Violence in the emergency department: A firsthand account

June 2001 27:3 JOURNAL OF EMERGENCY NURSING 279

L E S S O N S L E A R N E D

Violence in

the Emergency Department:

A Firsthand Account

Author: Mary Alexander, RN, MSN, Emmaus, Pa

Mary Alexander, Greater Lehigh Valley Chapter, is Director ofEmergency Services, Gnaden Huetten Memorial Hospital, Lehighton, Pa.Reprints not available from the author.J Emerg Nurs 2001;27:279-85.Copyright © 2001 by the Emergency Nurses Association.

0099-1767/2001 $35.00 + 0 18/9/116212

doi:10.1067/men.2001.116212

T he telephone rang on a busy Friday night. TheCommunication Center informed the staff toexpect a voluntary mental health patient who

was “walking in on his own.” Not long after that, thephone rang again, and the staff was told to expect an invol-untary mental health patient being brought in by thepolice. No other information was offered, and because thestaff was very busy, they only had time to notify security.

The patient arrived quietly on a stretcher with hand-cuffs on both his hands and feet. He was attended by 6police officers. Little information was given as the officersescorted the patient to the seclusion room. The ED physi-cian on duty that night told the officers to make sure thepatient was in restraints before they left.

An experienced nurse approached the patient and, perprotocol, requested the patient’s cooperation in changinginto hospital attire. The patient was cooperative when thepolice first removed the leg cuffs so his pants could beremoved. After he put on his pajama bottoms, he was thenreleased from his wrist handcuffs to put on the hospitalgown. The plan was to put him back into restraints becausehe had shown aggressive behavior to the police, but thepatient asked to use the bathroom prior to being placed inrestraints. Because he had been cooperative while in theemergency department and because the police were stillpresent, the nurse believed that letting him use the bath-room was appropriate. The police allowed him to use thebathroom rather than a urinal because the bathroom is with-in the confines of the seclusion room. The physician on dutyrequested a urine drug screen, so the nurse left the area toretrieve a specimen cup. When she returned to the area, shewent into the bathroom, with the police behind her. As she

280 JOURNAL OF EMERGENCY NURSING 27:3 June 2001

LESSONS LEARNED/Alexander

approached the patient, he punched her on the left side ofher face with his fist, causing her to fall backward and hit thedoor frame. The patient was immediately subdued by thepolice, and the nurse crawled out of the bathroom to safety.

The physician heard the ruckus and immediatelycame to see what had happened. When she saw the nursewith a bruised face and dazed look, the physician immedi-ately had the nurse sit on a chair in the nurse’s station andgot ice for her face. On further examination, the physiciannoticed that the nurse was bleeding from the back of herhead, so she placed the nurse on a stretcher for furtherexamination. As soon as the physician got the nurse set-tled, she immediately assessed the other patients to ascer-

tain that they were safe. The other nurse on duty had beenattending to the other patients and immediately turnedher attention to the injured nurse and to the other patientswho had witnessed the altercation.

The police immediately handcuffed the patient andthen started to leave the emergency department. Thephysician told them that they were not to leave, becauseshe had not yet examined the patient. They returned to theseclusion room while the doctor attended to the injurednurse. The physician was so upset by the injury to a staffmember that she irrigated the head laceration and put inthe first suture before she realized that she had not anes-thetized the wound. She immediately administered lido-caine and then completed her wound repair. Radiographsof the injured nurse’s head and facial bones were ordered,and then the physician focused her attention on theassailant/patient.

It was at this point that we received a history on thispatient. He was not from the area and was found at a con-venience store acting erratically. The police said the patientwas acting out and admitted to using cocaine and mari-juana, as well as drinking alcohol. They said that he want-ed to kill himself or others, so they brought him to ourfacility for a mental health evaluation. The patient had aloaded semiautomatic weapon on the front seat of his car.The physician examined him from head to toe, noting anyabrasions or contusions, and ordered a tetanus immuniza-tion because of an abrasion on his face; no other acutemedical condition was noted. She requested that the policetake the patient to jail and observe him for erratic behav-ior in a safe environment.

