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EMTALA: THE DEVIL NEVER ANTICIPATED THE DETAILS
The most important factor responsible for violence in the ED today is a law passed in 1986 called EMTALA (Emergency Medical Transfeer and Labor Act). The original purpose of the law was to prevent one hospital from referring or transferring indigent patients to another hospital solely for financial reasons. For that reason it was referred to at the time as an “anti-dumping” law.
Most federal laws operate under the principle of unintended results. I do not believe that the legislators who drafted this law realized that it would put healthcare workers, particularly ED nurses, in grave danger. The law stated that any patient could go to an ED any time he wanted to, 24/7, as many times a day as he liked, and that he had to be re-evaluated each time he presented. No money was provided to fund all this extra care, nor were patients given any responsibilities for this extraordinary access to medical care.
At approximately the same time our federal government decided that most paranoid schizophrenics with a history of violence could live on their own, with minimal supervision. Psychiatric institutions and hospital psychiatric beds decreased due to lack of funding. This theory, that a person who has been violent in the past will take the anti-psychotic medications prescribed for him regularly, has turned out to be a farce. The most common reason for a schizophrenic to require hospitalization is non-compliance with medications.
From the time that EMTALA was enacted, violence against healthcare workers has steadily climbed. Climbing parallel to the number of assaults in the ED is the number of drug and alcohol related incidents in the ED. In fact, from 2005 to 2008, only three years, the number of violent incidents related to drugs and alcohol increased from 1.6 million to 2 million. Policemen discovered that they no longer had to take responsibility for street drunks, whether they were violent or not. In the metropolitan area I worked in for the past ten years it is standard practice for a policeman to ask the drunk if he wants to go to jail or to the emergency room. Duh.
Can you imagine the same street drunk calling 911 for 30 consecutive nights at 11:00 PM for an ambulance ride to the emergency room, where he could sleep (hopefully) in a climate controlled atmosphere. This is not uncomon. He cannot be discharged alone while intoxicated and he has no friends who can drive. The ED physician is forced to work this patient up for altered mental status every night, spending thousaands of dollars per night, usually paid for by taxpayers.
As the economy faltered, mental health facilities closed, addiction programs lost funding, and the “drunk tank” at the police station was decommissioned. The ED became the final common pathway for every unsolvable social and behavioral problem in America. EDs are precluded by this law from turning anyone away, no matter how abusive he is, no matter how many times he has assaulted a member of the ED staff before. Given the frequency with which each alcoholic appears, and the demanding nature of many of them, it is not hard to imagine how friction could develop when the same patient urinates next to the bed every night or gropes the female employees regularly.
The number of psychiatric beds has shrunk to the point that multiple suicidal and homicidal patients must sit on a stretcher in the ED for entire shifts, sometimes two shifts, before a bed is found in a psychiatric hospital. Even if you had fairly normal coping skills I challenge you to lie on any ED stretcher for 8-24 hours. If you weren’t crazy before…Should we be surprised that these patients decompensate under these conditions and lash out at ED employees? The majority of patients waiting on a psychiatric bed just walk out of the ED. That’s right. And no one is going to lay a hand on them for fear of being charged with something themselves.
On the night shift in an inner city hospital a good description of the nurses’s job is “a waitress in Hell.” No matter how much compassion you start out with, how long would you want to work in a cauldron of intoxicated, belligerent, uncooperative, psychotic, or violent patients? Keep in mind that these patients are taking up a disproportionate amount of nursing time, leaving less time to see new patients and real emergencies.
Nothing in the EMTALA law and no other law requires a hospital to protect its own employees. You would think that this would be a given. It’s not. Certainly there are a few hospitals that are beginning to offer support and some protection to ED employees, but these are in the minority. I am saving a special post about hospital administrators, and what they care about, but let me make it clear that they are not concerned about the safety of ED employees.
One of the first things I learned about controlling a large number of potentially violent patients was to maintain a constant show of force to meet any threat. Instead of posting off-duty uniformed policemen in the ED, most hospitals employ non-uniformed women or non-uniformed elderly males, who spend their time walking the halls and watching cameras. Most are specifically instructed not to touch patients. The hospital is more concerned about being sued than it is about the nurse’s face being smeared into the floor. They don’t want the ED to look like an “armed camp”. They dislike metal detectors, even though they produce outrageous numbers of weapons on patients and visitors when they are employed. ED employees are told that they cannot strike back or defend themselves with fists. Under no circumstance are they allowed to hit a patient.
Let me digress here a moment on the subject of hitting patients. Now that I am retired I can freely confess that I have rendered four patients unconscious with a blow to the head during my 38 year career. In each case, the patient was strangling a nurse (2) or on top of her, beating her repeatedly (2) with his fists. Thankfully all four incidents occurred in a closed room. I was really sorry to see those big heavy bed pans retired. In each case, the nurse thanked me, we hugged, and I ordered a head CT on the patient. None of these four suffered significant injuries. We offerred up our middle fingers to the administrator and added head injury to the patient’s problem list. God knows how these guys get injured. I would do it again. And I would get fired if caught.
Back to uniformed officers. Without a symbol of authority and a non-verbal message that there will be consequences to unacceptable behavior, there is little to constrain patients with a tendency toward violence. They know that the laws that apply outside the ED do not apply inside the ED. They know that they can slap, punch, kick, grope, scratch, spit, and throw urine and feces at ED employees with impunity. The administrator insists that they are patients, and that they are “sick.” Thus, it is permissible for them to exhibit bad behavior.
It is my own position that no illness, no fever, no amount of pain, no amount of intoxication, no altered mental status from any drug, and no degree of impatience gives anyone the right to assault a nurse, or any other healthcare worker. DUIs are not excused from their behavior because they are drunk.
In summary, EMTALA has herded the most violent, mentally ill, intoxicated, drug-seeking, and drug abusing people on this planet into our EDs, and given them a green card to assault us without consequences. Should it be surprising that assaults abound? Since no protection is given to the ED employees, is it surprising that they are being abused at an alarming rate?
At the presnt time there has been some headway in legislatures establishing some type of punishment for assaulting a healthcare worker. In some states it is already a felony. Let me ask you? Would you rather be beaten up and then go to hearings for two years before the perpetrator makes a plea bargain, or would you rather have some protection, and never get assaulted in the first place?
Charles C. Anderson M.D. FACP, FACEP
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