Paramedic attacked by Patient in Emergency Department. It all began with a Stapler and continued to the Court
Paramedic safety is mandatory. But there are many situations where aggressions are challenging to prevent. The #AMBULANCE! community started in 2016 to analyse different situations. The primary goal is to make safer EMT and Paramedic shift, thanks to better knowledge. Start reading, this is a #Crimefriday story to learn better how to save your body, your team and your ambulance from a "bad day in the office"!
Living and working in a quiet city makes you even less prepared for any type of violence. That’s what happened to the main character of our story today, who had to face a drug abuse patient inside a hospital. This paramedic finds himself involved in a serious situation right inside the ED. The reaction to a violent behaviour should be the peace, but sometimes it is not so easy being calm.
BACKGROUND – Helping people in their time of need is a privilege that we in Emergency Medical Services (EMS) experience every day. I work in a small city in Alberta, Canada. We serve a population of approximately 100,000. The economy is largely based on farming and oil and gas production. The winters in this part of the Province are relatively mild so we have become a retirement hot spot. As a result we respond to a large number of cardiac calls, chronic pain issues, and other issues related to elderly health care. We are also located close to a military base that is used several times a year by the British Military for training. This adds to our call volume significantly as we respond to injuries they sustain while training and for soldiers who are off duty and out on the town.
In addition to ground ambulance responses, we have an air ambulance component. The long distance to a level 1 trauma center is mitigated by our use of a King Air 200 which is in an air ambulance format. We also have a Bell 209 Helicopter which is used as a regional rescue resource. Currently, I am based out of a Paramedic Response Unit which means I work alone and usually assist other crews on high acuity calls or when increased manpower is needed. I have worked here since 2003 and have been witness to many changes over that time.
One of the biggest changes I have seen has been our recent change in Dispatch Services. We used to be locally dispatched from a call center that dispatched all three Emergency Services (EMS, Police, and Fire). Now we have changed to an EMS only Dispatch center that is centrally located 300 km from here. This was done as a cost-saving measure when our service switched to a province-wide system.
We have our own Police service in the city (as opposed to our National RCMP) and we enjoy a good relationship with them. They are often corresponds to our calls and as a result, there is a camaraderie.
We work in a peaceful context. That peace is slowly being threatened by an increase in drug use in our city. We are located along the Trans Canada Highway which is the highway between major centers in Canada from East to West. As a result, we have a disproportionate amount of drugs that pass through and remain in our community.
Fortunately, we have not had many incidents of violence against our EMS personnel. These incidents are steadily increasing however and are largely due to drug use. The peaceful city I started my career with in 2003 has become one where we regularly use Narcan on a shift. Guns are not prevalent here. The violence we face is usually physical attack. I credit our Police service for the lack of many serious incidents against our staff.
Our local hospital is increasingly over capacity. The sheer number of people in our Emergency Room has resulted in increased incidents of violence there and for the need for increased security. Our wait times in the hallway with our patients has increased dramatically over the years which adds to patient stress.
THE CASE – My incident happened in June of this year. I had just transported an elderly patient to the Emergency Department and I was waiting in line with another EMS crew to give a report to the triage nurse and hopefully get our patient a bed in the department.
Our Emergency Department is similar to that of many small city hospitals. The waiting room is separated by a glassed in triage desk and a security door that requires a button to be pushed for entry from the outside. Security personnel have a desk immediately inside that door and can be found there 90% of the time. There is a holding room for potentially violent psychiatric patients beside the security desk that can be locked. Some of our security personnel are trained Peace Officers who are allowed to detain patients who may be a threat to themselves or others until Police or Psychiatrists decide on a plan for them.
While violence is not unheard of in our Emergency Department it is rare. On occasion, Security Personnel must restrain patients who are intoxicated or assist Police with restraining violent patients who are brought in for medical assessment. In general, the process is handled smoothly and the holding room is used effectively.
The day of my incident was the same as any other. I was talking to one of my colleagues as I waited for the Triage Nurse. EMS crews enter via a separate door so we give a report to triage behind the glass to the waiting room. A man passed behind me and walked up to the Unit Clerk in a brisk manner. He immediately started yelling and swearing at the Unit Clerk who was quite shocked and frightened at this aggressive display. At the end of his diatribe, he picked up a stapler and threw it at her. Immediately, he turned around and I was the first thing he saw. No more than 10 seconds had passed between the man walking behind me and him throwing the stapler.
At first he appeared to be surprised to see me as I think he was zoned in on the Unit Clerk. It didn’t take long however for him to see my blue uniform and assume I was a Police Officer.
He swore at me and punched me in the face. I had no choice but to subdue the man by force. The sudden nature of this struggle prevented me from really formulating a plan of action for this physical encounter. Luckily I was instinctively able to grab him around his head and wrestle him to the ground, while the patient was punching me in the back. I was surprised at how angry I was at him. The urge to let go of the headlock I had him in and begin punching him back was great. I was very aware however of the duty I had to not injure this man any more than I had to. I kept thinking about the video cameras recording the Emergency Department and how this would look if it were to be shown to my Superiors, or worse yet the media.
As it turned out, the Security Personnel that are at the desk next to the Triage Nurse 90% of the time, were not there when the incident occurred. So, in what seemed like a long time but was probably under a minute, I was assisted by two of my colleagues who were able to hold the Patient’s arms so he could not punch me. In the aftermath of the stapler being thrown they had gone to the assistance of the Unit Clerk and didn’t look back to see me struggling with the patient. Eventually, the Security Personnel arrived, arrested and restrained the patient, and put him in the holding room with the door locked.
