Oh Henry
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We need to return to a time when egregious behavior in the ED was handled quickly and appropriately.

“Do not go gentle into that good night.”
-Dylan Thomas

Pope John Paul II, in his seminal work Fides et Ratio, states that “Faith and reason are like two wings on which the human spirit rises to the contemplation of truth.” Democracy, more than any other form of government known to history, requires the exercise of reason on the part of its citizens in order to function.

Medicine is a stochastic art. Emergency physicians are nothing if not goal directed. Get in, get out. Stick and move! Meet ‘em, greet ‘em, treat ‘em and street ‘em.

Move, move, move. I personally believe that we are the last group of docs who deserve to carry the staff of Asclepius. Rich, poor, young, old, black, white, green, straight, gay, we see everyone without fear or favor. I’ll do a rectal on a pet chicken if they want; just put’em in a room.

But there is a caveat. I expect – indeed require – the respect of my own personal safety. No emergency personnel, be it EMT, tech, nurse, mid-level or physician, should work in fear. We deserve better. We should demand better.

Before I begin this diatribe I apologize for its intensity. But I am mad as hell and I don’t think we should take it anymore. I am tempted to go to an open window with a megaphone and shout out lines from T.S Elliot’s “The Wasteland.” Unfortunately, windows don’t open anymore, so I will use this paltry editorial space to wax eloquent on the ebb and flow of emergency medicine misery.

At this point, I am merely a simple old country doctor obsessing and reflecting on the American landscape, and I don’t like what I’m seeing. In the past week, I have had two phone calls from doctors who wanted to vent about the fact that they had been physically abused at work. (Incidentally, both of these travesties of justice took place in the state of New York. Surprise, surprise.) The first conversation was both instructive and frightening. An emergency physician was giving a family some bad news about the fact that “Fred” was not going to be admitted to the hospital. All of a sudden, some of the young relatives – both men and women – ganged up and started beating on the doctor. This wasn’t just loud shouting of words; this was fisticuffs. I came of age in the steel mills of Detroit, and I don’t mind a good fight.

But the hospital isn’t the place for displays of pugilistic prowess. In this case, security was called, and down came the withering 75-year-old security guard (Medicine’s answer to Barney Fife) whose dementia, I imagine, was only overshadowed by his extreme rheumatoid nodules. He was, of course, not allowed to “touch” the patients. The question is, if he is not allowed to restrain by threat of force, who is? What good is he? Lacking both brawn and authority, hospital security guards are frequently helpless. So then, here come the local authorities, who have already been called by the unit secretary. They always end up calling the cops. Enter the boys in blue, sworn to protect and serve. But wait! They refuse to make an arrest because the family is, “upset.” Well I’m upset! Why do they think they get an excuse to bully and beat a physician? Such bellicose behavior, with its physical and psychological pain inflicted upon the medical staff, is wrong. No one should feel they have the right to do this just because the situation is intense or unfortunate. If these folks had proceeded to strike the officers in the same manner that they struck the physician, they would have been handcuffed, and they might have received a few contusions, all of which I’d support. I want the same aggressiveness – that spirit of ‘nightstick justice – taken in the defense of my people.

Am I wrong here? I was head of a department for 22 years, and I had a great relationship with the police. When we needed them, they came. It was understood that if they got shot, they were the first ones we treated. No question about it. Good guys first, bad guys second. No problem with that. The quid pro quo was also clear.

When we pointed to surly individuals that were in some way disrupting or threatening the department, the police acted without hesitation. They had to restrain patients, and they occasionally arrested people. Infrequently, but with heart-felt zeal, they even inflicted pain. That was my experience, and I liked the arrangement. It was simple, direct and predictable. Whatever happened to the presumption that we are only trying to do our best and desire reasonable protection? We need to return to the days of wooden ships and iron men, which seem to be in short supply. I will refrain from revealing to you all my great stories of nightstick justice, but trust me, you have not seen an ass whooping take place until you have seen a police officer arrest a perp who just hit a nurse that he had been dating. It’s the only time I have ever had to stop an officer from ending the life of a patient right in our department.