The patient asked to use the bathroomprior to being placed in restraints.Because he had been cooperative whilein the emergency department andbecause the police were still present,the nurse believed that letting him usethe bathroom was appropriate.

The radiographs of the injured nurse revealed no facialfractures, and she was discharged home to recover physi-cally and emotionally. Her unit director and the vice

FIGURE 1This nurse received facial and head injuries after beingpunched by a previously cooperative patient who wasreleased from restraints to use the bathroom.



president of human resources were notified the followingday by the nursing supervisor. Both people called the nurseto inquire about her injuries and to determine if she need-ed anything. She said that her face was swollen and bruisedand that, except for a small amount of pain, she was doingwell. Staff took photographs of the nurse’s injuries imme-diately after the incident, but she was asked to return to theemergency department that evening so that additionalphotographs could be taken when the swelling and bruis-ing would reach their peak.

The photographs of the bruising on the nurse’s facewere upsetting to all the persons who saw them, but thatwas nothing compared with seeing her in person. About 50mL of blood had accumulated in the bottom of her cheek,which was turning shades of purple. Her left eye was redand swollen, and she reported having slightly blurredvision that she discounted, attributing it to the swelling inher eyelid. Perhaps the most devastating part of her injurieswas her disposition. She felt guilty that the patient had hither because now he might have to go to jail and pay for herinjuries and for replacing her glasses. She was told that itwas his choice to use drugs and alcohol that evening andhis choice to hit her, but no amount of reassurance couldconvince her that she had done nothing wrong, and it wasevident that the victim was being victimized again. Staff,on the other hand, believed that the assailant had to beheld accountable.

As we discussed the situation further, the nurseexpressed concern that she would have to go to court, andshe was not sure what would be expected of her. We toldher that her manager, as well as the vice president ofhuman resources, would be present to support her duringthe court proceedings and that she was not alone.

The assailant had been set free on $100,000 bail. Wewere surprised that the assailant could afford such a largebail, and because he was not from the area, we wonderedwhether he would appear for the court hearing. The pre-liminary hearing was held 5 days after the incident. Thenurse’s bruises were still quite evident, with various shadesof purple, green, and yellow showing on the left side of herface, as well as bruising around her left eye. Our group fromthe hospital arrived at the same time and spoke with thepresiding officer about the case. The assailant had arrivedwith 2 lawyers and his wife. We entered the building, andthe assailant and his wife were seated about 8 feet from

where we sat down. At this point we noticed the demeanorof the assailant. He was dressed in a conservative suit withclean-cut hair and was staring ahead, blowing bubbles withbubble gum. His wife looked at the nurse who had beenstruck, and when she saw the nurse’s injuries, she lookedstricken. It seemed to us that she appreciated the severity ofthe injuries sustained by the nurse and the seriousness ofthe charges against her husband. Discussions with the nurseand the district attorney were held in private, and then theassailant’s attorney asked for an interview with the nurse.She went into a room with the assailant’s attorney, her hus-band, and the district attorney and reiterated her account ofthe attack. At the end, the assailant’s attorney asked thenurse if she thought the man should go to jail for the inci-dent. He was, after all, a working, married man who had noprior police record. She thoughtfully replied that she didnot want him to go to jail, but she thought he shouldunderstand the severity of his actions. She later said that shewas not prepared for that question and felt awful that theman would go to jail because of her statement. The manthen met with his attorney and the district attorney to dis-cuss dropping some of the charges, predominantly thecharge of assault against a nurse. The district attorney wasnot agreeable to dropping the charges, and the assailant’sattorney requested a continuance.

He was not from the area and wasfound at a convenience store actingerratically. The police said the patientwas acting out and admitted to usingcocaine and marijuana, as well asdrinking alcohol.

