Being Threatened

How many of you have a job where you could, at times, be physically or verbally abused? And threatened? And pushed beyond your limits of self-dignity?

Welcome to the ER.

Anyone who has ever worked in an emergency department or a trauma center has a story to tell about being threatened. It's not a good feeling and, in fact, is something that one can carry with them long after the event, dwelling on their minds and weighing down their hearts. We all, I think, have a little part of our self-worth damaged at times like that. And even though you did nothing wrong, you still ask yourself repeatedly "What did I do to deserve this?" or "Could I have done something different?" Nine times out of ten, that answer would be "no." But that crazy thing called guilt can flip the coin and make you feel like you were responsible.

For example, when an alcoholic or druggie comes in and threatens to "beat the shit out of you" or "find out where you live and come carve you up," it's par-for-the-course, something we have all been trained to deal with. We are asked to look beyond the abuse and realize that it's "not the patient talking" but, rather, the drugs and alcohol. Yeah, okay. For the most part, I can buy that. But we all have limits, and it takes tremendous professionalism and restraint to continue treating that patient. And of course, we always do.

Likewise, if a psychiatric patient presents during a crisis, a break from reality, they may lose the ability to discern between what is normal, accepted behavior and what is harmful, threatening behavior. And again, the ER staff is usually on the receiving end of their irrational actions or words. Recently, a schizophrenic patient sprayed us with her saliva while glaring at us with her distant, disconnected eyes, spatting away and trying to bite or hit anyone near her. Even after a face-mask was placed, she still managed to hurl some extremely hurtful, vulgar comments at our staff, particularly at a medical student who had some acne issues and a female guard who was not a size 8. One of our nurses ended up with a bruise.

Hell, about ten years ago, I even had a psychiatric patient tell me that he was going to find out where I lived and "take you out." I hadn't been the first doctor and I'm sure I wasn't the last that he threatened but, trust me, you don't sleep well after something like that.

We accept these words and these blows, these mean-spirited, personal insults delivered with flailing arms and legs, because we signed-up for our jobs in the ER. But, we are still human, and there are days when this type of threatening or abusive patient is harder to accept and deal with.

The hardest part, though, isn't the expected threats, such as from the above patients. Rather, it's the unexpected threats from the sane-appearing patient who decides to take out all of his frustrations on the ER staff. For this reason, I rarely let a patient get between me and the treatment-room doorway.

A while back, I signed on to treat a twentyish male who had waited for about two hours for a complaint of one week of cough and cold symptoms, exacerbating his asthma. He continued to smoke despite feeling that his symptoms were getting worse, per the nursing triage note.

As I walked down our brightly-lit corridor, towards his room, I exhaled a deep, thankful breath, happy to have my last patient survive her stroke. Unknowingly, though, I was walking towards a room of rage.

I pushed the curtain to the side and walked into the room, all while extending my hand to introduce myself. Lying on a cot in the dimly-lit treatment room, watching the small TV in the upper corner, was a young man who looked very pissed-off. He may have weighed 130 lbs. wet, 5'7" or so. After I entered, he shifted his glaring eyes onto me.

"Hello," I started, "I'm Doc..." Unfortunately, I didn't get to finish. In a flash, this patient had jumped off his cot and towards me, his arm cocked-back and his fist balled. He stopped a few feet in front of me.

"I had to wait almost three f...ing hours for you to get your ass in here. Can't you see I can't breathe?" He yelled in full sentences, no distress evident. By triage notes, he was stable and had had an excellent oxygen reading. There was no mention of this patient being unreasonable, although I later learned that security had to approach him in the waiting room to calm down. He continued. "You motherf...ers are treating everybody but me."

Yes, my heart was racing. And yes, I was completely caught off-guard. We had a brief moment of silence where our eyes locked, and I could see his extreme rage.

"Put your fist down," I said firmly, holding my ground, shifting my eyes to his cocked-arm. "If you touch me, I promise you that you'll be covered with cops and security before you can blink." Instinctively, while speaking, I raised both of my hands, preparing to catch or block a thrown-fist. Why didn't I retreat? I'm not sure, exactly. Although I had about 70 pounds and six inches on this patient, that would mean nothing if this guy had a gun or knife. But frankly, during a moment like this, it's hard to fully grasp all that is happening.

The patient continued to keep his arm cocked as he ranted. "Motherf...ckers, sons-of bitches, assholes," he yelled, "making me God-damn wait like this. I want some God-damn treatment and I want it now." Finally, after his rant, he took a step back towards his cot.

By now, because of the commotion, I knew that security would be rushing to the room. And they did, but not before one of our techs, a 350 lb. brute, came in first to back me up. Security soon followed and, after we offered some very brash options of either being arrested (if he continued his behavior) or cooperating or leaving on his own accord, the patient requested to be treated. Since I'm not easily intimidated and wasn't sure how ill he was, I agreed to treat him, but not until after I spelled out in exact terms how we expected him to behave. He hesitantly agreed to our terms.

Under watchful eyes, I obtained a history from this patient and performed a thorough exam. I tried my best to maintain my professionalism and act as if this patient hadn't wanted to jump me mere minutes before. Fortunately, I found him to be just as the triage nurse had noted. He had been appropriately placed behind our more critical patients for treatment.

The respiratory therapist came down, soon after, to give this patient a breathing treatment. Before she entered the room, I explained to her why security would be sitting outside of his room in the hallway. We both walked to the room together, only to find no security sitting outside.

"Go back to the station," I said, "I'm not sure what happened."

Well, as it turns out, this patient, following another angry outburst aimed at our security, had decided to leave without any further treatment. And wouldn't you know, the next day he returned. I wasn't even aware he was back until I heard a big ruckus. Again, a lot of verbal abuse towards one of the ER nurses and one of my partners. Our security was ready, though, and the police were notified.

Although we'll never know for certain, there did not appear to be any alcohol or drugs involved. No psychiatric history, either. He simply was a very disgruntled, angry man who wanted his medical treatment immediately, for symptoms that had been present for almost a week. In order to jump the line of waiting cardiac, stroke, and trauma patients, he had been willing to risk threatening several of us.

At times, we can face some real dangers with our ER jobs. My hat is off to all of my fellow ER comrades, from the secretaries to the techs, from the nurses to the docs, and from the security to the police. I salute your continued resilience and professionalism, especially during these abusive moments.

As always, big thanks for reading. The next post will be Friday, March 12. Until then...