Note: As I was editing this article for posting, a news alert came over my phone. In the city of Atlanta, a patient with a purported mental illness produced a gun and shot five people in the waiting room and admissions area, killing one and severely wounding four others. I asked a question in this essay, and, unfortunately, it was answered by this act of violence. The violence was directed to our own in the emergency room.
The International Labor Organization defines violence in the workplace as “any action, incident or behavior that departs from reasonable conduct in which a person is assaulted, threatened, harmed, and injured in the course of his or her work.” Ground zero seems to be events that are taking place in the emergency department on a daily basis. Unfortunately, there are other targets such as abortion clinics, urgent care centers and psychiatric facilities. My son is an RN and is exposed daily on his psychiatric unit. Unlike the pandemic with hoped-for protection (PPE), there is no protection for an HCP (healthcare provider), and there exists a greater potential for PTSD from stress.
We need to look no further than our schools in the United States, to realize that both teachers and students also face the potential for violence and death, causing stress, PTSD, and a large number of students who are fearful of attending classes. In addition to being personally affected, HCPs also deal with the ramifications of violence by an average of 100 deaths per day in ERs as a result of GSW. After the demoralizing effects of a pandemic over the past few years, PAs, NPs, nurses, physicians, and other support staff are living in an epidemic of violence which is affecting them and their families with stress and burnout.
I have been encouraged by multiple friends to watch the Netflix series New Amsterdam. My wife and I watch approximately eight episodes per week; the show is 90% authentic, personal, imaginative medically and is administratively focused with situations, relationships, procedures and an inside view of a large not-for-profit medical center in NYC that has a focus on caring for all individuals whether they can pay for their services or not. An episode that I viewed a couple of weeks ago vividly demonstrates violence in the ER, its aftermath, its hoped-for prevention, and ultimately, its failed solution. Having engaged in more than forty years as a PA in trauma centers in surgery and emergency medicine, I feel an obligation to address this with my colleagues.
HCPs are faced with the potential for violence on every shift and it will inevitably affect them personally. Whether it be verbal abuse, physical or mental violence, or the fear and anticipation of the same, which in turn creates stress, pain, anger, burnout, possible loss of life or the capacity to work, in addition to the potential for PTSD and litigation. They have become both disappointed and helpless because of lack of intervention by systems, management, and local or state government. All have failed their staff because they have not intervened in a plan to make the workplace a safer haven for both patients and staff. You and I have entered the health field to care for the sick and the injured, not to be attacked by those same people with their words, their fists, or their loved ones armed with whatever weapons they may bring with them. When will we become the next victims and become sick and injured ourselves?
For some inescapable reason, institutions are failing to recognize how difficult it can be to give direct emergent care when a friend or family member or an unauthorized assailant becomes threatening. There is no doubt that this atmosphere or situation can be a springboard for medical errors. I was a Combat Medic during the Vietnam war and served in that country in 1966 and 1967. I was trained to react amidst the chaos of grenades and artillery explosions, light and heavy weapons pouring hot lead at myself and my teams. I both observed with my eyes and heard with my ears the screams, prayers, pain and fear of my fallen friends. Even our training did not adequately prepare us for our first firefight. That being said, how will we prepare our front-line emergency workers and EMTs for potential violence that they may encounter? Or for the exhausting trauma of dealing with victims of violence?
We need to ask ourselves and our employers how we can be protected from a lawsuit which was aggravated by violence in the ER. Where is our bulletproof vest? Can we be protected from violence in our departments? Can we be held to an alternate standard of care? Do we need to be armed like the jet pilots and teachers? Should there be signs posted at the entrance of our facilities and in our waiting rooms concerning weapons in the facility? Should we have armed police or security personnel? Do we need rules of engagement? Do we require training of targeted individuals who will serve as a de-escalation team such as is used for hostage negotiations and suicide counselors? And lastly, should institutions provide hourly, free classes to both attend and become certified in self-defense? It can be named Trauma Violence Boot Camp!
What is also needed is to possess a malpractice policy that spells out these scenarios, not a blanket general policy that will prove to be useless in a courtroom. Just as institutions fall short of protecting their employees in the manner that I have discussed, they also fall short of providing employees with a proper, excellent malpractice policy that will serve them in their time of need. Not just a policy that protects the institution but one that protects the professional employee. It is for this reason that I suggest a personal liability insurance policy that has only your name on its face. This is the only instrument that will perpetually protect a professional if it is written in the occurrence mode. This policy should not be contemplated with a new company with little funds but with an AA Best rated (Superior) policy that will be able to stand in any court with all actions that have been proposed. Are you wearing your body armor? Are you protected from personal litigation for your actions at a time when, admittedly, you were not at your best? These are the questions that I propose to you as the conclusion of this article on violence in the ER.
Written For CM&F By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor
malpractice insurancenurse practitionerphysician assistantprofessional liabilityworkplace violence