ED doctors on receiving end of threats, violence

Emergency physicians face perhaps the greatest likelihood of violent encounters with patients. But internists, surgeons and others are not immune.

By Damon Adams — Posted March 7, 2005

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A man high on cocaine punched four people in a Michigan emergency department before a doctor intervened and the unruly patient slugged him twice in the face.

The emergency physician needed eight stitches to close his gashed forehead. The patient spent the night in jail.

The scuffle was recalled by an anonymous emergency physician who participated in a new study on violence in emergency departments in Michigan. The study, released online last month by the Annals of Emergency Medicine, found that 76% of the 171 emergency physicians in the survey reported experiencing at least one violent act the previous year.

Three in four respondents to the 2002 questionnaire reported verbal threats, while 28% said they were victims of physical assaults. Nearly 12% were confronted outside the ED and 3.5% were stalked. The acts prompted 42% of the doctors to seek protection, including 18% who obtained a gun and 20% who bought a knife.

Although the survey involved only Michigan, the study's lead author and other physicians said violence occurs in emergency departments nationwide. "I have no doubt that this is a global problem," said lead author Terry Kowalenko, MD, program director of the emergency medicine residency program at University of Michigan/St. Joseph Mercy Hospital in Ann Arbor, Mich.

Medical leaders say emergency physicians face perhaps the greatest likelihood of violent encounters with patients because of their volatile work environment. Police and other personnel often bring violent patients to their departments, and the doctors often deal with intoxicated patients and their families.

"We generally don't wear ties in the emergency room, because that can be used as a noose by a psychotic patient," said Mark A. Brandenburg, MD, clinical associate professor, section of emergency medicine/department of internal medicine at the University of Oklahoma College of Medicine, Tulsa.

ED doctors not alone

The problem of violence does not end in the emergency department. Family physicians, internists, psychiatrists and others say they have fallen victim to violence from patients, too -- sometimes, with deadly results:

New York neurosurgeon Herbert Lourie, MD, was gunned down at his home in 1987 by a patient who held a grudge over a back operation.

Plastic surgeon Selwyn Cohen, MD, was shot and killed in 1991 in his Bellevue, Wash., office by a patient who was disappointed with her face lift.

California physician Erlinda Ursua, MD, died at a medical center in 2003 after a patient allegedly beat and strangled the doctor.

For a doctor who survives an attack, the violent encounter with a patient can change a career.

Internist Catherine Stroud, MD, quit practicing medicine after a patient threw sulfuric acid in her face as she arrived for work in 1995 at a Veterans Affairs medical center in Jackson, Miss. The man was angry that she had cut back his pain medication.

"I thought it was coffee because it was hot. The stuff was just eating me alive," said Dr. Stroud, who still lives in Mississippi.

Dr. Stroud was burned on her face and neck, and sought counseling. She didn't want to be closed in a room with a patient again. She retired and turned her efforts to her children and volunteering. The patient was sentenced to 20 years in prison, where he later died, she said.

"It just ruined medicine for me. Time has healed some of those wounds, but I'll never be the same person again," she said.

Internist Richard Blum, MD, has not been the same since a psychotic patient struck him in the back as he was teaching bedside diagnosis at a New York hospital in 1986. Dr. Blum fell forward and ruptured a disk in his back. He was paralyzed in one leg and left his practice about a year later. He now does consulting work and has no plans to see patients again.

"I couldn't sit. I couldn't do the walking required to go between the hospitals and the office," he said. "It changed my entire life."

Organized medicine pushes safety

American Medical Association policy encourages all health care facilities to adopt policies to reduce and prevent workplace violence and abuse. The AMA has supported efforts to develop guidelines or standards regarding hospital security issues.

Bad patient encounters "are more likely to happen in the inpatient setting or emergency room setting. [Doctors] have to have a heightened awareness in those situations," said Jeremy A. Lazarus, MD, vice speaker of the AMA House of Delegates and a psychiatrist in Greenwood Village, Colo.

To ensure a safe emergency department, the American College of Emergency Physicians said hospitals should provide adequate security personnel, physical barriers, surveillance equipment and other security systems. Hospitals also need to educate staff about preventing, recognizing and dealing with potentially violent situations.

"We believe it's incumbent on the hospital to create a secure environment that benefits both the patients and the physicians," said Robert E. Suter, DO, ACEP's president.

Doctors said hospitals don't allow emergency physicians to carry guns. Survey respondents who obtained guns likely keep the guns in their cars, Dr. Kowalenko said.

Many emergency physicians said they feel safe at hospitals that have security personnel or off-duty police officers in their departments. Emergency physician Todd Taylor, MD, said a K-9 is a useful deterrent at his Phoenix hospital. The sight of the barking dog usually is enough to bring calm to the rowdiest patient, keeping Dr. Taylor and the other physicians from the risk of fisticuffs or stitches to the forehead.

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Protecting yourself

Physicians say there are several ways to avoid a patient's physical assault or verbal attack in a hospital or office setting. Here are some recommendations:

  • Don't get between the patient and the exam room door when a patient is aggravated. You don't want the patient to feel trapped.
  • Leave the room and call for help if a patient becomes unruly.
  • Don't confront the patient. Speak in a calm and reassuring voice to diffuse the situation.
  • Know if a patient has a condition that could predispose him or her to outrage.
  • Make sure the facility has adequate security personnel in case of an emergency. Ask about panic buttons or other alert devices.
  • Clear potentially dangerous objects from the exam room or office; for example, remove letter openers from your desk.
  • Get security to escort you to your car if you have safety concerns after a bad patient encounter.

Sources: Robert E. Suter, DO; Mark A. Bradenburg, MD; Mike McGahan, MD; Kevin Kendall, MD; Nabil El Sanadi, MD; Jeremy A. Lazarus, MD

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External links

"Workplace violence: A survey of emergency physicians in the State of Michigan,"Annals of Emergency Medicine, abstract, online exclusive (link)

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