Duty to Violent/ Aggressive Patients

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We aren't trained security personnel or law enforcement. If a patient tries to leave, I won't stop them. If they are mentally unfit then we call 911 and have PD drag them back in. I work in one FSED with no security, so I think about this frequently.

You'd better believe that if you get hurt trying to restrain a patient, your worker's comp isn't going to pay for it, and if you inadvertently hurt a patient, their attorneys will hang you out to dry.

Obviously if one of my employee's life is threatened and I need to act, I will. But use common sense. I'm not going to tackle and wrestle Meth Man because my hospital won't staff security officers properly.
 
This is my clinical pathway:

1. A-hole with capacity hurts people/breaks things/threatens anyone -> PD, jail
2. A-hole with capacity just wants to leave -> bye, DC, GTFO
3. Person with a medical emergency/delirium where they aren't competent to refuse care or leave -> sedation, restraints, intubation if needed to facilitate care if critically ill.
4. Person with a medical emergency/delirium where they aren't competent to refuse care or leave but manage to get out of bed and manage to walk out -> PD, then go to step #3
 
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Fox800 said:
3. Person with a medical emergency/delirium where they aren't competent to refuse care or leave -> sedation, restraints, intubation if needed to facilitate care if critically ill.
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This I think is the most important point.

If you can defend the fact that a patient is just being rude or is a sociopath that is threatening physical violence, they get security/PD/AMA, whatever TF you need to get them out.

The problem I find is in the drunk A-holes. I'm pretty liberal giving them Haldol, ketamine, or something to put them down. I've had to intubate a few, and if all they have is ETOH on board I let them metabolize off and extubate/discharge vs admit to the unit depending on how busy it is.
 
I don't get involved in restraining/catching patients. I don't know if other staff (nurses and other non-security) are trained or supposed to be involved, and I stay out of that decision. Not enough security? Then they can walk, run, destroy the room, whatever they want.
 
I think @Fox800 has a good algorithm. It just depends on the situation. Most of the times if they are competent and clinically sober, I will have security and police remove them from the ER. It's not worth risking injury to staff or myself for that matter. However, how many of our patients are truly competent and "clinically sober"? There's a big gray area that sometimes dictates the need for restraints and sedation to ensure staff safety, pt safety and allows you to rule out anything emergent going on. I don't think there's a single correct answer all the time, you just do what you think is best given the circumstances.

One time I had this angry drunk who tried to strangle one of my nurses with oxygen tubing. By the time I got back there he was trying to hang himself with a bedsheet. I paralyzed him, intubated him, moved him to one of my resus bays and extubated him later on in my shift, observed him for a little while and sent him to our psych assessment center. A tad aggressive, but he was diverting almost all of the ED resources during his conniption fit. Luckily, I don't have too many pt's like that.

Ketamine 0.3-0.4mg/kg IM will work wonders.

This discussion made me chuckle. My younger self used to get all gung ho in residency when restringing these guys and would help the nurses jump on them and hold them down. We had this one burly gigantic dude that we were trying to dart with Geodon and he was in leather restraints (The big leather straps). I went over to dart him and he power kicks his leg and completely tears through the leather strap and side kicks me in the head and I careened over into the wall and put a big dent in the dry wall. I slid down with a bent needle and was shaking my head trying to figure out what the hell I was doing in this room and why I was on the floor. LOL, after that incident I figured maybe jumping on these guys and helping with the restraining was not in the best interests of my health.
 
Yeah it all depends on the decision making capacity. If the patient is a danger to themselves or others because they are delirious and violent, you can be held liable. Someone so drunk they can barely walk goes out and falls into traffic? Your fault if you let them walk. Someone high off bath salts physically violent and out of their mind who storms out and attacks a bystander? Your fault.

If someone is just angry and belligerent because they are just an awful person, then its totally fine to just let them go if they want (unless lets say they were suicidal and holding a gun to their head earlier in the day and are being held on a psych hold). But if someone is clearly delirious, you can't just let them walk.

As others have said, ketamine is a great drug in these situations. IM in the thigh and they go down. Then you can strap them to the bed safely and easily. It's pretty rare that I've had to intubate someone for social reasons, though it can happen. I had a bath salts patient not too long ago break through hard restraints twice that I had to. But I'd imagine I intubate someone for violent agitation less than once a year.
 
