Many years ago I had a patient in the emergency department who was young, accompanied by young friends and very demanding. I recall being terse with him. I was young and proud of myself for ‘taking a stand.’ (I’m not sure terse qualifies, but whatever…) I don’t remember what he wanted, although I suspect it was narcotics. I don’t recall the final resolution except that he and his friends left. I later learned that they were on a multi-state crime spree. Whoopsy…

Maybe my ‘sense of danger’ wasn’t quite as well developed then. The scenario could have ended very badly. I believe that I have since developed better radar, or at least have learned the inestimable value of de-escalating confrontation.

The story illustrates the fact that the ER has always been a place of danger. However it is growing steadily more dangerous by the year. In fact, I was once told by a deputy in the rural county where I worked for twenty years that ‘the ER is the most dangerous place in the county.’

(Surprising since there was a notorious bar called ‘The Last Chance’ which had seen no small amount of blood and brains spilled on its floors and in its gravel parking lot.)

We know that violence against healthcare workers is rising. The following articles gives examples of the degree of violence, the anxiety it is producing and offer some suggestions.

This quote from the article above is shocking:

“According to the US Bureau of Labor Statistics, healthcare workers accounted for nearly three quarters (73%) of all nonfatal workplace injuries and illnesses due to violence since 2018—five times the rate of any other worker in another industry.”

Why are people more violent in the ER these days? Maybe first and foremost because people can be more rude. That is, we allow it. When we moved to a customer service paradigm in healthcare, driven by pay tied to satisfaction metrics, some patients learned very quickly that they could do, and say, a lot and we would acquiesce just to keep ‘the customer’ satisfied.

There are all too many nurses who can tell stories of verbal and physical assault, and who were told by their superiors to ‘just let it go.’ And so it continues. Recently, in one hospital, I heard a patient say to female nurses ‘you bitches had better get me out of here quickly.’

Administrative support goes a long way here. If you let your staff be abused, the abuse will continue. If you advocate for them, and make it clear to problem patients, then it has a better chance of stopping.

I suspect that people are violent in the ER because we are available 24/7/365 and many times violent people do violent things that land them in the ER, frequently in the wee hours of the night. It’s hard to dial back that violence when you’re fresh out of the situation.

In addition, alcohol. Alcohol, dear reader, is associated with 50% of all violence world-wide. I struggle to remember a violent act that resulted in an ER visit when neither victim nor assailant was intoxicated.

Of course, there are other factors. While in no way excusing violent behavior, maybe the trend we’re seeing is also because people are frustrated and struggling with so many problems. They have jobs that pay poorly and families barely getting by. They can’t afford their insulin. Great-grandparents are raising great-grandchildren. Seniors have no help when they live alone; and they’re far worse off as inflation grows.

Sometimes patients can’t afford gas to come to the hospital, much less gas to visit family members when we transfer them to distant hospitals for specialty care. Not uncommonly, they ask me, ‘doc, how is she going to get home?’ I don’t usually have an answer.

The people who come to us, day and night, are desperate and feel as if they have been backed into a corner, financially, and personally.

Certainly the well-crafted division in America doesn’t help, as we are divided by messaging (and divide ourselves) into increasingly hostile camps based on politics, race, gender and culture, even based on the geography of rural vs urban, north vs south.

I think all of this contributes to the tendencies towards violence towards healthcare workers. Those staff members may represent a group their patients disdain, or distrust. Furthermore, sometimes nurses, medics, physicians and others are they only people to whom they have access in crisis.

It’s not surprising that their venom spills over onto the only people the interact with on those very bad days. My friend Mike, a wise and excellent PA once said to me, ‘Ed, I think the reason people act out in the ER is because it’s they only place they have any control.’

Of course, there are other problems. Children, teens and adults are diagnosed with not one but several psychiatric disorders, are heavily medicated, and still suicidal. Sometimes a new prescription at a clinic is the closest they come to ‘mental health care.’ This causes anxiety and frustration in adults and minors alike as patients are often held in emergency departments for days to weeks in hopes of psychiatric beds.

Those with more profound mental illness, those with schizophrenia or other psychotic disorders that leave them continually hallucinating, delusional and paranoid, well they simply move from ER to short psychiatric admission to home or street (but I repeat myself) and then back to the ER. It’s a kind of terrible, hopeless loop.

