Media and Crisis Management
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Media and Crisis Management

Avoid Violence in the ER – and Elsewhere

Posted on: October 24th, 2013

Violence in schools, colleges, theaters, malls, offices, and elsewhere has stunned us. One location where violence is rare but an everyday possibility is the hospital emergency room. The primary threat: the patient.

ER staffs understand this and take precautions. Do they know something that can help the rest of us, generically-speaking, deal with potential trouble under our noses? Yes, based on the recommendations of retired Associate Professor of Emergency Medicine at Wake Forest Baptist Medical Center, Dr. Ralph Leonard (who likes to be called Monty).  His violence-prevention suggestions for ER physicians echo proven crisis management principles. Herewith, to aid hospitals and the rest of us, I have combined Monty’s medical guidelines with the inherent principles (in parentheses) that apply to all of us.

Assess the risk the minute you lay eyes on the patient. This time-honored advice for diagnosing illness also applies to threat assessment.  Is the patient agitated, fidgeting, wringing hands or showing an angry expression? If so, your first task is to learn why. Address these issues now. (This is a metaphor for the need of all organizations to perpetually monitor potential threats especially in social media. Identify smoldering problems before they erupt.)

Address verbally assaultive patients before they get worse. At this heightened state Monty says, “You don’t need to know how the flames got started, you just need to get water on the fire.” His tips for trying to calm the patient:

  • Try to determine what is happening from the patient’s point of view.
  • Show that you are on their side. Don’t argue with them.
  • Try saying, “I’m sorry. I hear you. If I were in your shoes I would feel the same way. Tell me what I can do to help you.”
  • Go into “mother mode” by offering water, soda, snacks or whatever you perceive would placate the patient.

Monty says take these actions within the first minute or two. Otherwise you may rapidly find yourself coping with the worst-case scenario: a violent patient. (Monty’s advice is classic “take care of the victims.” Solve their problems and you often solve yours. Also: Get it over with! Don’t make it worse!)

If patient eruption is imminent or beginning consider injecting a calming medication while always remembering that a medical condition may underlie all of it and thus require fast treatment. (This is the equivalent of “fix the – real- problem.”)

Patient violence survival ideas:

  • Stay an arm-and-a-half and a leg-and-a-half away.
  • Don’t let the patient get between you and the door.
  • Look for indications of hidden weapons: bulky clothing or bags.
  • If weapons are present, get out, alert security.

Monty says he’s got a collection of knives taken from patients including a 12-inch butcher knife.

There are at least four good reasons to identify and thwart a potentially violent patient before it’s too late. You can avoid:

  • Injury to hospital personnel and the patient
  • Consumption of precious man-hours in an already busy ER’s to manage, resolve, and investigate the incident
  • Diversion of personnel from the primary job of caring for other patients. Treatment delayed is treatment denied.
  • Reputation damage. Hospital violence unnerves witnesses, aggravates already physically or emotionally stressed patients, and is not a good story to have repeated in the community.

While I am making lists, Monty says there contributing factors that could also be early warning signs to alert ER personnel to patients who inclined to cause trouble. The patient has:

  • A personality disorder
  • Been using drugs or alcohol
  • A psychiatric disorder
  • Stressed from the medical surroundings
  • Some combination of all of the above.
  • Alarming facial expression and/or body language

Clearly there are many ways that violence-prone patients telegraph intentions for those who are alert. It is not a stretch to say that employees in all working environments send us signs of trouble.  We all need to remain vigilant these days.

I often say crisis management is a “team sport.” Dr. Monty Leonard urges all members of the ER team to speak up if they see something awry. His final advice is that while ER violence may be rare physicians and their team dare not drop their guard.

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