If you didn’t like the first story, you are really going to hate the second one. Again, the state of New York. Again, an emergency physician confronted with violence by an intoxicated patient. The physician dodges a punch, and then prevents the clearly compromised patient with altered mental status from leaving the department by wrestling him to the floor and getting other personnel to restrain him. With appropriate invocation and the reverse logic of Justice Cardozo’s opinion on informed consent, this physician acts to protect the patient from causing harm to himself or others, despite the fact he was obviously refusing care.  This is in the best tradition of medicine. Oh, by the way, this is the same hospital where another emergency physician was sued for not stopping an intoxicated patient from leaving the department who was then hit by a car. Bad doctor! Bad doctor! Now, our emergency physician is reprimanded by not only his own hospital, but is reported to the New York State Medical Board. Our hero physician must now get an attorney and go before the medical investigator who works for the state. In her holier-than-thou position on the Board, this non-practicing internist suggested that to keep his license, our doctor needed to take courses on how to manage difficult patients.

What an insult! This is total and absolute crap. I hope this particular state employee is in the emergency department when an irrational, 250-pound drug-intoxicated biker goes berserk. How to handle difficult patients, my ass. I am certain the investigators next job will be running for Congress.

Which is it, America? Do you want us to do what is right, or what some pinhead politicians think is politically correct at any given moment in time? Should we step in and proceed and protect incapacitated individuals from harming themselves or others? Should we take those incapable of rational thought and separate them from the herd? Egregious behavior is just that, and it needs to be separated from those who are seeking care, and certainly not at the physical or mental expense of the physician. Should we allow them to hurt others, including other patients, themselves or our staff members? If every state chapter of ACEP and national ACEP itself are not involved in the promulgation of legislation to protect us, then they are not worth the money we pay to belong. If we aren’t there, we can’t give care. It’s as simple as that. It seems to me that there are few areas in the politics of emergency medicine where we can all agree. The debates between neo-socialists and the free marketers will continue. But our personal safety seems to me an area where we can all pull together. But don’t think I have any strong feelings about this.

 

Comments   

# me 2011-06-18 17:57
standing ovation.

i've been punched by a patient's drunk family member. in new york, real shocker there. security was unable/unwillin g to touch him. i had to ask a different family member to please drag his ass outside where he won't interfere with our work.
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# Not surprisedjim 2011-06-28 08:45
Doesn't surprise me in the least. For reasons unknown violence and other disruptive sociopathic behavior that would otherwise result in arrest is tolerated and enabled in Emergency Departments. This is one of the many unintended consequences of the "customer service" approach to medicine, where we bend over backwards to "strive for 5" on a Press-Ganey survey to satisfy demands of administrators who can only manage to find the ED when a big donor arrives for care.

There was a time when being drunk and disorderly or disorderly conduct meant arrest, a night in jail in police custody, and released or bailed out the next morning. Now these patients are gleefully dropped off by police for a "psych eval," only to be discharged and repeat the cycle later in the week, if not the day.

As far as ACEP - you are on the mark. However ACEP stopped earning its dues years ago.
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# Lest we forget our Press-Ganey friends...tadom 2011-07-02 17:45
Our hospital's new HUGE push is to decrease our LWOTs and oh yeh, that means these addicted/ stoned/ unreasonable/ labile creatures. Everyone is so worried about reimbursements & patient complaints that no one in The Ivory Tower gives a crap that EM docs have zero problem giving patients what they NEED, but dammit I hate the insinuated threat that we too must give them what they WANT. Reinforcing their bad habits & behaviors benefits no one. I'm waiting for my hospital-issued badge cozy reading, We Value Quiet over Quality because that sadly seems the trend.
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# Being on the other side Ethan 2012-04-25 10:49
I'm a security guard at a hospital and I totally understand your frustration. Almost everyday we deal with an out of control patient/visitor . We have to constantly second guess our every move because we have staff and our own supervisors yell at us when we physically confront an individual. We have handcuffs, oc spray, and tasers. I have not used either of these tools due to the fact that I have to be on my dying breath to be able to use them...So instead of using oc spray on a violent person, we as security have to put ourselves in harms way.

My job is to bring safety and security to the staff, visitors, and patients. I try to do these things to the best of my ability. When I do, I get called back to the supervisor’s office every time. I’m not against accountability but I am against the constant flow going against me while doing my duty.
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