1. THE VIOLENT PATIENT Ülkümen Rodoplu,MD

2. Overview Violence in the Emergency Department Recognition of potential for violence Causes of violence in the emergency room Violence Management Physical methods Protocols & Procedures

3. Psychiatric emergency Disturbance in behavior, feeling or thinking If not attended to, can result in harm to the patient or someone else. Due to external or internal stress overwhelming the person’s ability to cope.

4. Prevalence – Emergency Department ED often first point of entry Atmosphere of the ED is often one of confusion and rapid place. Intoxication, concealed weapons and stress potentially all present at the same time

5. Why ? Staff in the ED receive the most amount of verbal and physical abuse out of any other department. Nature of the work implies exposure to violence. Methods of violence management are vital

6. Violence and the Airway E.P.s predictably encounter both Final outcome of many pathologies Failure to manage appropriately leads to injury and/ or death

7. Recognition of Violence Aggression towards an individual toward creating fear Stress behaviours in individuals include use of profanity and verbal outbursts pacing or frequent alteration of body position or posture indicate increasing agitation

8. Causes of Violence Not always gang related; and not all gang members are violent in certain situations (i.e. child birth) Understand root of behaviour psychiatric drug induced (either intoxication or withdrawal) child, elder or spousal abuse frustration due to long waits, unrealistic expectation

9. Causes of Violence Overcrowding Creates volatile situations Increased waiting times Neglect of patients who require urgent attention Proximity of rival groups gangs intoxicated driver in close proximity to victims

10. 10 Incidence -USA -127 Emergency Department… Result: -One verbal threat daily (n=41, %32) -One weapon threat daily (n=23,%18) Lavoie FW, Carter GL, Danzl DF, et al. Emergency department violence in United States teaching hospitals. Ann Emerg Med 1988;17(11):1227-33.

11. Incidence 5 year follow up: -72 (%57) hospital had their staff thretened with gun (once). -55 (%43) hospital had their emergency staff threateneded physically (once). -102 (%80) hospital had injury. -9 (%7) hospital had death. Lavoie FW, Carter GL, Danzl DF, et al. Emergency department violence in United States teaching hospitals. Ann Emerg Med 1988;17(11):1227-33.

12. 12 Incidence - 2003, State Hospital in Hong Kong - 3 Months 25 cases with 26 violent patient … - %64 verbal violence - None had gun CH Chung. Emergency department violence: a local scene. Hong Kong Journal of Emergency Medicine. Volume 10 Number 1, January 2003

13. 13 Incidence Reasons for violence: Long waiting time (%36) Mental disorder (%28) Dissatisfaction for the care given (%20) %69 male, 21-50 years of age.. CH Chung. Emergency department violence: a local scene. Hong Kong Journal of Emergency Medicine. Volume 10 Number 1, January 2003

14. Pathophysiology Increased incidence of violence exists in XYY men. Increased testosterone in man and premenstrual syndrome in women proposed as causes of violent behavior. Low levels of CSF 5-HIAA found in some who commit violent crimes Violent criminals decreased violence with administration of 2-5-hydroxytryptophan, seratonin precursor.

15. 15 Organic reasons No history of physiatric disorder Sudden onset agitation Violence → ??? Age 40 ↑

16. 16 Organic reasons – Intoxication – Hypoglisemia / Hypoxia – Infection (septisemia, menengitidis) – Organ failure (liver, kidney) – Heat stroke

17. Organic Reasons – Organic Brain Syndrome (seizure, trauma, tumor) – Delirium – Trauma – AIDS – Electrolyte abnormality

18. Pshyciatric disorders Schizophrenia Paranoid ideation Catatonic excitement Mania Bipolar affective disorder

19. Personality Disorders -Borderline -Antisocial -Delusional depression -Posttraumatic stress disorder.

20. Treatment Modalities Interview Techniques Environmental Factors Physical Restraints Chemical Control

21. Case Presentation 69 yo M, Brought by family after lighting a fire in bathroom. Patient has no complaints. Hx of Schizophrenia P=110, BP 150/90, RR 20, T 37.9 No distress, refusing to speak.

22. What actions are reasonable at this point? A: One to one observation B: Undress and fully examine the patient C: Offer the patient medication D: Round up sufficient personnel to restrain the patient E: Stall until you can sign out to your partner before taking any definitive action F: Medically clear him, transfer to Psych.

23. Interview Considerations Calm and Direct Empathic Assurance of priorities Verbalize limits/expectations Consistency among staff

24. Interview Techniques Eye Contact Personal Space Door Position Body Language – Angle of confrontation – Hand and arm position

25. Management through Physical Methods Access control Minimised unguarded entrances; lock extraneous entrances / exits at night Secure sensitive areas with access control Hand-held metal detectors used by security Enforce visible identification of all staff Plexiglass between waiting room & ED dept Block unauthorised vehicle access to the emergency department Visible security inside & outside

26. Management through Physical Methods Rankins and Hendey suggest that removing weapons did not decrease number of assaults Training of ED staff to handle violent situations remains crucial

27. Management through Protocol & Procedure Develop a safety plan with hospital security Rehearse response mechanisms Code word called out when violence erupts Close contact with law enforcement during high- volume or disaster management scenarios Debrief after major incidents to refine procedures Access patient history either by records, friends or family to gain proper perspective on a patient Undress patients to reveal concealed weapons and disarm if necessary

28. Management through Protocol & Procedure Security should recognise an escalating situation Either between parties or individual misconduct Separate rival gang members or victim- perpetrator groups Do not show condescension towards gang members. Cultural differences and language barriers may already cause tension Immediately use chemical and/or physical restraints with sufficient personnel

29. Chemical Control Rapid Tranquilization – Safety – Titratability Haloperidol Benzodiazapine Droperidol

30. Haloperidol Buteryphenone antipsychotic 5- 10 mg. IM, PO, IV onset 20 minutes t1/2 of 19 hours Side Effects

31. Dystonic Reaction Akathesia Neuroleptic Malignant Syndrome Cardiovascular Effects Seizure Threshold

32. Benzodiazapines Lorazepam Less predictable effect – Paradoxical disinhibition – Dose requirements Less titratability Less Antipsychotic effect Greater risk of cardiorespiratory depression

33. Droperidol Buteryphenone antipsychotic 2.5- 5 mg IM or IV Onset minutes t 1/2 2-4 hours Side effects

34. He is still uncooperative. At what point do you decide to physically restrain this patient? A: Before he does any damage B: After a psychiatrist has evaluated him and determined a lack of capacity C: After he does some damage D: When danger becomes imminent

35. Physical Restraints For Imminent Threat of Harm Preparations – Overwhelming Show of Force – Initiate only When Prepared – Preparation

36. Physical Restraint Once Initiated, Swift and Definitive Suspend Negotiations Team Leader Secure Large Joints Constant Reassurance

37. What do you do if he tries to leave before you have sufficient personnel ? A: Physically block him B: Have the nurse physically block him C: Offer him money to stay D: Notify local constabulary

38. Monitoring Documentation – Neurovascular – Cardiovascular – Airway Consideration of removal Transfer Considerations

39. Summary Multifactorial approach Teamwork Early intervention Life saving when necessary