The Police later arrived and investigated the matter. I have received a subpoena to testify at the man’s trial in November. I have since been informed that the patient had been inside the Emergency Department. He was in the holding room waiting to see a doctor about his drug use. The holding room door was not closed or locked as he was not considered a threat of violence.
THE ANALYSIS – The impact of this incident has been surprising. While only minor injuries were sustained by the unit clerk, the aggressive patient, and me, the consequences are still ongoing.
Before exploring the analysis of this incident I want to list the questions that came to my mind immediately after the assult and now.
First off we can ask the obvious question….why did this happen? Clearly, the potential threat this patient presented at the time of him being put in the holding room was improperly gauged. Or was it? Perhaps, no one put in the holding room should be left unattended. After all, the designers of the Emergency Department put the security desk next to the room for a reason.
Is it impractical in a small city hospital with limited security resources to dedicate a person to monitor that room when it is occupied? Where were the security personnel at the time of the incident? Does the presence of the glass barrier between the Emergency Department and the waiting room provide a false sense of security? Should there be other barriers in the department? Do I have the training to react appropriately when faced with a physical assault? Did I hurt the patient more than was necessary to subdue his aggression? Why do I feel guilty about going to court to testify against him? All of these questions have been in the back of my mind since the incident.
The review of the incident done by our security department revealed that this patient had come in to be seen by a doctor regarding his drug problem. He was known to the security personnel from previous visits and had only been verbally aggressive in the past. Our local Police Service has also dealt with this patient on numerous occasions and did not seem surprised when they heard of his aggressive actions. So clearly the Security Personnel on duty that night did not properly gauge his potential risk for violence. Having said that, they do not currently, nor at the time of the incident, have a policy of monitoring the holding room when it is occupied. Nor does the policy state the door must be closed. If left unattended the door to the holding room should be closed in my opinion.
At any one time, there are three Security Personnel working in the hospital. The hospital has a busy Emergency Department and it also has the only high acuity psychiatric unit within 300km of any other center. The security policy is that one security guard is to be stationed in the psychiatric unit and the other two are to circulate throughout the hospital and its grounds. The security desk for two personnel, however, is located, as previously described, beside the holding room in the Emergency Department. So, as is human nature, the two guards tend to be found at their desk where they can interact with staff and use the computer to pass the time. When a security incident occurs, the two guards respond and can call for the third guard if needed via radio. They can also have their dispatch call the Police if needed. Obviously, responding to a security incident should not be done alone, so the presence of a patient in the holding room presents a problem. At the time of my incident, the two security personnel were outside with another patient who needed monitoring while smoking. The patient that became aggressive was then left unsupervised and the door to the holding room left open. The Emergency Department was very busy that night and the aggressive patient became very impatient with the delay in seeing the doctor. This patient should not have been left unattended.
As previously noted I work in a peaceful context. There are a few incidents of violence that occur in our service but they are usually not serious. The Emergency Department waiting room has its share of incidents of hostility, but once again the consequences are usually minor. In the review of the incident, I do feel the glass barrier provides a false sense of security. The thought of being attacked by a patient while on the “safe” side of the barrier never occurred to me. I was wholly unprepared for an aggressive patient. Having said that I recognize the practical limits of barriers being added. Clearly, this incident could have been mitigated by better monitoring of the holding room and by my improved awareness of my surroundings.
When I received my EMS training I was given instruction on self-defence. When hired to the EMS Service I was given additional instruction on dealing with aggressive patients. All of that training, however, was focused on preplanned, coordinated approaches to aggressive patients. My incident happened in what seemed a blink of an eye. I did not have time to preplan my approach as I have done with aggressive patients in the past. The only coordination I could manage was after I was in a full-fledged physical struggle with this patient and my coworkers came to my assistance. While I was able to fight off the aggressor, I do feel I was lucky. More training in self-defence would be appropriate.
When struggling with the patient I was able to place him in a hold that allowed me to control the movement of his head and therefore limit his ability to hurt me. I was keenly aware that this hold could quickly devolve into a choke hold and I did not want this to occur. I feel somewhat ashamed that my mind immediately went to the presence of the security cameras and how this would “look” as opposed to how this patient was going to breathe. In hindsight, I do not think I could have managed this aggression any differently. The simple physics of the patient being taller than me did not allow a different strategy.
Mental illness and drug abuse is an ever prevalent part of EMS in any part of the world. Since beginning my career, I have developed a sense of compassion for these people. I endeavour to remember that they are people with an illness like any other. I have often chided my colleagues who indulge in inappropriate humour about these patients. For all of these reasons, I have a sense of guilt over hurting this man. His physical injuries were not severe but the impact on his life from this incident is still ongoing through the court system. Do I need this man, who clearly has issues he needs help with, to be sentenced to jail time for a punch to my face? I don’t feel it necessary but that outcome is out of my control now that it is in the court system.
The resulting changes from this incident are disappointing. Security policy on the monitoring of the holding room has not been changed. Apart from an initial concern over the wellbeing of the staff involved by our safety officials, no action has been taken to provide extra training or security. My fear is that this incident will quickly fade from people’s minds and be filed away as yet another “near miss”. In this world of ever-tightening budgets, I do not see things changing until a much more serious incident occurs. I can assure the reader however that I have changed the way I view my surroundings. Hopefully, that is one positive that comes from all of this.
Lessons learned from this event are that the need to be aware of my surroundings does not change when I enter the emergency department. This is a point I have tried to convey to my colleagues so that they can benefit from my experience. Another lesson learned is that I need to be cognizant of the unpredictability of patients dealing with drug and alcohol issues. This unpredictability means that a person who is assessed on entry to the emergency department can behave very differently as the long hours go by in their wait for medical treatment.
Despite the risks we face in this job, I consider it a privilege to have the training and responsibility to help those in their time of need.