- The Washington Times - Sunday, February 10, 2002

Hospitals can be scary places for patients, but for doctors, nurses and others who work there they can be downright dangerous.
"Every emotion is expressed in the emergency room every day. Emotions are raw, and there's always a risk. Abusive patients and the families of patients can become violent as the result of stress," says Dr. Thomas Arnold.
Dr. Arnold, a professor of medicine and acting chairman of the emergency medicine department at Louisiana State University's Health Sciences Center, adds:
"Things [such as patient care] can never go fast enough for patients' relatives. Sometimes they object violently when other, more urgent patients are treated before their relatives. Then, too, people sometimes turn on doctors when, unfortunately, we must inform them their relative has died."
Consider what happened to Dr. Paul Matera, emergency room physician at the District's Providence Hospital.
"It was about 2 a.m. I was working on a trauma patient with numerous, serious chest and abdomen stab wounds. He was 19 or 20 years old, and very large, weighing about 250 pounds. I had been talking to him, telling him what I was doing while trying to stabilize him and keep him alive," he said.
"Suddenly he sat up and spun me around. He hit me in the back of the neck with his fist, rupturing a number of discs."
Despite the pain, Dr. Matera continued to treat his patient. He made little of the assault then or later, although it nearly crippled him.
Subsequently Dr. Matera has had three surgeries to repair the damage to his back. He says the latest surgery performed this summer has finally eased the persistent pain. Two years ago the American Medical Association awarded him its rarely presented Medal of Valor for "courage under extraordinary circumstances in non-wartime situations."
Dr. Matera's story and similar tales are being repeated these days partly as a result of the September 11 attacks. They have caused hospital administrators and medical association officials to examine whether medical facilities are equipped to cope with the consequences of other terrorist acts. In the process, they have found that many lack the ability to protect their workers even in normal times much less in periods of chaos.

Patient violence
One survey released in December asked emergency room managers and other representatives from 50 hospitals about worker safety at a national conference. It found that: "Despite the increase in concerns about bioterrorist threats, respondents cited patient violence as the number one threat to emergency department personnel."
The finding coincides with larger studies by the 154,229-member American Nurses Association. For instance, in a national, on-line survey of 4,826 nurses conducted in November, fewer than 20 percent said they felt safe in their "current working environment."
Seventeen percent of the nurses reported they had been physically assaulted in the past year. More than half said they were threatened or verbally abused.
The introduction to the Occupational Safety and Health Administration's largely ignored, voluntary Guidelines for Preventing Workplace Violence for Health Care Workers states: "More assaults occur in the health care and social services industries than in any other."
The document points out that the incidence of violence is increasing and also notes that "between 1980 and 1990, 106 occupational violence-related deaths occurred among the following health care workers: 27 pharmacists, 26 physicians, 18 registered nurses, 17 nurses's aides, and 18 health care workers in other occupational categories.
"The nursing staff at a psychiatric hospital sustained 16 assaults per 100 employees per year. This rate compares with 8.3 injuries of all types per 100 full-time workers in all industries and 14.2 per 100 full-time workers in the construction industry."
Statistics that pinpoint the number of assaults to various practitioners in different hospital departments have not been compiled. And officials of the nurses' association and the American College of Emergency Room Physicians, among others, say that about 80 percent of the cursing, pushing, slapping, punching and throwing events that occur go unreported.
Some of the victims keep quiet because they consider such things normal job hazards. Others contend hospitals and hospital management groups ignore their complaints and at times retaliate against complainers by firing them or transferring them to less desirable jobs.
Still, the Bureau of Labor Statistics this summer hinted at the dimensions of the problem. It disclosed that in 1999 health care providers were the victims in 43 percent of all nonfatal workplace assaults in the United States. The rate of assaults on health workers was five times the rate for employees in all other industries.
Half the incidents involved hitting, kicking and beating. Attacks described as "squeezing, pinching, scratching or twisting" made up 15 percent of the assaults. Biting was relatively rare, but, at 2 percent, it was twice as common as stabbing.
Nursing aides, orderlies and attendants were the victims in 61 percent of the attacks. Registered nurses were assaulted 13 percent of the time and licensed practical nurses 10 percent. Technicians, guards and police were targets also, but less often.

