The Combative and Difficult Patient

Foundations

Combative patients are among the most difficult patients encountered by emergency clinicians. Often brought in against their will, they can be agitated, confrontational, difficult to examine, and they may physically harm themselves or others. The emergency clinician should seek to control the patient and the situation, diagnose and treat reversible causes of violence, ensure that there is not an organic cause contributing to the behavior, and protect the patient, staff, and other patients from harm.

The emergency department (ED) is a volatile environment owing to high stress, illness, prolonged waiting times, and often perceived gaps in communication. Given that the ED is open 24 hours a day, 7 days a week, combined with the availability of potential hostages and accessibility to drugs or weapons, compound the potential for violent behavior. The assault-injury rate of health care occupations is nearly 10 times that of the general sector, and over half of all health care providers will be victims of violence of some form during their careers.

Emergency care providers throughout the world are more likely than other health care providers to experience violent events, such as verbal threats, physical assaults, or confrontations outside the workplace. In 2018, The American College of Emergency Physicians (ACEP) conducted a poll of 3539 emergency physicians across the country in which nearly 50% reported having been assaulted while at work in the ED, with over 70% having witnessed an assault in the workplace. In this survey, nearly all assaults were committed by the patient (97%), but in 28%, it was reported that family or friends acted as an accessory. Similar rates of violence and aggression toward physician and nursing staff are typically observed, and both men and women generally appear to be at comparable risk. ^, Violent incidents are far more likely to be verbal threats or acts of intimidation than physical assaults and, in the ED, may be acted out by patients, as well as their family, friends, or other visitors. The actions of combative patients have consequences that extend beyond the physical injury of ED caregivers, such as provider posttraumatic stress disorder symptoms or lost provider work productivity, and also serve as a major contributor to burnout. ^,

Clinical Presentation

Initial Patient Evaluation

Evaluation of the combative patient begins with attention to safety measures. All patients should be screened for weapons before the interview. The use of metal detection is ideal upon ED entry, and additional attention may be needed for patients brought to the ED by ambulance and thereby bypassing routine security screens. The practice of undressing patients and placing them in a gown is useful as a non-confrontational survey for potential weapons that also discourages fleeing in some circumstances or, conversely, aids in identification if a violent patient suddenly flees from the ED.

The ideal setting for the patient interview emphasizes privacy without isolation, such as a seclusion room specifically designed for the interview of potentially dangerous patients. Prior to the medical interview, security should be stationed strategically and the door left open to facilitate both intervention and escape for the provider. The patient and interviewer may be seated roughly equidistant from the door, or the interviewer may sit between the patient and the door. Blocking of the door, however, poses a risk of harm to the clinician if the patient feels the urge to escape. Ideally, examination room doors should swing out, and more than one exit should be available. The clinician should have unrestricted access to the door and avoid sitting behind a desk. The room should not contain heavy or potentially dangerous objects that may be thrown. There ideally should be a mechanism to alert others of danger, such as a panic button or a code word or phrase that summons security (e.g., “I need ‘Dr. Armstrong’ in here.”). For personal protection of the provider, earrings, necklaces, and neckties should be removed. Personal accessories that may be used against the caregiver, such as a stethoscope or scissors, should also be removed. The clinician should be aware of any objects within the room or on the patient’s body that might be used as weapons, such as pens, watches, necklaces, key chains, cell phones, or belts.

Violence risk assessment of a potentially combative patient can be difficult. Violence often erupts after a period of mounting tension. The astute practitioner may identify verbal or nonverbal cues and may subsequently have the opportunity to defuse the situation. In a typical scenario, the patient first becomes angry, then resists authority, and finally becomes confrontational and violent. When clinicians have a “gut feeling” that a dangerous situation may be developing, they should take appropriate precautions. Violent behavior may also erupt without warning, especially in patients with an organic brain syndrome, so clinicians should not feel overly confident in their ability to sense impending danger. An obviously angry ED patient should be considered potentially violent. Patients with a history of violent behavior are more likely to inflict serious injury, and certain patient behaviors may suggest impending violence ( Box 185.3 ).

To prevent escalation, the patient should be removed from contact with other agitated accomplices, as well as from other provocative patients. A quiet area enabling direct observation is optimal. Because increased waiting times correlate positively with violent behavior, consider evaluating the potentially violent patient accelerated to prevent escalation of aggression. When feasible, expeditious triage and evaluation of these patients may avoid the challenging consequences of violence for the patient at hand, the ED staff, and ultimately the care of other ED patients. Often, the perception of preferential treatment alone may serve to defuse the patient’s anger.