Mr. Hat said:
So then here’s what I’m getting at though. If I call security and they don’t respond in time to stop the patient leaving, is it still my fault? And then if I call PD but they don’t get to the person in time to stop the adverse event, is it still my fault? In other words, are you saying that I am under obligation to personally restrain these people to stop them from leaving if security doesn’t get there in time, to put myself and my staff at risk, even though I’m not trained and can’t carry a weapon, because if I don’t then I will be at fault?
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Depends. You absolutely will be considered at fault if say a patient is so drunk they can’t walk straight, says they are going to go kill themself, goes to leave, staggers out, and walks into traffic. Yeah, if you let that happen, you will be at fault.

You do have a weapon. Its ketamine. It works longer than stun guns do.

There’s a lot of grey area here, obviously. Not every case is straight forward as I mentioned above. I’m sure there are some cases you’d get away with letting a violent patient go. But if they don’t appear to exhibit decision making capacity, they are your responsibility.
 
Mr. Hat said:
So then here’s what I’m getting at though. If I call security and they don’t respond in time to stop the patient leaving, is it still my fault? And then if I call PD but they don’t get to the person in time to stop the adverse event, is it still my fault? In other words, are you saying that I am under obligation to personally restrain these people to stop them from leaving if security doesn’t get there in time, to put myself and my staff at risk, even though I’m not trained and can’t carry a weapon, because if I don’t then I will be at fault?
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No. You did your duty. There is gray area where you can give sedating medications and handle the patient, but at some point it becomes too dangerous. Your duties do not include physically restraining violent patients without security or LE assistance. At our EDs we are told to not touch these people, if they are with it enough or strong enough to jump out of bed, we should let them walk out the door if security is not there - they will chase them down/attempt to locate.

This is in a southern state where we have very liberal use of force laws, too.
 
I will say though like anything else with malpractice, I’m sure this highly depends on your individual state laws and case law. Any questions about who you can or can’t hold should probably be addressed with risk management.
 
Fox800 said:
No. You did your duty. There is gray area where you can give sedating medications and handle the patient, but at some point it becomes too dangerous. Your duties do not include physically restraining violent patients without security or LE assistance. At our EDs we are told to not touch these people, if they are with it enough or strong enough to jump out of bed, we should let them walk out the door if security is not there - they will chase them down/attempt to locate.

This is in a southern state where we have very liberal use of force laws, too.
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Yeah, too be honest, I don’t think I’ve ever worked in a hospital where security wasn’t immediately available to hold someone down. Patients don’t go from zero to 100% violent. It’s usually obvious when a situation starts to escalate. You personally shouldn’t ever have to tackle someone, I agree. But why would it ever get to that point in the first place? Is security not in the ED? Even if there is a short delay in their response, didn’t anyone see this coming? IDK. I just never in a decade as an attending have been in a position where I’ve personally thought I’d need to tackle someone.
 
I used to be more aggressive about holding people. We do have an obligation to all patients.

Now I have kids. My obligation of coming home safe to my wife and kids supersedes my obligation to my patients.
 
gamerEMdoc said:
Yeah, too be honest, I don’t think I’ve ever worked in a hospital where security wasn’t immediately available to hold someone down. Patients don’t go from zero to 100% violent. It’s usually obvious when a situation starts to escalate. You personally shouldn’t ever have to tackle someone, I agree. But why would it ever get to that point in the first place? Is security not in the ED? Even if there is a short delay in their response, didn’t anyone see this coming? IDK. I just never in a decade as an attending have been in a position where I’ve personally thought I’d need to tackle someone.
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I work in one FSED with no security, and our medium-sized double coverage ED. I did recently have a patient that was brought in for "drug intoxication" rip out her IV, scream at everyone, and run out the door before security (who's desk is less than 100 feet away) could show up...
 
Let's say you're one of my small, female colleagues working the overnight at our tiny freestanding ED with two geriatric nurses. You mean to tell me that if a 6' 5" 400 lb linebacker woke up from his intoxication and decided he wanted to leave, but lacked capacity, they would have a responsibility to try to physically restain him? What if they're still holding on to him when he gets out into the parking lot? Can they let go then, or do they have to wait until he's on a public street?
 
