American College of Physicians: Internal Medicine — Doctors for Adults ®


Strategies to help you cope with violent patients

By spotting the warning signs and working with problem patients, you can learn how to protect yourself.

From the October ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

A drunken patient lunges across a hospital check-in counter and punches a physician in the face. An elderly woman off her medications kicks a doctor in the abdomen. A 300-pound woman with low blood sugar goes berserk in an emergency room, screaming obscenities and hitting hospital staff.

While these are all extreme examples of patients who lose control, violence in health care is not as rare as you might think. Statistics show that more than one-third of all assaults on people in service industries occur in health care facilities.

Because residents and fellows are on the front lines of providing health care, experts say they are particularly vulnerable to patients' violent outbursts. Here are some tips to help you spot—and head off—problems with patient violence.

Be suspicious. Paul Franke, ACP-ASIM Member, director of a hospitalist group at Carlisle Regional Medical Center in Carlisle, Pa., said that physicians often get into trouble with patients because they aren't suspicious enough. "Normally, a physician walks right up to the patient's bedside fairly quickly," he explained. "At that point, it is too late. The patient lands a punch or starts to bite."

Instead of rushing into an exam room, Dr. Franke suggested approaching patients slowly, especially if you don't know them or have reason to question their mental state. "Stay more than arm's length away until you get a better sense of the patient's intention and mood," he said.

Linda DeFeo, MD, an emergency physician at Prince George's Hospital Center, a trauma center outside of Washington, agreed that vigilance is key. "The best emergency room physicians are hypervigilant," she said. "They are always scanning patients for subtle nonverbal clues."

She once saw physicians working with an 80-year-old patient who had stopped taking a psychiatric medication. The patient was in a restraining device and appeared completely calm and quiet. When a physician removed her restraints, however, she kicked him hard in the stomach. While being more vigilant wouldn't have prevented the patient from lashing out, Dr. DeFeo said it might have helped the physician dodge the blow.

Take specific threats seriously. Patients often announce their frustration and anger long before they act out. If a patient makes a specific threat, experts say you should take it seriously—and spread the word to colleagues and attendings.

Vicki Carroll, RN, a Colorado nurse who has written about violence prevention in health care settings, recalled one hospitalized patient who threatened to kill the next person who tried to get him out of bed. The night shift didn't tell anyone about the threat, however, and when physical therapists tried to get him out of bed the next morning, the patient stabbed two of them with forks.

While a verbal threat is an obvious warning sign, many physicians and nurses are so used to dismissing vague threats that they ignore the dangerous ones. According to Ms. Carroll, you need to heed threats that are direct and unequivocal.

The most dangerous patient Ms. Carroll said she'd ever encountered issued exactly that kind of threat—and followed up on it. The patient, a 300-pound woman with low blood sugar, had already slammed her car into the back of a police cruiser. At the time, she told officers that she was in a bad mood and warned them to leave her alone.

The police brought her into the emergency room in handcuffs, where she became extremely violent when physicians tried to test her blood sugar. A group of eight people was eventually able to restrain her—after she threw several staff members around the emergency room.

Look for warning signs. While the fork-wielding patient did issue a direct threat, hospital staff learned that his behavior was part of a bigger pattern. His wife later explained that the patient had a past history of violence.

According to Ms. Carroll, the single most important predictor of violent behavior is a history of violence. If someone tells you that a patient has been violent in the past, she said, make sure all physicians and staff members get warned.

What if you don't have any background on a patient? One simple strategy is to watch for unexplained behavioral changes.

Judith Schubert, executive director of the Wisconsin-based Crisis Prevention Institute, a group that trains people all over the country to avoid violent situations, said physicians should be wary of patients or family members who act in an uncharacteristic manner. If a normally talkative individual is sullen or withdrawn, for example, ask if they're having any problems.

Ms. Schubert also suggested watching out for patients who are blowing off steam by flipping through magazine pages too quickly, talking rapidly, pacing or fidgeting. When you see such behavior, telling colleagues that "Mr. Jones seems agitated" may be all the warning they need to avoid a violent confrontation.

Don't ignore problem patients. You can't stop irrational patients from acting out, but you may make a difference with patients who start out being rational but then get frustrated or menacing.

Ignoring irritated patients is one of the surest ways to provoke them to violence, particularly when they feel that no one is addressing their needs. Charlene Corinaldi, MD, a senior emergency medicine resident at a large community hospital in Brooklyn, N.Y., recalled one physician who ignored a drunken patient who was angry and demanding help.

"The physician wouldn't even look at him," she said. "I think he was hoping the patient would just stop or calm down. To get his attention, the patient grabbed the physician and punched him in the face."

The Crisis Prevention Institute makes this suggestion: Give patients some attention even if you don't have enough time to fully address their concerns. Ms. Schubert suggested asking demanding patients if they want anything while they wait, even if it's just a glass of water. "If you ignore the early level of behavior," she said, "you spend a lot more energy defusing a disruptive situation later on."

When dealing with agitated patients, try to reestablish some level of communication by asking them what's their objective in arguing and carrying on. "Talking about why they are angry can calm people down," said Melissa C. Bartick, ACP-ASIM Member, a hospitalist at Deaconess-Nashoba Hospital in Ayer, Mass. If you have trouble calming patients or addressing their concerns, Dr. Bartick said to ask a quality manager or other authority for help.

"Then patients at least know that you're taking their complaint seriously," she said.

Give patients some space. Just as you should keep some distance when first approaching irrational patients, giving agitated people some personal space can help you avoid problems. Not keeping your distance escalates conflict, because people who are losing control instinctively try to defend their personal space.

Brooklyn's Dr. Corinaldi suggested leaving at least two feet—the width of a desk—between you and a patient who's angry. If you get any closer, she said, patients may feel like they are being attacked. She also suggested that as situations escalate, slowly start to step away—but don't back yourself into a corner.

Ms. Schubert said that leaving some open space between you and the patient—such as facing patients at an angle, instead of head-on—can set patients more at ease. Avoid pointing, clenching your fists or folding your arms. And she suggested keeping your hands open and in clear view. This kind of body language communicates calm and allows you to defend yourself more easily.

Experts agree that you should never turn your back on an angry patient. If somebody has a weapon, get out of the way, contact the police and do not engage them under any circumstances.

Don't let situations escalate. When situations start heating up, Dr. DeFeo advised, "take your own temperature" to make sure you're not getting drawn into a conflict. Be as nonconfrontational as possible and avoid accusatory tones.

At the same time, you have to be able to shift gears. Physicians can get so busy or stressed that they operate on autopilot in order to maximize efficiency. Remember that some situations require a calm, human touch.

"Don't ignore an obvious problem situation out of the need to be efficient and process the paperwork," said Dr. Franke.

Call for backup. Finally, recognize those situations where you need help from the police or security. In emergency rooms, for example, drug-seeking patients will often start to lose control when they realize you're not going to give them what they want.

Dr. Franke, who has seen such patients at Carlisle Regional, begins by telling them that their complaint does not warrant the types of medications they seek. "If a situation continues to escalate, politely excuse yourself," he said. "You can say, 'Let me think about this, and I'll be back in to talk.' Then come back with security or the police."

Sometimes, the best way to avoid a violent confrontation is to bring security with you from the start. Dr. DeFeo recalled watching a physician tell a mother that she suspected the woman's child was being abused. "The mother went crazy and started throwing things at the doctor," she recalled. "If I was in that situation, I would have brought security with me before engaging the mother."


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