Several evenings later, when the nurse returned to hernight shift, 2 trained, licensed psychologists conducted acritical stress-debriefing meeting with all the staff whowere working that night, including the physician and secu-rity guard. All parties expressed some feelings of guilt, andall parties except the injured nurse felt intense anger. Shesaid she did not feel angry and was concerned becauseeveryone told her that was how she should feel. All partiesexpressed a feeling of vulnerability because their perceivedsafe environment had been violated. The security guard,



who was quiet throughout the entire discussion, said thathe believed the assailant needed to go to jail because if hegot a mere “slap on the wrist,” others would believe thatthey could go to any emergency department and hit anurse, with no real punishment. His poignant statementsummarized all of the group’s thoughts. It is too soon tocomplete this story. We have heard that the defendant plead-ed guilty to assault and driving under the influence, but thisinformation has not been confirmed, nor has a sentencebeen determined at this point. The nurse returned to workafter 5 days. Her physical injuries are healing, and staffmembers are supporting her in her healing process.Unfortunately, with that one punch to a nurse’s face, theentire ED staff was made to feel vulnerable. We work in asmall rural community and this doesn’t happen here…but itdid. When the police bring in the next “drug crazed”patient, the ED staff will get a complete history of thepatient’s behavior before releasing restraints and never lettheir guard down. More importantly, we hope that none ofthe caring nurses will leave the emergency department or thenursing profession for a safer workplace.

Editor’s note: We are indebted to the author, thenurse manager of the emergency department involved, forcontacting the Journal and bringing this assault to theattention of our readers, and we especially thank the nurseinvolved for wanting the story to be published. Even today,a negative stigma and some blaming, or at least distancing,is associated with assault of a nurse, and many myths stillprevail (eg, “If you are savvy, you can dodge the bullet andavoid being struck by a patient”). This nurse knows better.Her main hope is that this case will help prevent other col-leagues from being harmed, and we are indebted to her forallowing her story to be told.

Unfortunately, this scenario could have happened atcountless other hospitals across the United States. It is acompelling case that illustrates several teaching points thatI myself learned after working with many violent patientsand victims of violence at Boston Medical Center (former-ly, Boston City Hospital) and Massachusetts GeneralHospital. At both institutions, we were fortunate to have ahighly professional, capable security department with ateam on duty 24 hours a day, and still, we were constantly

learning lessons. A few quotes from this case inspired thefollowing practical suggestions:

“The ED physician on duty that night told theofficers to make sure the patient was in restraintsbefore they left.” Making this request was wise. It is safeto assume that because the patient was accompanied by 6police officers and had handcuffs on his legs and arms, thepatient had shown some evidence of aggression. A goodED policy is not to remove cuffs (or to change the cuffs,one at a time, to hospital restraints that stay on) until thereis time to obtain at least a brief history.

“Little information was given as the officers escort-ed the patient to the seclusion room.” Do not let policeofficers leave until they give at least a brief report and aphone number where they can be reached easily. Policeofficers or security personnel may have to wait to speak tothe appropriate person, but the request that they wait isnot unreasonable. Officers often wait with prisonersbrought to the emergency department. If the officer isneeded somewhere else, it is possible that another officercan be sent to relieve him or her. For guidance on otherpolicies, rural hospitals might want to tap the experience ofsecurity departments at larger hospitals, which experiencemore violence on the part of patients.

She requested that the police take the patient to jail and observe him for erratic behavior in a safe environment.

In a situation in which there is little time to obtaininformation, ask 3 quick questions:1. “What is the worst thing the patient did?” The answer

to this question will give you an idea of the worst typeof behavior you can expect from the patient. Thisexample also provides the staff with a quick phrase orsentence with which to chart the rationale for usingrestraints. Even though it seems that use of restraints isincreasingly discouraged, such regulatory bodies as theHealth Care Financing Administration simply requirethat the “least restrictive” methods be used and that thereason for the degree of restraints used be documented.



The danger posed by this patient could have beenunderscored easily with a simple note, such as: “Tookcocaine and marijuana. Threatened to kill himself andothers at a convenience store. Carried a loaded semi-automatic in the front seat of his car.” This note wouldprovide more than enough regulatory and legal ratio-nale for the use of restraints. I cannot imagine that any-one would disagree.

2. “What drugs/medications has the patient taken?”Learning that the patient has taken certain drugs thatobliterate his or her capacity to reason or “calm down,”or that he or she has taken haloperidol (Haldol), tellsyou a lot.

