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Life in Emergistan

ED Violence, EMTALA, and the Customer Service Mentality

Leap, Edwin MD

doi: 10.1097/01.EEM.0000578624.46841.1b
Life in Emergistan



Two shootings occurred about two hours apart in two South Carolina EDs this April. It's a relatively small state with a close-knit emergency medicine, nursing, and EMS community. The news was tragic, unsettling, and personal.

It was a reminder of how vulnerable we all are in the emergency departments of this country. I don't think it's a stretch to say that every person who works in a busy ED has seen a patient who filled everyone with fear. We have all seen someone become dangerously angry or coldly menacing, leaving us thinking that he would harm someone during his visit or return later. I, and many like me, have been directly threatened. All too often, the suspicions of the staff were confirmed as violence erupted in what should be a safe place.

We are collectively shocked by these things, but they really aren't surprising. It's nothing less than miraculous that they don't happen more often, and it's all too easy to blame inadequate hospital security measures when the truth is that the blame for ED violence can be shared widely.

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Potential Danger

We can certainly blame EMTALA for making the emergency department into a place anyone and everyone can come anytime for anything. This seems like a kind, compassionate plan, and access to emergency care has saved untold numbers of lives. But it comes at a price—it has turned the ED into a place where addiction, personality disorders, social dysfunction, and criminal behavior could have a 24/7/365 home.

Combined with the remarkably toxic customer service mentality and the assorted satisfaction scores we live with every day, we have a situation where dangerous individuals can come into the emergency department to be treated and subsequently inflict harm on those who intend to help them.

We can also blame the pain scale (or our response to it), which allows manipulative and potentially dangerous individuals to act out, knowing that staff are held to certain standards regarding their care, however deceptive their issues may be. How many times have physicians and nurses been reminded that the trouble patient may be difficult but is also a customer? How many times have we been told, “You can't create an addict in the ED?” Until, of course, we did. And how many times have addicts said things like “You'll be sorry” to those who refused to give them their requested drug?

The mental health crisis in America is also to blame. We need to reinstitute the state psychiatric hospital system and make it easier to get help for these patients. They take up tremendous time and resources, and they harm other people. I think we're past the old idea that psychotics don't hurt anyone. They sometimes do. They are also often subject to violence on the streets when they are homeless. The ED should not be expected to manage this enormous problem.

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The Greatest Tragedy

Dangerous criminals also come to the ED to be cleared for jail. Sometimes this is appropriate; other times they would be better served by a screening in jail where their potential to harm others is restricted.

Legal and administrative policies have made the ED into the most dangerous place in town, a place where criminals, addicts, the intoxicated, and the dangerously mentally ill are seen all the time, over and over, by staff who are ill-equipped to handle the danger. We have made our emergency departments into potential combat zones where the staff often have no way to protect themselves. And I submit that no other place has as much potential for danger and as little done to prevent it.

The greatest tragedy is perhaps that all too often, the safety of the ED is one of the lowest priorities of any hospital. (Ask any nurse or physician who has been urged by a supervisor not to press charges.) Some hospitals have armed, well-trained security. Most do not.

People deserve to feel safe at work, but are robbed of this because decent locks are too costly, as are plexiglass and any security beyond an unarmed contract person who isn't allowed to touch anyone.

Every town considers its emergency department to be critical to the safety of the community. Too many hospitals act like their highly skilled, expensive, dedicated, and courageous staff just aren't worth the effort or cost to keep them safe.

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Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter @edwinleap, and read his past columns at

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