The Combative Patient

1. The Combative Patient Indiana University Emergency Medicine

2. Case • 28 yo male brought into ED by police after fighting at a local fast food restaurant • Bystanders report history of drug and alcohol abuse • Sustained several lacerations and abrasions while resisting arrest

3. Physical Examination • Belligerent and spitting • Strong odor of ETOH • HEENT: PERRL with nystagmus • Forehead laceration • Many contusions and abrasions • Demanding release from the ED

4. What do you do now? • He wants to leave - Can he? • Should you sedate him? Restrain him? Wouldn’t that be assault? • What is the standard of care in the diagnosis and treatment of this patient? • How can you protect yourself and your ED staff from harm?

5. Another scenario • You see a patient in the ED who is loudly unhappy with their care • Security is summoned to escort the patient out of the ED • The patient threatens to wait for you after your shift

6. ED is Prone to Violence • Duty to see and treat everyone • 24 hour open door • High stress • Waiting times • Availability of hostages • Limited security

7. Violence in healthcare is common • ~50% of providers become victims of violence • ED, Psych, Geriatric units most prevalent • 1992 survey of ED residents • 62% concerned about personal safety • 50% feel security measures inadequate • 1997 survey of psychiatry residents • 73% threatened, 36% assaulted • 66% not trained to manage violent pts

8. Violence against ED workers • Gates DM J Emerg Med 2005; 31(3): 331-7 • Survey of ED workers in 5 Cincinnati hospitals (n =242) • In the previous 6 months: • 96% of physicians reported verbal harassment or threats • 51% of physicians reported physical violence • 8% had had violence management training in the previous year

9. Weapons carriage in the ED • Estimated 4-8% of ED patients • Major trauma victims often armed • Rapid escalation

10. Is there a way to predict who will become violent?

11. Risk assessment • Positive predictors of violent behavior • Male gender • Prior history of violent behavior • Drug or alcohol abuse • NOT predictive: age, ethnicity, education, diagnosis, marital status • Clinicians are notoriously poor at predicting who will become violent

12. Verbal and nonverbal cues “Pre-violent agitation” • Provocative behavior • Angry demeanor • Pacing, gripping arm rails • Clenched fists • Tense posture, loud speech

13. What is the #1 patient characteristic that predicts violent behavior?

14. Intoxication

15. ED Evaluation the Violent Patient

16. Goals of ED Evaluation • Ensure provider and patient safety • Functional vs. organic disease • Organic disease may be reversible (hypoxia, hypoglycemia) • Rapid deterioration possible with organic disease • Appropriate disposition

17. Disarm all patients • Prior to interview • Weapons detectors at the door • Undressing and placing in a gown is a non-confrontational search • Routine disarming results in increased feeling of safety for patients and staff

18. Setting of Interview • Privacy but not isolation • Seclusion room • Ideally two exits available • No heavy objects or potential weapons • Heavy furniture, bolted down • Easy access to security • Security button, or verbal code such as “I need Dr Armstrong in here.”

19. Setting of Interview • Examiner sits closest to door or equidistant from door • Remove personal accessories • Glasses, watch, ties, necklaces, pocketknives • Be aware of objects on pt’s body which can be used as weapons

20. Verbal Techniques • Be honest and straightforward • Non-confrontational demeanor • Avoid direct eye contact • No sudden movements • Act as a patient advocate • Offer food or drink (cold)

21. Verbal Techniques • Be attentive and listen • Address violence directly • “You seem angry” • “I want to help you, but I cannot allow you to threaten me or the ED staff” • Do not challenge the patient’s ego • Do not lie to the patient • Never downplay threatening behavior • Excuse yourself if escalation occurs

22. Functional vs. Organic Functional • Rarely present >45 years old • Alert and oriented • History of psychiatric illness • Situational factors Organic • All ages • Altered alertness • Impaired orientation • Abnormal vital signs • Acute onset

23. Functional vs. Organic • Unrecognized medical emergencies admitted to psychiatric units.Am J EM 2000; 18(4): 390-3. • 64 psychiatric pts transferred to medical floor w/i 24 hours of admission • Most common eventual diagnoses: • Drug/alcohol toxicity/withdrawal (66%) • Metabolic (14%) • Infection (9%) • Documentation very poor

24. Organic Disorders • Hypoxia • Hypoglycemia • Intoxication or withdrawal • CNS infection • Endocrine disorders • Medication reaction • Many others

25. History • Psychiatric, medical, social history • Drug/alcohol use • Prior episodes of violence • Medication use and changes • Interview family and friends, as patient may not be a reliable historian

