Friday, August 3, 2012

Dr. Anderson Seeks Goals Against Violence in EDs

X-ray machines and metal detectors are used to...
X-ray machines and metal detectors are used to control what is allowed to pass through an airport security perimeter. (Photo credit: Wikipedia)


It would be nice if America was not a violent country that led the world in non-war-related homicides, year after year. It would be nice if we didn’t live in such a culture of violence that it is nearly impossible to turn on the news without seeing or hearing about a murder. We are bombarded with a steady stream of shows and movies about murder. In many American cities, at least one person is murdered every single day. Americans are always shocked at the latest school shoot-out, postal shoot-out, or fast-food shoot-out, but these events are not rare.

During my training at Grady Hospital in Atlanta I encountered a significant number of Israeli surgical residents. I asked them how they ended up in the United States. They answered, “At home we see a fair amount of Arab-Israeli violence, but most of it is blunt trauma from explosions. Here in America, in every big city, somebody gets shot or stabbed several times a day. It’s a good place to learn about penetrating wounds to the chest and abdomen.”

And it was. In a typical 24-hour trauma shift one could expect six or eight penetrating wounds (knife or gun) that required major surgery. The surgical side of the ED had four operating rooms, fully equipped with IVs hanging. There was a long hall outside with a rail for handcuffing less injured warriors. This is where I learned about managing a whole lot of potentially violent people. Outside the ambulance entrance to the ED, rows of people sat on the rails and watched for their relatives and friends to come in.

The crowd was controlled by the presence of armed, serious, uniformed officers who could use any measure necessary to control an individual who was out of control. They carried sprays, billy clubs, and yes, guns. They carried radios to call for help. They did not place themselves in positions where their guns could be taken from them. They did not use their guns to threaten people. They carried their weapons to respond to people who were carrying guns or knives and to protect the employees. I thought they did a great job. I witnessed one prolonged shootout inside the department between the police and the Black Panthers.

I received further education in control of potentially violent people in the military. One armed marine stood at the ambulatory door of the emergency department. Again, the principle of showing force prevented violence. For most people the mere presence of that marine kept them under control.

I know what you’re thinking. We’re too civilized in our hospital to need billy clubs, pepper spray, and armed guards. Haven’t been out much lately, have you? If metal detectors were not an effective means of keeping weapons out of an area, Homeland Security would not have them in every airport in the country. We are not talking about controlling violence in band practice or at Wal-Mart. We’re talking about controlling violence in a place that collects sociopaths, homicidal schizophrenics, freaked out druggies, angry victims looking to get even, relatives looking to get even, gangs looking to get even, and intoxicated folks who are completely unpredictable. These patients are bunched into small spaces and feel they have no privacy. They must wait in uncomfortable beds for hours to days because the administrator does not want to spend the money on appropriate staffing upstairs. Meanwhile this administrator wants all the patient’s friends and relatives to have the freedom to move in and out of the treatment area without passing through a metal detector. He doesn’t want a uniformed officer to frighten anyone.

May I ask you a question? What purpose does key pad entry to the treatment area serve if those people entering do not pass through a metal detector? In the first 6 months that a Detroit hospital had a metal detector between their treatment area and waiting area, they confiscated 33 guns and 1,234 knives. In Los Angeles doctors discovered that 25 % of male trauma patients had weapons on them upon arrival and 31% of females were armed.

Whether you like guns or hate guns, if your psychotic patient has one and no one else in your hospital does, he can kill a room full of people before help arrives. There is a big difference between a security guard who is armed and one who is not. In Virginia, certified security guards who are armed have essentially the same powers that a policeman has within the territory they are hired to protect. They have the same limited immunity that a police officer has when he touches a person. It is very unusual for a policeman to be charged with assault in the line of duty.

As long as the officer is not behaving like the officers who assaulted Rodney King, the judge will give little weight to the violent patient’s complaint of “police brutality”. A certified armed security guard can arrest a violent or out-of-control patient for a misdemeanor or a felony. He can pursue a fleeing perpetrator. He can pass out summons to court. He can legally handcuff you. In short, he can protect you without fear of being sued.

On the other hand, the unarmed security guard may be able to pick up a couple of cupcakes from the cafeteria for you, but he can’t do squat to protect you. He won’t take someone to the ground and handcuff him. He carries no weapon in a place that is full of armed and potentially violent people. Off-duty police officers make excellent security guards for the ED, for obvious reasons.

I would like to repeat something. Until a person experiences deadly violence they have no idea of their vulnerability. I recall how difficult it was for me as an intern to accept that a certain number of people in almost every metropolitan bar go there to watch potential victims drink alcohol. They quietly sip their drink and watch for loud voices, laughter, unsteadiness, or drowsiness. They wait for one of these people to leave alone. Usually within a half a block from the bar the intoxicated person is beaten to a pulp in the face and head. The sociopath who does the beating doesn’t even know his victim. He doesn’t want the intoxicated victim’s wallet. He just enjoys beating other human beings senseless. I have repaired hundreds of such head wounds. So what’s my point? My point is that the ED is far more dangerous than a bar and it caters to these sociopaths. If you are not willing to admit the presence of evil among your typical ED patients and visitors, God go with you. I hope He’s armed.

In summary, in my view the two most important things that ENA should lobby for are metal detectors at every interface that the public has with the ED and armed, uniformed officers who cannot leave the ED while on duty. I applaud the efforts of ENA to demand stronger penalties for people who abuse them. I will repeat my basic question. Would you rather sit through two years of court hearings that end in a plea bargaining or would you rather be protected from this person and never get assaulted?

Stay tuned for my next post on fear of litigation, and how it contributes to violence in the healthcare workplace.

Charles C. Anderson M.D. FACP, FACEP
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