“She struck so fast that all I was aware of was a burning pain across my face. I bled freely. I did not realize I was within reach and was behind her at about a 30-degree angle. She had already assaulted the EMS crew that brought her in. … She asked forgiveness from me when the Geodon and Ativan kicked in, and of course, I forgave her.”

Dr. Margaret Staggers, FACEP, an emergency physician at Beckley (W. Va.) Appalachian Regional Hospital and past president of the West Virginia chapter of ACEP, was assaulted by an elderly psychotic patient last July. Such violent patient assaults against emergency physicians led to an ACEP Public Health and Injury Prevention Committee objective focusing on workplace violence.

The exact number of assaults on emergency physicians remains unknown because it’s underreported. However, the Bureau of Labor Statistics has provided sobering information on the reported prevalence in the entire health care/social services sector, estimating 900 deaths and 1.7 million nonfatal assaults annually. Physicians say many health care workers fail to file a formal report because of:

• A perception that assaults are part of the job.
• A belief among employees that reporting will not benefit them.
• A concern that assault will be viewed as evidence of poor job performance.
• A lack of institutional policies.

Overcrowding and long wait times appear to increase the likelihood of emergency department workplace violence, with increased exposure to the disgruntled. One example is a 1993 incident when a patient opened fire and critically wounded three emergency physicians at Los Angeles County–USC Medical Center. The Los Angeles Times reported that the patient wanted a painkiller.

In 2009, the Emergency Nurses Association (ENA) initiated an annual survey focusing on the extent of current ED violence, estimates of underreporting, and trends in ED violence against nurses.

The survey revealed last year that 54.5% of the 7,169 emergency nurses responding had experienced physical and/or verbal abuse from a patient and/or visitor in the previous week. Of the nurses who experienced physical violence, a sixth were assaulted more than four times in the previous week while working in the ED.

Unfortunately, only a third filed formal reports.

This underreporting could still be an improvement from the way such violence was handled in years past. Emergency physicians who practiced during the early years of emergency medicine reported that such violent encounters were just part of the job. Dr. Richard Hencke, FACEP, a veteran emergency physician in northern California, relates two incidents when he tackled violent patients to prevent tragedy. In 1977, Dr. Hencke wrestled a patient in custody who had managed to grab the arresting officer’s gun. Dr. Hencke said it took the officer some time to intervene and retrieve the gun while Dr. Hencke attempted to subdue the woman with a physical hold from behind.

In the second incident a few years later, he rescued a paramedic from the grips of a suddenly psychotic patient and spent minutes locked in physical entanglement with the patient until hospital security arrived.

In recent years, incidents of emergency department workplace violence have captured the attention of risk management and physician groups that do not consider being physically assaulted a “part of the job.” However, recognition alone of workplace violence by such groups does not fully address the issue.

After her experience with workplace violence, Dr. Staggers noted, “No changes were made because of this incident, but it was suggested that I file for worker’s comp. We aren’t covered by compensation.” This lack of coverage adds insult to injury for the many ED physicians who work as independent contractors and are assaulted at work.

In January 2012, a Los Angeles emergency physician who asked to remain anonymous said he was assaulted by a patient in the ED who wanted to be admitted solely for a place to sleep and had no medical complaints. When the patient was told he was not going to be admitted, he jumped on the doctor and punched him in the face multiple times. He recounts that it took the security guards a few minutes to get to them and pull off the offender. The doctor said he suffered multiple injuries to the face and a fat lip, but thankfully, no permanent intracranial injury.

“I did end up leaving that evening after the assault. Fortunately there was a backup person on call,” he said. “I was a little bit shaken up – and ugly-looking – so it would have been tough to do a good job if I kept working. On the other hand, we do what we need to do. They asked whether I wanted to press charges. I said, ‘Yes.’ They took a statement. I got a call the next day saying that he was out already, that he had pled guilty and that there was a restraining order. He was back at outpatient psych the next day. It is a little bit frightening that this guy, with a history of poor impulse control, now can focus on my name as the person who is causing problems for him at the VA, with parole, etc., and that with about 30 seconds and a web browser, he can find out where I live.”

ED Commitment Reduces Violence

Hospital administrators and emergency department leadership need to recognize workplace violence as a major issue and take the necessary steps to ensure that violent incidents are reported without repercussions for the affected employee. Appropriate actions should address safety, legal, and psychological ramifications these employees may face. There is reason to be optimistic that further cultural changes can provide a safer work environment for all emergency care providers. The ENA survey found that nurses who practiced at facilities where hospital administration and ED management are committed to minimizing workplace violence had fewer violent incidents. Emphasis on descalation training, environmental changes, and, most important, a zero-policy toward workplace violence can foster peace over violence.

Resources Available

The ACEP Public Health and Injury Prevention Committee works to increase awareness of violence in the ED. Most recently, the committee published a compilation of resources on emergency department violence (tinyurl.com/ED-Violence). More work is forthcoming as the committee attempts to ensure violence-free ED environments for all health care providers.

Please Take This Workplace Violence Survey

The ACEP Public Health and Injury Prevention Committee launched a survey for emergency physicians to document the extent of workplace violence as an impetus to help change the current culture of ED violence and prevention. Please take the opportunity to participate and to help safeguard the longevity of our practice of emergency medicine. Go to www.acep.org/snapsurveys/2012workplace/2012workplace.htm.

Dr. Cao is a PGY-2 resident at Carolinas Medical Center in Charlotte, N.C., and is the EMRA representative to the ACEP Public Health and Injury Prevention Committee. Dr. Sachs is an attending physician for the UCLA Emergency Medicine Residency and a Clinical Professor at the UCLA David Geffen School of Medicine. She is also medical adviser to Forensic Nurse Specialist and member of the ACEP Public Health and Injury Prevention Committee. Dr. Polansky is an attending physician at Kaiser West Los Angeles Medical Center and member of the ACEP Public Health and Injury Prevention Committee. She serves as chair of the subcommittee addressing the workplace violence in the ED objective.