy with a gun, Dr. Rhee explained. It could escalate things. But I guess a wife can get away with it - or at least one wife can.
© 2004 Lippincott Williams & Wilkins, Inc.