Xerxes1729 said:
Let's say you're one of my small, female colleagues working the overnight at our tiny freestanding ED with two geriatric nurses. You mean to tell me that if a 6' 5" 400 lb linebacker woke up from his intoxication and decided he wanted to leave, but lacked capacity, they would have a responsibility to try to physically restain him? What if they're still holding on to him when he gets out into the parking lot? Can they let go then, or do they have to wait until he's on a public street?
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Weird situation but some big guy (about 6'6, maybe low to mid 300lb range) having acute psychosis in the ED and flipping out. Security was overwhelmed and I physically had to step in to help and it ended in a physical 1 on 1 restraining session until security and nurses could help out. I'm 6'2 and 245lb/very muscular; common sense dictates that I step in to help rather than let everyone get assaulted.

Not sure why other doctors couldn't?
 
Never ever help restrain a patient. It's not worth it. Document de-escalation attempts, that you asked them to leave, and that you called PD when the walked out. It's not worth permanent injury over this. I doubt there has ever been a suit where a doctor was named because he/she didn't personally, physically restrain a person. That would be a tough sell to a lawyer.
 
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Drunk patient lawsuit highlights hospital risk management issues

A recent court ruling should motivate hospital risk managers to conduct a careful periodic review of their facility’s procedures and legal obligations when it comes to treating intoxicated patients.
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gamerEMdoc said:
Yeah it all depends on the decision making capacity. If the patient is a danger to themselves or others because they are delirious and violent, you can be held liable. Someone so drunk they can barely walk goes out and falls into traffic? Your fault if you let them walk. Someone high off bath salts physically violent and out of their mind who storms out and attacks a bystander? Your fault.

If someone is just angry and belligerent because they are just an awful person, then its totally fine to just let them go if they want (unless lets say they were suicidal and holding a gun to their head earlier in the day and are being held on a psych hold). But if someone is clearly delirious, you can't just let them walk.

As others have said, ketamine is a great drug in these situations. IM in the thigh and they go down. Then you can strap them to the bed safely and easily. It's pretty rare that I've had to intubate someone for social reasons, though it can happen. I had a bath salts patient not too long ago break through hard restraints twice that I had to. But I'd imagine I intubate someone for violent agitation less than once a year.
Click to expand...
 
I never restrain anyone. Not my job. I personally give ketamine myself because state nursing board forbids nurses from administering it in non-intubated patients.

I'm blessed to have about 4 security guards (armed with both guns and TASER's) and a police officer 24/7. Violence is not tolerated in my ER. In fact, there are signs all over the ER that say so.
 
MedicineZ0Z said:
Not sure why other doctors couldn't?
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Because if the patient gets injured, you're going to get hosed. And unless you're really, really well trained in restraint techniques, any injury and the lawyers will own you.
You are not security/police (probably). Even if you are police, when you're working clinically you're not.
 
Dr.McNinja said:
Negative ghostrider. Case law already says you are not responsible for their bad decisions. If you kick them out, then you're on the hook. They walk out on their own? Their fault.
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But wasn't there a NY case about a guy that eloped, and got hit by a car, and cleaned up? I'm a bit encumbered right now, so I can't look it up.
 
Fox800 said:
I work in one FSED with no security, and our medium-sized double coverage ED. I did recently have a patient that was brought in for "drug intoxication" rip out her IV, scream at everyone, and run out the door before security (who's desk is less than 100 feet away) could show up...
Click to expand...

That is not a medical emergency.

People who have purpose in ripping out their IV and cussing at people are NOT DELIRIOUS. They are mean a**holes. Nobody with a head bleed or a Na+ of 106 acts like that
 
Dr.McNinja said:
The referenced above where it got dismissed?
Nope.
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Sorry, I thought Apollyon was mentioning it saying you can't hold an intoxicated patient against his/her will.

Although after my late shift and getting my brain fried from all the complicated patients, I'm still not sure what your cryptic response was even suggesting. I'm off to bed...
 
MedicineZ0Z said:
Weird situation but some big guy (about 6'6, maybe low to mid 300lb range) having acute psychosis in the ED and flipping out. Security was overwhelmed and I physically had to step in to help and it ended in a physical 1 on 1 restraining session until security and nurses could help out. I'm 6'2 and 245lb/very muscular; common sense dictates that I step in to help rather than let everyone get assaulted.

Not sure why other doctors couldn't?
Click to expand...


