Emergency Physicians Assaulted, in Fear at Work

Ingrid Hein

October 02, 2018

Nearly half of the more than 3500 emergency physicians who responded to a survey conducted by the American College of Emergency Physicians (ACEP) report having been spit on, punched, kicked, scratched, or bitten at work, and more than 60% of respondents say that the incident happened in the previous year.

"Nearly half of these incidents resulted in injury," said ACEP President-Elect Vidor Friedman, MD, who presented the findings at the group's scientific assembly in San Diego.

Although "the results of this poll are not a surprise," he told Medscape Medical News, they are "quite troubling."

An invitation to complete the online survey was sent by email to 32,714 current ACEP members in August. Of the 3538 physicians who completed the survey, 47% said they had been physically assaulted and 71% said they had witnessed an assault.

In addition, 24% of the respondents said they had experienced two to five violent incidents in the previous year, and 1% reported experiencing more than 10 assaults.

But it's not just physical assaults. Inappropriate comments or unwanted advances were reported by 96% of women and 80% of men who work as emergency physicians.

"And the physicians are the least likely to be affected," he pointed out. Nurses and other healthcare workers are even more likely to be victims of violence in the emergency department. "But there is gross under-reporting."

"It's a noble specialty; we don't turn anyone away," said Leigh Vinocur, MD, from the University of Maryland School of Medicine in Baltimore, who is a former chair of the ACEP committee on emergency department violence.

We get into medicine because we are compassionate and recognize that this behavior can be part of the disease process, she told Medscape Medical News.

The first time Vinocur was assaulted was by a patient suffering from a drug overdose who had presented to emergency.

"An intern gave the patient a big dose of Narcan — a drug used to reverse the effect of opioids — directly into his IV. He bolted," said Vinocur. "He started screaming that we ruined his high."

"He grabbed me by the throat and started choking me. Most of the team scattered," she recalled. "My necklace broke. Then the radiology tech put him in a chokehold." And Vinocur said she vowed to never wear jewelry to work again.

More needs to be done to protect medical staff and ensure that patients don't suffer the consequences, Friedman said.

"We need better law enforcement and better security," he explained. "We have to develop a culture of zero tolerance." This is an "ever-growing problem," he pointed out, "but we don't know if it's because people are starting to report it, or if there's an increase."

Changes in Violence

Fear in the workplace is increasing, according to results from a study that looked at changes in the incidence of violence in the emergency department over a 13-year period, which was also presented at ACEP today.

Surveys looking at violence in an emergency department in Michigan were conducted in 2005 and 2018 by Terry Kowalenko, MD, from the Oakland University William Beaumont School of Medicine in Michigan, and his colleagues.

The team compared data from 268 respondents who responded online from each of the 2 years.

Emergency physicians experienced a 10% increase in physical assaults from 2005 to 2018 (38.1% vs 28.1%). The percentage of respondents who reported experiencing "any" type of violence remained stable over the study period, at about 72%.

And respondents reporting "feeling fear at work" increased from 1.2% in 2005 to 8.1% in 2018.

We're not saying that every ER needs a metal detector, but it needs to be something the institution takes seriously.

An increase in security guards, cameras, metal detectors, and visitor screening might be needed. "We're not saying that every ER needs a metal detector, but it needs to be something the institution takes seriously," said Kowalenko.

"We would like to do the front-end stuff — security and de-escalation — better," he added.

Under-reporting is a big problem, he explained. Only 3% of respondents to the ACEP survey said they pressed charges for an incident of assault. Many people are under the impression that law enforcement does not support them.

"We know of a nurse who brought a civil suit against someone and was told, "you knew what you were getting into; this is part of the job," Kowalenko said.

Although reporting is important, education for healthcare workers is key. In many states, such assaults are felonies, but the downside is that a victim has to make a complaint, he added.

Recognizing the Signs

Vigilance and a constant awareness of potential behavioral changes are important, Vinocur said, as is training on de-escalation.

"Is this a victim of gang violence, or is it related to gang violence? Substance abuse? Are they manic?" she asked. "You have to make sure you don't let them get between you and an exit."

He grabbed me by the throat and started choking me.

Much of the time, violence in the emergency department can be attributed to drug abuse, overcrowding, or the boarding of psychiatric patients who are waiting for a bed and appropriate treatment, she said. "The emergency room is a reflection of society as a whole."

Friedman, Kowalenko, and Vinocur have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2018 Scientific Assembly. Presented October 2, 2018.

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