However, despite what we were told for ages in medical school and residency, these patients can be very dangerous. I personally know a nurse who was nearly choked to death by a psychotic patient. This was not a ‘one off.’ It happens a lot.

We need a return to the honest-to-goodness psychiatric/state hospital where the psychotic could go for evaluation and, well, sometimes just to live in safety. Safety for them and safety for the populace. When I was growing up in Huntington, WV, we had the Huntington State Hospital. The mentally ill might walk around town, but they had a place to go back to.

This isn’t cruel, it’s actually compassionate all around and if you ask anyone else struggling with this issue in the ER, they’ll mostly agree.

The whole psychosis issue is made more complicated by the nearly ubiquitous use of marijuana which, as we are seeing more and more, causes psychosis.

Here’s a little fact sheet on the issue from those crazy right wing fun-deniers at Yale:

In fact, our patients don’t even consider marijuana a drug.

‘Do you use any street drugs?’

‘Nope, none.’


‘Well, yeah, I do that daily. But not drugs.’


The methamphetamine crisis adds gasoline to the fire as well. Our patients on Meth are frantic, agitated, aggressive, hallucinating, delusional and paranoid. They are difficult to restrain or medicate. As such, they are dangerous; to themselves and to the staff. And when restrained or medicated improperly they can experience cardiac arrest, seizures, muscle damage (called rhabdomyolysis) with kidney failure and other dangerous complications of their drug use. (Ditto cocaine, but where I work it is less of an issue than meth.)

I have a personal pet theory that the confluence of cannabis and methamphetamine really escalates agitation and psychosis. And they are often found together. But what do I know?

So hospitals are ‘hamstrung’ in some very real ways. The issue of restraining dangerous patients (physically or chemically) is the stuff of legions of committees and meetings. (Often run by people not dealing with violent patients.) And in my experience, the policy sometimes sounds like this:

‘Don’t restrain people, but if you do, don’t hurt them. But also, don’t do it. But don’t let them leave. And try not to hold them against their will. Thank you for your hard work making our hospital a center of excellence!’

Security staff can be so heavily lectured and warned that they simply won’t touch violent patients. (And sometimes for good reason as the security officer may be a fairly unhealthy senior citizens who could be badly hurt in an altercation.)

I have seen off-duty police officers employed by hospitals. I’ve also seen police substations located in emergency departments. This seems to work well, not only because they are trained and equipped to handle these folks but they also have power of arrest and can be available much faster than they would from a frantic 911 call. (And because those with outstanding warrants seem to quietly slip away, or at least not cause any problems.)

The issue of violence in the hospital ER is much bigger than the violence itself. And that’s pretty darn big. The problem is that it injures (or sadly kills) highly trained and valuable professionals. It drives them away from that place where their skills are desperately needed. And it is an intellectual distraction in an already very distracting place.

Certainly, errors happen in hospitals in general, and in the emergency department in particular. The number of errors leading to actual harm has been hotly debated in medical circles, but here’s a recent discussion.,of%20the%20public%20health%20problem.

The hard reality is that it’s actually nothing short of a miracle that more mistakes don’t happen. Hear me out…

When we take the staggering (and also wonderful) complexity of modern healthcare, add in people living longer with more medical problems and medication interactions, don’t add the necessary numbers of physicians and nurses, gut primary care so that people can’t find a family doctor, add the burdensome and user-unfriendly systems of electronic medical records to which physicians are daily chained for data entry, multiply by hospital and governmental requirements for privacy, for proper billing, for public health monitoring, for safety metrics etc., we have the prescription for many errors.

When we then make the hospital feel unsafe due to loud, threatening patients and when we allow it to be unsafe due to inadequate ability to enforce rules on behavior and restrain or arrest those who are dangerous, then it can only be a matter of time until we make the association between the danger of the hospital and increasing rates of bad outcomes.

Physicians and nurses generally aren’t prepared for violent assault. As such, even the threat is a distraction; how much more the actual attack. Small wonder health care professionals are disappearing from negative work environments.

Violence in healthcare is no simple problem and it will have no simple solutions.

But every day at work is a day that a violent act can happen; not just in my places of employment but all across the land.

Pity that a place of healing can so quickly turn into a place of danger.



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