3. “Who can we contact for additional information?”Family and friends often can tell you what drugs thepatient usually takes, how he or she usually reacts tothem, and where he or she is usually hospitalized, forexample.In this case, a quick report would have revealed that

this patient was very toxic—that is, he was at best morepassionate and less inhibited, as is the case with alcohol,and at worst paranoid to the point of psychotic, as can bethe case with people who have consumed marijuana andcocaine. He had homicidal ideation and had acted uponthat ideation by obtaining and loading a lethal weapon. Healso had threatened a stranger with no provocation. Thesesigns are ominous, particularly the fact that he was unpro-voked. If he is paranoid about a perfect stranger who hasprobably said or done little to anger him, imagine howmuch worse his behavior will be when he is restrained,asked personal questions, injected, examined, etc.

At the end, the assailant’s attorneyasked the nurse if she thought the manshould go to jail for the incident. Hewas, after all, a working, marriedman who had no prior police record.

“Because he had been cooperative while in the emer-gency department and because the police were still pres-ent…[the patient was allowed to use the bathroom priorto being placed in restraints].” This scenario would not be

unusual in many emergency departments. However, evenif a patient is adamant that he cannot void while on thestretcher, this is exactly the type of patient who should beoffered a urinal. I do not know about any incidents ofharm that have occurred when patients have been allowedto use a urinal or bedpan, but plenty of examples of vio-lence exist when such patients have been allowed to standor go to the bathroom. The potential for harm is tremen-dous when a patient like this one is allowed even to stand,let alone go into a bathroom. You can position the urinal,raise the head of the stretcher a bit, run the faucet, and/orkeep at a distance to provide a little more privacy to help apatient like this void. Furthermore, a patient who has beenin restraints and then is released, knowing that he or shewill probably be put back in restraints, may have moreincentive to try to escape.

When she returned to the area, she went into thebathroom, with the police behind her. As sheapproached the patient, he punched her....” Make surethat police or security personnel are always between youand the patient until the patient is securely restrained.Although the officers’ proximity, even in the same room,will be a deterrent to some patients, it will mean nothingto others, particularly toxic patients. Staff should not haveto be within striking distance of a patient until securitypersonnel or police have secured the patient withrestraints. If the police have decided that 4-point restraintsare necessary when transporting the patient and that heshould be accompanied by 6 police officers, as in this case,then restraints are surely necessary in the emergencydepartment, where it is likely that only one nurse will be inattendance. It is important to have a patient like thisrestrained securely. Leather restraints may look awful, butif someone needs restraints, they need ones that do the job.Flimsy cotton restraints or bandages may not do the job,and they may cut into the patient’s skin when pulled.Positioning of restraints is important as well. If both thepatient’s hands are secured by his side, he can sit up, throwthe upper half of his body against staff, bite, hit someonewith his head, or even overturn the stretcher. It helps torestrain one arm above the patient’s head and one by hiswaist to keep him from hurting staff or himself. It is alsoimportant to restrain legs so that knees cannot be liftedsuddenly. Restraint positions should be alternated (again,



by security, not by staff ) at predetermined intervals, andcirculation should be checked so no harm is done to thepatient. The risks and benefits of giving an antipsychoticagent, like Haldol, or an antianxiety agent, like lorazepam(Ativan), should be explored. Much like a cardiac patientwho is in need of medication, if physical and/or chemicalrestraints are not applied, this patient may be in consider-able psychic pain and suffer harm by thrashing uncontrol-lably. One patient I took care of actually managed to dis-lodge several teeth by biting and pulling the sheet with histeeth, even after being placed in 4-point restraints.

“Staff took photographs of the nurse’s injuriesimmediately after the incident, but she was asked toreturn to the emergency department that evening sothat additional photographs could be taken when theswelling and bruising would reach their peak.” Again,the ED staff was very wise to take photographs. They maynot be used, and in fact, do not necessarily have to be used,but they can be invaluable months down the road. Takinga photograph is always a good idea, even when staff arehurt or made ill at work for other reasons. A photographof a staff member’s swollen face after an allergic reaction tolatex is one example. Also, having a photograph mightenable the police to go to court without the victim in cir-cumstances such as this, where the police were present andcan testify as to what happened.

