Sunday, February 27, 2005
Copyright © Las Vegas Review-Journal

Emergency room violence concerns health care workers

University Medical Center Public Safety Supervisor Lt. Leonard Griffin sits at the security desk in the hospital emergency room. Photo by Clint Karlsen.

The sound of the fist shattering his nose echoed in the doctor's head.

"I'm going to kill you," the patient shouted, throwing another punch.

Reeling from a blow to the face that left him choking on his own blood, the emergency room physician, struggling to regain his vision, dropped his clipboard and desperately wrestled with the man he had been trying to help.

It wasn't a scene from television's "ER." Dr. David Golan was part of a real-life drama played out last March at University Medical Center.

A 6-foot, 180-pound fitness enthusiast, Golan was staggering from the punches. But he managed to get his patient in a headlock, pulling him around the treatment room.

Another doctor rushed to help his colleague. Together, with help from security, they tackled the man to the bloody floor, where a nurse injected him with a sedative.

"We appear to be waiting until someone is killed before we take the right security steps in emergency rooms," said Golan, whose face was so badly beaten he required plastic surgery. "And I'm not talking just about medical personnel. Other patients can be part of this intolerable situation, too."

Caregivers like Golan say violence in emergency rooms and toward emergency response personnel is a real concern, especially considering they have to work directly with volatile people who may be intoxicated, on drugs or have a history of mental disorders. Legislators have recognized the issue as well, and in 2003 upped the crime to a felony to commit a battery or assault on a health care provider.

The American College of Emergency Physicians thinks emergency room violence is serious enough to do studies on it.

A survey of emergency room physicians in Michigan released this month found that in the past year, nearly 75 percent had been subject to verbal threats; 28 percent were victims of physical assaults; 11 percent were confronted outside the emergency department; and 3.5 percent experienced stalking events.

"Though this study dealt only with Michigan, we believe we're talking about a nationwide problem," said Dr. Todd Taylor, a spokesman for the national medical body.

Whether those statistics track with what occurs in Southern Nevada is anybody's guess. They either aren't kept, aren't released, or are admittedly incomplete.

Dr. Dale Carrison, director of the emergency department at UMC and chairman of the state Homeland Security Commission, said hostile behavior toward doctors and nurses in emergency rooms is "no stranger" to every hospital in the Las Vegas Valley. He said "that a day doesn't go by" when abuse that shouldn't be tolerated is experienced by medical personnel.

Some health care workers wonder if security efforts used in Las Vegas afford enough protection. Security often consists of unarmed guards, cameras and a locked door to the inner workings of emergency departments.

Although emergency personnel receive psychological training to defuse situations, they say more liberal use of physical restraints on psychiatric patients, coupled with metal detectors to screen out weapons, may be necessary.

"I got thrown up against the wall in the UMC emergency room by somebody who I'm sure was on drugs," said 72-year-old Arlene Gilbert, who retired last week after 50 years as a registered nurse. "It's very, very scary. Something more has to be done about that sort of thing."

Dr. Gary Joseph Goldberg, an associate medical director of the Sunrise Hospital emergency room, prides himself "on being able to talk people down" who are confrontational.

Still, Goldberg worries that abuse toward health care workers at Sunrise will increase now that the hospital has joined UMC as a trauma center in the Las Vegas Valley.

The idea of a metal detector to screen out weapons "should be explored," he said.

At other major trauma centers across the country, trauma center personnel have become innocent victims of mental patients or drug- or gang-related vendettas.

No one knows that better than Golan. Before his arrival in Las Vegas in 1994, three of his colleagues in the University of Southern California emergency room were shot by a deranged patient. Two of the three can no longer practice medicine.

"I was very lucky," Golan said. "I got caught up in a conversation or I would have been there, too. They put in metal detectors after my friends got shot."

UMC's Carrison, who says guns have been found on some patients, isn't sure metal detectors would be helpful. He said experience has shown in airports that someone who wants to get a gun past authorities generally can.

Carrison, a former FBI agent, said the cost of hiring people to man detectors could be problematic.

Brent Hall, an emergency medical supervisor with the Clark County Fire Department, has brought many people to emergency rooms.

Though he said he and his staff are adept at defusing situations, he has been "bruised" by violent patients or their friends.

"It's usually a loss of life that brings about this kind of change," he said of the installation of metal detectors. "It would be nice if we could learn from other people's situations instead of acting like it can't happen here."

Las Vegas police Lt. Craig Platt, who helps direct the command area that includes UMC, said a combination of hospital security and police has been able to "de-escalate gang situations" that arise there. Once gang members realize everything is being done for their wounded comrades they settle down, he said.

