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The Violent Patient


Being called to manage a violent patient can be one of the most anxiety-provoking and difficult tasks asked of a psychiatrist. Often, the phone call is from a nurse or another physician who is frightened of a patient and in a situation that is out of their control. The call may be from the emergency room of a hospital or from an inpatient psychiatric or medical unit. As a psychiatrist on call, you are expected to be the team leader in a multidisciplinary approach to help maintain the safety of the patient and those in the immediate vicinity. You may feel that you are expected to single-handedly make the patient nonviolent and make the staff and other patients feel safe and comfortable again. Because violent behavior or threat of violent behavior is often already in progress at the time you receive the call, you are asked to arrive right away and have immediate solutions. Behavioral emergencies are complex and difficult, as they require ongoing evaluation and changes in management strategy as new information becomes available. There is a sense of urgency; however, we often do not know a diagnosis, and there is limited time for decision making.

To be effective at helping to restore a safe environment, it is essential that you take a moment to collect your thoughts and prepare yourself to interact as calmly, clearly, and directly as possible with people who are upset and dangerous. Remember that you are being called on to do your best to prevent any harm to yourself and others, and you will need the support of other staff members. This chapter helps you to approach and manage the violent patient in a stepwise fashion beginning with the initial phone call through the bedside evaluation and management.

Phone call

Questions

These questions are in the order that you might ask them when called to deal with a violent patient. Depending on the acuity of the situation, you may have to ask some of these questions on the scene. The answers will determine how you will manage the situation, as seen later in the “Bedside” and “Management” sections.

  • 1.

    Where is the patient located? (emergency room, inpatient psychiatric unit, inpatient medical unit)

  • 2.

    What is the patient doing right now?

  • 3.

    Does the patient appear threatening, or has he or she verbally threatened violence or already behaved in a violent manner?

  • 4.

    Has anyone been injured, and, if so, how badly?

  • 5.

    Have security personnel been called, and are they at the scene?

  • 6.

    Does the patient have access to weapons of violence, including hospital furniture and medical equipment?

  • 7.

    Is the patient psychotic or delirious? What is/are the patient’s psychiatric diagnosis/diagnoses, including substance abuse?

  • 8.

    Does the patient have any medical illnesses?

  • 9.

    Are medications and restraints ready for immediate use?

Orders

  • 1.

    Call hospital police to the area if this has not been done already.

  • 2.

    Have as-needed (PRN) medication, both orally (PO) and intramuscularly (IM), available to be administered, even if the patient has already received PRN medication (the patient may need more than the first PRN dose). If there is no standing order for PRN medication, haloperidol (Haldol) and lorazepam (Ativan) should be ready for use on arrival.

  • 3.

    Remove any potentially dangerous materials and attempt to keep other patients away from the vicinity of the patient.

  • 4.

    Have restraints and the seclusion room ready for use if necessary.

Inform RN

“Will arrive in … minutes.”

This situation should become your top priority, and you should make every attempt to make it to the scene as quickly as possible.

Elevator thoughts

What issue(s) might be at the root of a patient’s violent or potentially violent behavior?

  • First attempt to rule out medical illnesses leading to agitation including delirium (from multiple medical etiologies including infection, electrolyte abnormalities, myocardial infarction), agitation associated with dementia, and cognitive deficits including developmental disabilities

  • Next consider agitation and violence stemming from substance intoxication (cocaine, amphetamines, and phencyclidine [PCP]) or withdrawal (alcohol, opiates, and benzodiazepines)

  • Then consider different psychiatric etiologies including:

    • Psychosis (paranoia, command or noncommand hallucinations)

    • Manic symptoms (grandiosity, psychomotor agitation, irritability, psychosis)

    • Akathisia (feeling of inner restlessness and a need to be in constant motion) from antipsychotic medication

    • Impulsivity/explosiveness

    • Dissociative state

    • Poor frustration tolerance/needs not being met or perceived as not being met

    • Avoidance of an undesirable situation (e.g., incarceration, transfer)

Again, take the time on the way to the scene to assess your own demeanor, take a deep breath, and remember that you will be most helpful and a more effective team leader if you are a calming, rational presence.

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