He believed the assailant needed to goto jail because if he got a mere “slapon the wrist,” others would believethat they could go to any emergencydepartment and hit a nurse, with noreal punishment.

Having gone to court with many victims of violence, Ihave seen the discouraging and dangerous slowness of ourjustice system. It is helpful to obtain the name of someoneyou can call from time to time to inquire about the statusof the case. I have found that the investigating police offi-cer (or detective), the assistant district attorney in charge ofthe case, or someone from a victim witness advocate pro-

gram is most helpful. It is a good idea to get a name andnumber early. Another staff member or the nurse managercan call for updates, to spare the victim the emotional effortrequired to even pick up the phone and think about it.

“…the assailant’s attorney asked the nurse if shethought the man should go to jail for the incident....”Nurses are characteristically unfamiliar with and uncom-fortable in the position of causing harm, rather thanhelping. People who are assaulted are also in a position offeeling very vulnerable and most likely are inclined to feelprotective of themselves. They do not want to incur thewrath of or invite retaliation from the perpetrator, his orher supporters, or the court system. The situation can bedisconcerting. What can be done to help? In my experi-ence, when I accompanied victims of violence to courtover the years, those who had been victimized appreciat-ed having someone present to “run interference” and helpshield them from the perpetrator, even to the point ofphysically standing between them and the perpetrator sothey did not have to make eye contact, which was partic-ularly distressing. Having friends and family close by canmake going to court less intimidating. In my experience,the person who has been assaulted often feels that theyare “causing trouble” and taking up everyone’s time.Nurses who find themselves in this position might moreaccurately view themselves as simply witnesses to a crimeagainst the state (which is what assault is). They are ful-filling a civic responsibility. Given a history of drug abuseand apparent access to very dangerous weapons, thisassailant is likely to hurt someone else. The nurse in thiscase was there only to tell the court what happened.Preventing harm to the public is the business of thecourts, not witnesses. Courts decide whether perpetratorsshould go to jail, not nurses.

The nurse in this instance was not obligated to talk tothe defense attorney. The tactic that the defense attorneyused might not be illegal, but it seems unkind at best andeven unethical to cause further emotional distress to some-one who has already been hurt. It is also misleading to por-tray the nurse as someone who wants, let alone decides, ifthe perpetrator goes to jail. Sometimes, prosecuting attor-neys are relatively inexperienced. A veteran may havehelped the nurse to avoid that discussion. Victims have no



obligation to ever talk to defense attorneys or even to pros-ecuting attorneys, for that matter. The only time nurses areobliged to talk to someone is when they are called to testi-fy. However, I am aware of instances in which defenseattorneys and private investigators who were working withperpetrators and defense attorneys called a victim or anurse at home, implying that they had the right to ques-tion the person who had been assaulted. A nurse whoreceives such a call might consider deferring the conversa-tion until advice can be sought from the hospital lawyer. Ihave never discussed a case with a defense attorney,although I have had conversations with assistant districtattorneys prosecuting cases, particularly when the victimwas someone I took care of or when I was going to testify.

We no longer use the phrase “car accidents,” becausethese incidents are often predictable and preventable.Hospital administrations, colleagues, and courts all need tothink of assaults in the same way. In this case the nursemanager and the hospital provided solid support for thenurse involved and are great role models in this regard. Thenurse manager even filled in for the nurse so she couldhave some time off while her injuries healed.

Surprisingly, a judge in a Massachusetts courtroomwas recently heard to say, after a hearing on an assault on anurse, that the assault “came with the territory.”Fortunately, many people are chipping away at and work-ing to dispel this myth. California ENA and theMassachusetts Nurses Association have been quite active inaddressing this issue, and the current ENA OccupationalInjury and Illness Committee also is addressing it.

Being beaten does not “come with the territory.”

Submissions to this column are welcomed and encouraged.Submissions may be sent to:

Gail Pisarcik Lenehan, RN, EdD, FAANc/o Managing Editor, PO Box 489, Downers Grove, IL 60515

630 663-1263 • [email protected]

Documents

Violence in the emergency department: A firsthand account