If you cause harm to the patient from you putting your hands on them, you're ****ed

If you get harmed in the process as a provider, few people care (especially given you're an off service FM intern, there would be little recourse for you if this patient beat your ass after you very stupidly tried to restrain them 1:1)

If you get harmed in the process and are unable to work, don't expect a payout from your job that will help cover your loans and provide you with a physician's lifestyle

If you try to sue the patient for harm, don't expect to get any money and most of these psychos don't have money to take anyway.






100% not worth it to play hero. I'm a big dude and I've watched ⅔ of my residency get clocked in the face at some point or another from some agitated patient. No thanks. Security, Haldol, Versed +/- sux and an ET tube if need be.
 
thegenius said:
That is not a medical emergency.

People who have purpose in ripping out their IV and cussing at people are NOT DELIRIOUS. They are mean a**holes. Nobody with a head bleed or a Na+ of 106 acts like that
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Correct. Just pointing out the lackadaisical response (lack of response) by security when they were called for because the pt was making a scene.
 
Zyprexa/droperidol x2, +/-Haldol/Ativan, Ketamine, +/- a tube. Move on with life, you have other patients to see.

I learned a lot from my nocturnist attendings. You can't hold the entire department hostage providing 2:1 RN to patient ICU-level care because they're acting like an idiot on meth. No one else gets taken care of.
 
While the NY case is encouraging, realize that the case hinged on the documentation. The physician painted a picture that while intoxicated, the patient was still able to safely ambulate and appeared oriented. Ie, they were trying to paint a picture the patient had capacity to make their own decisions. I don’t think this means you have no obligation to let people that don’t have capacity to make decisions go. If someone comes in high off bath salts, tries to bite a nurse, is flailing around and hallucinating, you can’t just say he can leave if they say they want to go.

One thing I heard a long time ago on risk management monthly was that if you are going to let someone walk AMA who has been drinking, you really need to be careful to document that while they had been drinking, you paint a picture as to why you believe that the patient is sober enough to maintain decision making capacity. I generally will always say that the patient was walking around without signs of ataxia, wasn’t slurring their speech, seemed to understand the risks we discussed, etc.

In the end, I think there are obvious cases that the person can leave. And obvious cases where the person can’t. Its the ones that are in the gray area that are very difficult, yet thankfully not common.
 
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Lexdiamondz said:
If you cause harm to the patient from you putting your hands on them, you're ****ed

If you get harmed in the process as a provider, few people care (especially given you're an off service FM intern, there would be little recourse for you if this patient beat your ass after you very stupidly tried to restrain them 1:1)

If you get harmed in the process and are unable to work, don't expect a payout from your job that will help cover your loans and provide you with a physician's lifestyle

If you try to sue the patient for harm, don't expect to get any money and most of these psychos don't have money to take anyway.






100% not worth it to play hero. I'm a big dude and I've watched ⅔ of my residency get clocked in the face at some point or another from some agitated patient. No thanks. Security, Haldol, Versed +/- sux and an ET tube if need be.
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I'm not letting staff get harmed when I can very easily help restrain my patient until others can provide appropriate assistance. Restraining them properly means there's just about 0 chance of them (the patient) getting harmed. And short of an elite heavyweight MMA fighter , I wouldn't be remotely concerned about self harm.
Dr.McNinja said:
Because if the patient gets injured, you're going to get hosed. And unless you're really, really well trained in restraint techniques, any injury and the lawyers will own you.
You are not security/police (probably). Even if you are police, when you're working clinically you're not.
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Ah I think you missed the point. This is just providing the initial restrain so that security and staff can do their thing.
 
I work in at least one hospital where security doesn't exist.

And others where there aren't enough security officers to restrain a large, agitated patient.
gamerEMdoc said:
Yeah, too be honest, I don’t think I’ve ever worked in a hospital where security wasn’t immediately available to hold someone down. Patients don’t go from zero to 100% violent. It’s usually obvious when a situation starts to escalate. You personally shouldn’t ever have to tackle someone, I agree. But why would it ever get to that point in the first place? Is security not in the ED? Even if there is a short delay in their response, didn’t anyone see this coming? IDK. I just never in a decade as an attending have been in a position where I’ve personally thought I’d need to tackle someone.
Click to expand...
 
