11 Investigates: Violence in the ER

11 Investigates: Violence in the ER

TOLEDO (WTOL) - Dr. Terry Kowalenko, a former emergency room physician in Michigan, was barely into his career when he waited on a man seeking to be prescribed a narcotic.

“I did not give it to him. He told me, ‘I know your shift ends at 11, and I know where the doctors’ parking lot is. I’ll be there waiting for you,’” he says. “That still sticks with me. He looked like a guy who could do harm.”

Dr. Kowalenko has authored numerous studies on violence in emergency departments. The latest report he had a hand in was released by the American College of Emergency Physicians in October.

According to that study, nearly half of the doctors polled have been assaulted at work and 70 percent of emergency room doctors say violence in ERs is increasing.

Perhaps most worrisome to the everyday patient is that 80 percent of those who say violence is increasing believe that violence has directly impacted patient care.

“It does. Instead of having one nurse handle a patient, several will. If there is a situation that requires more than a handful of nurses, it takes time away from other patients,” says Jessica Nelson, who has been a nurse at the University of Toledo Medical College for close to eight years and has been in the ER for five.

Patient care was one of the concerning findings for ACEP, because many people are already disgruntled by long waits during ER visits.

“When violence occurs in an emergency department, patients can be injured or traumatized to the point of leaving without being seen,” said Dr. Vidor Friedman, the president of ACEP. “It also can increase wait times and distract emergency staff from focusing on other patients who urgently require a physician’s assistance.”

In Toledo, UTMC, Toledo Hospital, and Mercy St. Vincent Medical Center have security procedures in place if a gunshot victim is brought to the ER. If a suspect is on the loose, an ER can be locked down. Patients will still be treated, but there could be longer waits and screenings that family members may have to endure.

But the bigger concern is the increasing violence that health care workers are facing. There are studies and reports that have pointed to real, daily danger faced by emergency department employees. A recent Annals of Emergency Medicine survey of Michigan ERs found that 72 percent of ER physicians experienced violence in the past year. According to the Bureau of Labor and Statistics, “intentional” injuries against hospital workers have increased nearly 50 percent between 2011 and 2016 – from 6.4 per 10,000 to 9.0 per 10,000.

In Toledo, police responded to emergency rooms at St. Vincent, UTMC, and Toledo Hospital more than 350 times through November. Some of those visits were to collect information from witnesses or victims, but several of them involved fights, assaults, or menacing behavior.

Close to 30 states have made it a felony to assault a health-care worker, including in Ohio, where it is a fifth degree felony. But the increased criminal penalties have coincided with an opioid epidemic that has ravaged the nation, and particularly Ohio. The increasing number of heroin and opioid users has meant not only a surge in patients needing to be revived by Naloxone but also in patients who are angry and violent in the emergency room.

“We are in the thick of an opioid epidemic. We see individuals who display behaviors that are not representative of who they are,” says Dr. Brian Kaminski, vice president of quality and patient safety for ProMedica Systems. “We see bad behaviors that are driven by the addiction and substance abuse problem.”

Even more than doctors, nurses bear the brunt of much of the bad behavior as they work to stabilize patients before doctors even arrive in the room. Close to 80 percent of ER violence occurs in a patient’s room, according to the ACEP report.

“I don’t know if I’ve ever met a nurse – in the ER or not – who has not had violence brought to their person,” says Nelson.

Health Insurance Portability and Accountability Act protections prohibit nurses or doctors from discussing specific cases, but it was clear when WTOL talked to seven current or former nurses and two doctors that the ER can be a dangerous place, and it is only growing more dangerous.

Why is this happening?:

  • Patients are coming to the hospital in pain, scared, and  sometimes impaired, deluded, or demented. The recent surge in violence has  coincided with the opioid epidemic. 
  • Psychiatric patients often get processed through the ER  because of a shortage of beds at mental health facilities.
  • Emergency rooms have long waits for service. The more  minor the injury or illness, the longer the wait as more serious cases  take precedence.
  • Nurses and doctors work in conditions that involve  needles, catheters, narcotics, and long, hectic hours.
  • An increasing number of people are carrying guns or  other weapons.

“We talk about STAMP – staring, verbal tone, anxiety, mumbling, and pacing. These have proven to be indicators that lead to violent behavior,” says Susanne Brue, associate chair of clinical education in the nursing program at Lourdes University in Sylvania. “I instruct students to have nothing between you and the door, know the (police and security) resources they have available, and know the warning signs so they can put all the pieces together.”

Lourdes is one of the top nursing programs in the region, with 365 students currently enrolled. The faculty has decades of experience – good and bad. Some of the best lessons result from their personal stories. Bob Ingram, an assistant professor in the college of nursing, was working at Detroit Receiving Hospital when a mother of a patient knocked him out with no provocation. Hollis Hamilton, the dean of nursing, was riding in an elevator with another nurse in Dallas when a woman on steroids stepped onto the elevator and physically assaulted both of them.

“Nursing students need to learn to develop situational awareness,” Hamilton says. “You can’t daydream in nursing. You have to constantly be thinking about what’s going on.”

But it’s not just the violence that concerns those in the field or those studying the issues facing our emergency workers. Medical workers see a lot of things during a 12-hour shift. An ER doctor or nurse may have to treat a patient for a migraine, then go next door and have a young person die in their hands.

“You do CPR on a kid or you see a baby come in with the hand of a fireman on him doing compressions … those days stick with you forever,” says Kevin Kraus, who is in his 13th year in UTMC’s emergency room.

When his shift ends, Kraus pops in a CD, listens to music, or, better yet, finds sports to listen to on his 40-minute drive home.

“Sports is the best drug in the world, he says, chuckling. “It’s free and no side effects.”

For Kraus and others interviewed for this WTOL report, they all praised the security, counseling, and pastoral services offered by their hospitals. The hospitals go above and beyond to create a safe environment for their staffs. But the workers also emphasized the solace they find among co-workers. Katie Frisch, who has been in the Toledo Hospital ER for four years, says dinners and conversations with others from the ER help her cope with the stress and tragedy.

“We are a family,” she says. “We might just hang out outside work, or I’ll go home and watch Netflix or read, something to get me off what happened during that day.”

Besides listening to a game, Kraus will grab some french fries on the way home after a tough day.

Nelson reiterated the family atmosphere that develops among ER workers, forged by shared experiences – the patients who are saved and those who are not. There are outings to Mud Hens games, play dates with workers’ children. There was even a trip to a pumpkin patch in October.

“We’re a different sort down here. We really are a family – the doctors and nurses. It’s so nice to have the support of the administration,” she says.

Nelson lost her daughter shortly after birth. That experience allowed her to empathize even more closely with families losing loved ones – or even experiencing a life-changing event -in the emergency room. Three years ago, her and other ER workers began sending out sympathy cards.

“I’ve found solace in sending the cards to patients and their families, to let them know that this does affect us. We are still thinking about these people. They go home with us. We carry them with us throughout our careers,” Nelson says.

Emergency department workers are facing escalating violence and compiling memories that will never leave them, but they are committed to handling that stress with grace and ensuring quality care for everyone they see – whether it is a gunshot victim or someone with chronic back pain.

“Not everybody can work in the emergency department. You might have one patient who is in the process of giving birth; the next patient is in the process of dying; the next person has had a stroke; and the fourth patient has a sore toe that has been bothering them for six months and is yelling and screaming more than the other three,” Ingram says. “You never know what will happen.”

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