Hospital security does a good job defusing situations, he said.

The National Institute for Occupational Safety and Health reports that long waits for service are a major factor in provoking hostile behavior among people who already are under stress.

Long waits are a growing problem in the Las Vegas Valley, as mental patients take up emergency room bed space meant for people with physical ailments.

An institute study in 2002 of violence in hospitals, though not focusing strictly on emergency rooms, reported there are 8.3 assaults per 10,000 workers, much higher than the rate of nonfatal assaults for all private-sector industries, which is 2 per 10,000 workers.

The study reported that a security screening system in a Detroit hospital may have saved lives or injuries. Stationary metal detectors supplemented by hand-held units prevented the entry of 33 handguns, 1,324 knives and 97 Mace-type sprays during a six-month period.

Las Vegas law enforcement authorities, who file reports by address, don't break out statistics on what happens in emergency rooms.

UMC was the only hospital that would release any data involving emergency room violence to the Review-Journal.

But Cheryl Persinger, a UMC spokeswoman, said it's probable the documentation is incomplete. That, she said, is because people who go into the health care arena "want to help people and probably tolerate more than they should."

"Our administration wants them to start reporting more of what happens," she said.

In 2004, Persinger said, there were eight disturbances at the adult emergency room and trauma unit involving altercations instigated by either patients or visitors.

One of those involved Dr. Golan's battle. The information does not include specific details or whether anyone was turned over to police.

UMC also took 13 "informational reports" at the two units. In those cases, security just filed a report about something that concerned an employee. There were also six reports of trespassing, in which people who may have been verbally abusive were asked to leave.

For-profit hospitals, which make up the largest health care presence in the Las Vegas Valley, refuse to divulge statistics. Some of their emergency room personnel, including Dr. Goldberg at Sunrise, do have safety concerns, however.

Amy Stevens, a public relations executive who oversees marketing efforts at Sunrise, Southern Hills and MountainView hospitals, said she consulted with Mike Tymczyn, who controls public relations efforts for Valley, Spring Valley, Desert Springs and Summerlin hospitals, and concluded they would rather not divulge information about violence.

"We just want people to know that they have a safe place to come to," she said.

Tymczyn said not talking publicly about security concerns at Valley Health System hospitals will help "prevent acts of terror."

Spokesmen for the St. Rose Dominican Hospitals and North Vista Hospital also refused to release statistics.

North Las Vegas police officer Tim Bedford says North Vista is fortunate when it comes to hospital violence. "They have the North Las Vegas Police Department literally right next door, so nothing can really get out of hand," he said.

Pam Turner, director of emergency services at Valley Hospital, said there probably is unwanted physical contact with her staff by patients or visitors two or three times a month. Verbal abuse, she said, is the largest problem.

Last month, she said, she was threatened by a visitor who wanted a loved one cared for a certain way. "He said, `I will hurt you. I will come back and find you.' "

Golan said the beating he received the night of March 27, 2004, could easily have been prevented. He said UMC didn't take any preventive steps as a result, so he quit and took an emergency room physician position at the St. Rose Dominican Hospitals.

The man who assaulted him, he said, told the nurse when he came into the emergency room he was a schizophrenic and voices were urging him to kill people.

"He was then taken back to a waiting area and left alone," Golan said. "Even though he appeared calm, action should have been taken right then. No one even checked him for weapons. We were just lucky he didn't have anything other than his fists."

Golan said he was trained with a simple rule: If someone said they were homicidal or suicidal, they were to be believed. Golan said just because someone is initially calm, it does not mean no action should be taken.

In the past, he said, security would immediately be brought to the scene when a person said he was going to do harm to himself or others. A search would be conducted as the individual was disrobed. The person was then put in a gown and in restraints.

"The idea is that someone seeing overwhelming force and being put in restraints doesn't allow the violence he's talking about to be carried out," Golan said. "It is the safest way to deal with a problem for everybody."

Restraints, however, are no longer used the way Golan used them at USC or for his first six years at UMC.

The Joint Commission on Accreditation of Healthcare Organizations, which sets standards for medical institutions, decided in 2001 restraints should seldom be used.

Dr. Mary Cesare-Murphy, executive director of behavioral health accreditation for the commission, said last week that "our standards don't prohibit restraints, but they put emphasis on using them only as a last resort."

In some cases they can be dangerous, and, she said, even result in deaths.

But Golan said if leather restraints are used correctly and sedation is administered, no patients should be injured or killed.

"What is happening in emergency rooms is just insane," he said. "We give people who say they're going to kill people a chance to do it. No restraints, no metal detectors. The truth is, I think emergency room policies are crazier than some of the people we see."