I'd get out of the way.
MedicineZ0Z said:
Weird situation but some big guy (about 6'6, maybe low to mid 300lb range) having acute psychosis in the ED and flipping out. Security was overwhelmed and I physically had to step in to help and it ended in a physical 1 on 1 restraining session until security and nurses could help out. I'm 6'2 and 245lb/very muscular; common sense dictates that I step in to help rather than let everyone get assaulted.

Not sure why other doctors couldn't?
Click to expand...
 
MedicineZ0Z said:
I'm not letting staff get harmed when I can very easily help restrain my patient until others can provide appropriate assistance. Restraining them properly means there's just about 0 chance of them (the patient) getting harmed. And short of an elite heavyweight MMA fighter , I wouldn't be remotely concerned about self harm.
Click to expand...

You don't get it. This is not your job.


Unless you are specifically trained to restrain patients, you getting involved only exposes you to a potentially unlimited amount of risk with absolutely no benefit. Agitated delirium is no joke - cut the MMA fighter BS I don't care how tough you may think you are, a disinhibited psychotic adult has the potential to seriously injure anyone. I've seen guys kick and scream their way through 500mg of Ketamine, any normal person 1:1 would get rocked.

Even well trained security and psychiatric nurses can still accidentally hurt a patient while restraining them. The difference is that they're much better protected should these adverse events arise - you are not. It is very easy to accidentally break a clavicle or dislocate a shoulder, especially if you are as big as you think you are, untrained and your adrenaline is pumping. When that happens, your personal involvement as an untrained individual with alot of malpractice coverage will be heavily scrutinized.


By all means though, go ahead and put your untrained hands on a patient - when **** goes sideways let us know how things turn out.
 
I'm not in a position to judge. . . but I remember seeing a non-so big woman who was psychotic, (not intoxicated) bash an RN's head against the wall while she was fighting with two security people despite Haldol. It took 4 security people to drag her out.

I'm not getting involved.
 
Mr. Hat said:
In all of the emergency departments where I've worked over the years, first as ancillary staff and then as a physician, the status quo seems to be that violent and aggressive patients often get restrained solely by, or with the aid of clinical staff (doctors, nurses, techs). In other words it's not just security doing the job. This seems to be an unspoken expectation. However after events in which I was injured trying to help with restraint (once fairly seriously), and in which I had some nurses and techs get hurt, I made the decision that clinical staff no longer lay a hand on my patients barring self defense. And I try not to let people get into the situation where they'd need to use self defense, ie no one gets into a corner. What this means is, if a violent patient (whether drunk, drugs, psych, or just a POS) wants to leave, I don't try to stop them. I call security right away, and if the person gets out the door before security gets there I call police, but I do not and will not lay a hand on them, nor will I allow my staff to. They're free to walk out. If said violent/ aggressive person isn't trying to leave I just keep everyone away from them until security gets there, including shutting the patient in the room if possible. Yes that may mean that they could injure themselves or break equipment in the mean time. But I don't care, it's not worth staff getting harmed.

However I have had some staff members question me, basically stating that we have a "duty" to protect the patient and others, and that if we don't restrain them and something happens we could get in trouble. My counterargument is that we ARE fulfilling our duty by calling security and police if necessary. If the hospital doesn't have adequate security immediately present in the ED to restrain a patient, that is their fault not mine, and does not place the onus on me or my staff. I/ we are not trained security personnel or police. I never took an oath to put my life on the line to stop someone from hurting themselves or others. Nor am I allowed to carry any kind of weapon to protect myself and others if it escalates to that. And in fact I'd argue that even aside from the physical risk to myself, laying my hands on a patient actually puts me at higher medicolegal risk than not. Much easier to explain to a court that I let the guy walk out and get run over because I'm not trained or credentialed to restrain/ assault someone, than to try to explain to a court why I thought I had the right to break a guy's arm taking him down.

What say you all?
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Nowhere on the Hippocratic oath does it say, “Thou shall be killed or injured so the CEO can save money by not having to pay for effective security to protect the staff and customers, while he sits in a cozy chair, in an oak walled office, calmly gazing at paintings of past CEOs, far, far away from all danger.” Or maybe I missed that paragraph.

Self defense first. Medical care second, if you can do it without self harm. If not, then it’s the hospital’s responsibility to have an effective security staff. If not, and if a harm to self or others, call the police and simply wait like the rest of the world while protecting yourself.