Lack of media attention
Compounding the problem is the fact that "incidents of hospital violence are reported in local media as isolated events. They're not usually reported nationally, and they're not seen as symptoms of what is a widespread, ongoing situation," says nurse Victoria Carroll.
Miss Carroll, a teacher of medical-surgical nursing at Northern Colorado University School of Nursing in Greeley, has been studying hospital violence for a decade. She says the public has little idea of the dangers involved in trying to save lives and heal the sick.

Dramatic cases
When pressed for examples, she and others refer to a cluster of famous and dramatic cases that occurred in the 1990s. They note, for example that:
At Alta View Hospital in Sandy, Utah, Richard Worthington, 42, shot a nurse in the back, killing her. Then he took seven other staff members hostage for 18 hours. He said he had wanted to kill the obstetrician who performed a tubal ligation on his wife. However, he failed to locate the doctor.
At the Los Angeles County-USC Medical Center, Damascio Ybarra Torres shot three emergency room doctors and took two women hostage to get back at doctors whom, he said, treated him "like an animal."
At Valley Lutheran Hospital in Mesa, Ariz., Jean Dooley, who was recovering from a hysterectomy, became upset, pulled a gun and shot a nurse and an ambulance attendant, wounding both.
At Chippenham Medical Center in Richmond, Va., Dawn Cooper, 42, strode into the emergency room and shot her ex-husband and his wife. The husband died; the wife became a quadriplegic.
Last summer, nurse Brenda Maynard testified before a health policy committee of the Michigan Legislature. She related that in June, an emotionally disturbed patient at a hospital she refrained from naming was recovering from hip replacement surgery. He became annoyed when she cautioned him to stay in bed for fear he risked re-injuring his hip.
When her back was turned, he left the bed, grabbed her by the neck with both hands and began strangling her. He promised to kill her. But she managed to break his grip.
Then he grabbed her shirt and swung her repeatedly into a wheelchair, metal table, computer station and onto the floor. He began bludgeoning her with one of the hand pumps used to inflate air mattresses, but another nurse finally arrived and saved her life.
Mrs. Maynard is on disability leave and fears the hospital will not reinstate her if she mentions where the attack occurred.

Left with the undesirables
It is common knowledge that unruly alcoholics, drug addicts, psychotics and hoodlums frequently are brought to hospital emergency rooms, and many one study says 25 percent are armed with guns, knives, blackjacks and other weapons.
Also, as Jeanne McGrayne, a former emergency room nurse, says: "The police and sheriff departments drop off at the emergency room prisoners they don't want to deal with."
Miss McGrayne, now a consultant to Irving, Texas-based VHA, a network of 2,200 community-owned health care organizations and physicians, adds:
"Often family members who are tired of dealing with Uncle John, who is drunk and violent at home, call for him to be committed.
"The rescue squad comes and takes him to the ER. There doctors have to examine him and see if he is a danger to himself or others so they can determine whether to commit him. Meanwhile, six or seven hours go by, and he's causing problems while the ER staff is trying to deal with really sick patients.
"Because no one else will care for them, the ER staff gets the dregs of society. Many times I've had to inject patients right through their clothing with a drug to calm them, they're so angry and aggressive. And into this situation we bring our 3-year-olds who fall from their tricycles and break a wrist."

Dealing with violence
All concerned know the prescription for dealing with hospital violence. Among other steps, hospitals have been advised to hire more nurses, beef up the security staff, install metal detectors, control entrances and exits to limit access, keep patients and relatives informed about what's happening and remove from waiting areas all lamps, ash trays and anything else that can be thrown or used as a weapon.
Yet hospitals frequently do not have the resources to implement the needed security measures.
"These days, hospital emergency departments are used as primary care units. They're the family doctor. They're flooded with people who come in with colds and so forth. This taxes the system and stretches resources that otherwise might be available," Dr. Arnold said.
He adds: "It's true that many hospitals would rather pay workman's comp than heighten security. When someone is killed, they will pay millions to rectify the situation. Yet a few thousand dollars or so to add staff and to train doctors, nurses and aides in violence prevention actually could remedy this situation."

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