26. Physical Examination • Vital signs including temp, pulse ox • Neurologic and mental status exam • Signs of drug or alcohol use • Nystagmus, ataxia, pupils, needle tracks • Toxic syndrome identification • Anticholinergic, sympathomimetic

27. Diagnostic Studies • Studies guided by clinical findings • Laboratory • Rapid glucose • Electrolytes, medication levels • “Tox screens” of limited benefit • CSF analysis • Radiology/Other • CT/MRI, EEG, EKG

28. Disposition • Who needs to be admitted/observed? • Suicidal/homicidal ideation • Psychotic • Organic etiology • Intoxicated • Consider psychiatric consultation prior to discharge • Specific follow up is mandatory

29. Restraining the violent patient

30. Physical Restraints • Humane and effective • Facilitate diagnosis and treatment • Legal issues • Documentation, agreement of others • Courts have supported physicians who restrain patients for safety

31. Physical Restraints • Indications: • Prevent harm to patient/others • Prevent significant disruption or damage to surroundings • NOT indications: • Convenience • Punitive response

32. Type of Restraints Used • Leather restraints are strongest • Soft restraints most commonly used • Posey vest • C-collar • NOT bandage gauze • Facemask if spitting

33. How to restrain a patient • Assemble a restraint team • At least five persons including team leader • One female if patient is female • Leader outlines restraint protocol • Enter the room in force with professional attitude • Do not negotiate • Restrain to solid frame of bed

34. The patient has been successfully restrained

35. Monitoring • Frequent monitoring • Standardized form • Complications: circulatory obstruction, pressure sores, paresthesias • Rhabdomyolysis, acidosis, and death are reported in pts struggling against restraints

36. Physical Restraints • Factors Associated with Sudden Death for Individuals Requiring Restraint for Excited DeliriumStratton SJ et al. J Emerg Med 2001: 19:187. • Case series of 18 patient deaths • Factors most associated: • Hobble/hogtie position • Continued struggling in restraints • Stimulant drug use • Do not place patients in the Hobble Position!

37. Physical Restraints • Do NOT allow a patient to struggle in restraints! • Sedation and monitoring are very important

38. Chemical Restraints

39. Ideal chemical restraint • Effective & rapid acting • IV/IM/PO • No addiction • No tolerance • No adverse effects • Does not exist!

40. Haloperidol • Commonly used • 2.5 - 10 mg IM/IV q 30-60 min • Maximum 6 doses/24 hours • Effective within 10-30 min

41. Haloperidol: Adverse Effects • Dystonic reaction, akathisia • May treat with diphenhydramine or benztropine • Neuroleptic malignant syndrome (<1%) • Autonomic instability • Hyperthermia • Lead-pipe rigidity • Idiosyncratic reaction • QT prolongation

42. Benzodiazepines • Used alone or with haloperidol • Lorazepam (Ativan®) • 2-4 mg IV/IM q 15-30 minutes • Titrate to effect • Side effects: Sedation, respiratory depression • Bonus: Treats ETOH and benzo withdrawal

43. Haloperidol, Lorazepam, or Both? • Am J Emerg Med 1997;15:335-40. • Prospective double-blind RCT of 98 agitated pts • IM haloperidol (5mg) vs. IM lorazepam (2mg) vs. both • Similar rate of adverse events • Tranquilization achieved more rapidly with combination treatment

44. Newer (atypical) antipsychotics • Olanzapine (Zyprexa®) • Ziprasidone (Geodon®) • Risperidone (Risperdal®) • Aripiprazole(Abilify®)

45. Newer (atypical) antipsychotics • Oral or IM dosing • Rapidly dissolving oral tablets • Oral dosing requires patient cooperation • Fewer movement disorders than typical antipsychotics • A number of studies demonstrate utility in acute agitation • Reasonable alternative to traditional agents, but role in ED not fully defined

46. What if you are assaulted?

47. Assault • Immediately summon help • Defend yourself without attacking • Deflect rather than inflict • If bitten, push toward the mouth and hold nares • If choking attempted, tuck in chin to protect airway/carotids

48. If the assailant is armed • Comply with demands • Try to remain calm • Do not argue, lie, or bargain • Attempt to establish a human connection, tend to injured hostages

49. Assault • Each hospital should have a plan of action to be utilized in case of extreme violence • Prevention and safety measures • Notification of security and police • Evacuation • Medical treatment • Crisis intervention

50. Medicolegal Considerations