Department of Emergency Medicine, Bundaberg Base Hospital, Qld 4670, AustraliaAustralia
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Making the call to “Take someone down” in the ED is never to be taken lightly. The only time such a drastic decision should be made is to prevent imminent harm to the patient or others. It should always be the most senior doctor in the department at the time who makes the clinical decision that the physical and/or chemical restraint of a person is necessary and sanctioned by law at that time.
Open Journal PUBLISHERS Short Communication Dealing with Violent Dangerous Patients: The Medicolegal Pitfalls * Navin Naidoo, MBBCh, LLB, FACLM, JD, FACPE* Department of Emergency Medicine, Bundaberg Base Hospital, Qld 4670, Australia * *Corresponding author Navin Naidoo, MBBCh, LLB, FACLM, JD, FACPE General Practitioner Gympie, Department of Emergency Medicine, Bundaberg Base Hospital,, Qld 4670, Australia; E-mail: navinnaidoo@gmail.com Article information th th nd th Received: October 20 , 2019; Revised: November 28 , 2019; Accepted: December 2 , 2019; Published: December 6 , 2019 Cite this article Naidoo N. Dealing with violent dangerous patients:The medicolegal pitfalls. Emerg Med Open J. 2019; 5(1): 9-11. doi: 10.17140/EMOJ-5-153 “Takedown” in the Emergency Department (ED) an all too regu- to more appropriate facility capable of dealing with a safe extuba- lar occurrence that is set to escalate dramatically in years to come. tion in a known violent aggressive patient.
This was prophesized by a newspaper headline from 1991, “The growing ranks of aggressive, addictive and deranged people for The law is vague as to duties of care, etc, especially when whom the emergency department is the last resort.”1 the violence does not come from a patient. Violent non-patients are best dealt with by the police and hospital security without re- Making the call to “Take someone down” in the ED is quiring a medical takedown. There are times when violent beha- never to be taken lightly. The only time such a drastic decision viour from a non-patient escalates to the point where that person should be made is to prevent imminent harm to the patient or becomes a danger to others and himself. If that person is behaving others. It should always be the most senior doctor in the depart- in a manner that falls beyond what is considered normal, does it ment at the time who makes the clinical decision that the physical preempt a psychiatric diagnosis and place a duty on the doctor in and/or chemical restraint of a person is necessary and sanctioned charge to consider a medical takedown?
by law at that time. This area is a minefield for doctors. The duty of care of the physician is in direct conflict with the patient or EDs are especially prone to violence. They provide an violent person’s right to bodily integrity, freedom of movement, environment filled with emotional stress; patients may suffer pro- freedom from bodily infringement, refusal to consent to medica- longed waiting times, confusion, and gaps in communication. In tion, and several other inherent civil liberties that every person has addition, the 24-hour open-door policy and the widespread avai- as an automatic right to.
lability of drugs and weapons in the community compound the problem.3 Giving the order to have several people as of neces- sity they need to be big strong well-trained people, physically The 1993 shooting of three physicians on duty in Los overwhelm and subdue someone and then place physical restraints Angeles County ED underscores the tragic consequences of ED to continue to subdue, and without consent inject chemically se- violence. The problem is not isolated to a few urban areas. In a dating agents into the body of that person, is a treacherous path 1988 survey of 170 U.S. teaching hospitals, 32% reported at least for any doctor, no matter how experienced or qualified an ED one verbal threat daily, 18% at least one threat with a weapon daily, practitioner may be (author personal experience, October 2019). and 25% reported restraining at least one patient per day. Within A successful takedown often leads to the person requiring intuba- the previous five years, 7% of the institutions experienced a vio- tion, ventilation and ongoing sedation until there is the capacity to lent death in the ED. Eighty percent had a staff member injured deal with a safe extubation. There are many recorded deaths as a due to violence.4 result of involuntary physical and chemical sedation,2 and almost inevitably it will involve some sort of bodily injury. If the initial Assaults may come from patients, visitors, or members facility does not have the capacity to safely deal with such a patient of a patient’s family. Parents of ill children may turn to violence after forced and necessary sedation, they may require transporting from frustration. A 1994 survey of 44 pediatric EDs revealed that cc Copyright 2019 by Naidoo N. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows to copy, redistribute, remix, transform, and reproduce in any medium or format, even commercially, provided the original work is properly cited. Emerg Med Open J. 2019; 5(1): 9-11. doi: 10.17140/EMOJ-5-153 more than half reported one or more verbal threats a week, 77% for training purposes.
reported at least one physical attack on staff per year, and 25% sustained actual injury to staff.5 De-escalation of violent situations is always the goal, and ED staff and security must be regularly trained in de-escalation ED nurses are particularly likely to be assaulted. Nearly techniques. The use of bodycams by security staff are advocated 70% of all emergency nurses are assaulted on duty during their when dealing with violent and dangerous patients, and for proof career.6 Yet, as alarming as these statistics are, up to 80% of all ED of the danger, a patient presented at the relevant time. The effect assaults are not reported.7 of violence on doctors and nurses is profound and devastating. An assault at work is demeaning, insulting and often devastating The articles referenced provide a comprehensive and to a doctor or nurse’s psyche and well-being. Violence to medics exhaustive discussion of the duties that need to be complied with often causes them to leave the profession and may lead to serious in the circumstance of a “Medical Takedown”, and every emer- ongoing psychological and mental health issues. Retro-thinking gency doctor and nurse should regularly read the brilliant article by mandatory reporting laws relating to healthcare workers and men- Louis Kao and Gregory Moore.8 tal health issues, perpetuates the problems faced by victims of violence at work for fear of mandatory reportings. Post-traumatic A polarizing discussion of some controversy is presently stress disorder (PTSD) often follows significant acts of violence, surrounding the conventional agents that should be chosen for and victims suffer lifelong consequences.
takedown situations. This article is not intended to explore the me- dical decision making related to the emergency choice of a tran- The advent of more and more potent mind-altering nar- quilising agent. That is a complex and voluminous topic that is cotics, an ever-increasing violent society, the normalization of vio- deserving of an arena all on its own. This article is intended to lence in sport and as part of masculinity, political and religious merely enlighten front line medical practitioners about the poten- polarization, alcohol, religious seculism in a global village context, tial legal dilemmas that they may expose themselves to through the and racism itself are all factors that seem destined for continued use of physical and chemical restraints. There is an understanding violence to be part of human existence. EDs need to factor in this that some hospitals arm their security personnel with tazers and reality and ensure that their staffs are not only well protected from firearms. In our ED, the choice is mostly limited to our security any violence itself, but also the legal outfall from necessary take- that are mainly big burly men and a few drugs, including droperi- down decisions. I will go so far as to say that health departments dol, haloperidol, olanzapine, midazolam and ketamine. The huge and governments have an obligation in this regard. concerns about the safety of droperidol and the need for an elec- trocardiogram (ECG) prior to administration being a prerequisite