When I see a CEO wrestle a bloody, spitting, psychotic fugitive high on a speedball to the floor in his Armani suit so you or I can place an IV for sedation, post video and I’ll reevaluate my position in this.
 
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MedicineZ0Z said:
I'm not letting staff get harmed when I can very easily help restrain my patient until others can provide appropriate assistance. Restraining them properly means there's just about 0 chance of them (the patient) getting harmed. And short of an elite heavyweight MMA fighter , I wouldn't be remotely concerned about self harm.

Ah I think you missed the point. This is just providing the initial restrain so that security and staff can do their thing.
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Sweet baby Jesus.

The ED in most towns has the 3rd highest per capita concentration of violent felons of any building in the region - right behind the jail and the local titty bar. I suggest you adjust your thinking accordingly before you get your ass shot or stabbed.
 
This dude just wants to get into a fight. He can't be helped.
Lexdiamondz said:
You don't get it. This is not your job.


Unless you are specifically trained to restrain patients, you getting involved only exposes you to a potentially unlimited amount of risk with absolutely no benefit. Agitated delirium is no joke - cut the MMA fighter BS I don't care how tough you may think you are, a disinhibited psychotic adult has the potential to seriously injure anyone. I've seen guys kick and scream their way through 500mg of Ketamine, any normal person 1:1 would get rocked.

Even well trained security and psychiatric nurses can still accidentally hurt a patient while restraining them. The difference is that they're much better protected should these adverse events arise - you are not. It is very easy to accidentally break a clavicle or dislocate a shoulder, especially if you are as big as you think you are, untrained and your adrenaline is pumping. When that happens, your personal involvement as an untrained individual with alot of malpractice coverage will be heavily scrutinized.


By all means though, go ahead and put your untrained hands on a patient - when **** goes sideways let us know how things turn out.
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Sent from my Pixel 3 using SDN mobile
 
gamerEMdoc said:
While the NY case is encouraging, realize that the case hinged on the documentation. The physician painted a picture that while intoxicated, the patient was still able to safely ambulate and appeared oriented. Ie, they were trying to paint a picture the patient had capacity to make their own decisions. I don’t think this means you have no obligation to let people that don’t have capacity to make decisions go. If someone comes in high off bath salts, tries to bite a nurse, is flailing around and hallucinating, you can’t just say he can leave if they say they want to go.
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Regional variation. I practice in Texas. If a patient comes in and says they're actively suicidal, I'm not legally allowed to physically restrain them from leaving. I can chemically provide anxiolysis, but I cannot commit them to a 72 hour hold. Only a justice of the peace can do that.
 
I'm honestly curious what the people who say we should help in physically restraining people think about this.

Should we be armed and able to protect ourselves and staff from armed assailants as well?
 
Better solution:. All ED patients and visitors go through metal detectors.
Dr.McNinja said:
I'm honestly curious what the people who say we should help in physically restraining people think about this.

Should we be armed and able to protect ourselves and staff from armed assailants as well?
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Sent from my Pixel 3 using SDN mobile
 
Dr.McNinja said:
I'm honestly curious what the people who say we should help in physically restraining people think about this.

Should we be armed and able to protect ourselves and staff from armed assailants as well?
Click to expand...

I don’t think that EPs or nurses should be involved in physically restraining people, but I have no problem with staff having valid CCPs bringing their concealed weapons to work. In fact, I often wonder how many guns I’d find on my colleagues if I could “mind freeze” time like Professor Xavier and frisk everyone in the ED...
 
"More guns" never the answer. Better answer is "less guns."
ShockIndex said:
I don’t think that EPs or nurses should be involved in physically restraining people, but I have no problem with staff having valid CCPs bringing their concealed weapons to work. In fact, I often wonder how many guns I’d find on my colleagues if I could “mind freeze” time like Professor Xavier and frisk everyone in the ED...
Click to expand...

Sent from my Pixel 3 using SDN mobile
 
TheSingularity said:
"More guns" never the answer. Better answer is "less guns."

Sent from my Pixel 3 using SDN mobile
Click to expand...

Oh, I don’t know. It seemed like a good answer every time I was in a gun fight. I bet Jack Wilson thought it was a good answer too. But, feel free to disagree. 😉
 
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