ER safety

[drboris]

Does anyone ever worry about being physically hurt, besides needle sticks and other exposures, while working in the ER?

Is this a realistc concern, that violent and angry patients may try to hurt the ER doc?

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[Sessamoid]

Does anyone ever worry about being physically hurt, besides needle sticks and other exposures, while working in the ER?

Is this a realistc concern, that violent and angry patients may try to hurt the ER doc?

Not particularly.

 

[drboris]

how about crazy psych patients?

 

[VienneseWaltz]

how about crazy psych patients?

My psych preceptor told us a story about a pt hospitalized in the substance abuse unit for alcohol abuse ... He found the patient roaming on another floor and approached him, at which point the patient decked him. Turns out his nurse had forgotten to give him the past 2 doses of benzos.

 

[DrMom]

You can encounter violent patients anywhere.

 

[Sessamoid]

Rare is the patient that can not be adequately sedated with the medications in the Pyxis.

 

[EctopicFetus]

Dr. Boris,

I agree with Dr Mom about pts being dangerous in any place. I was at Cook County doing Medicine and my friend told me that her attending got slapped in the face by a patient and it broke the attendings glasses.

That being said I am currently doing my EM clerkship at Mt Sinai and we have had some violent patients. Fortunately, we have security there and if you think a patient is dangerous you just call security for some 4 pt restraint action. In the end patients can be violent and not everyone is thankful for the work you do.

 

[Febrifuge]

The ED is riddled with cameras; nearly all the staff can call for restraints on a pt that may be a threat to self or others; several of our RNs are former military; and we freely mete out the righteous power of Droperidol. I feel safer in the ED than I do on the bus.

 

[spyderdoc]

The ED is riddled with cameras; nearly all the staff can call for restraints on a pt that may be a threat to self or others; several of our RNs are former military; and we freely mete out the righteous power of Droperidol. I feel safer in the ED than I do on the bus.

A few months back when I was still up in Norther Cali, I had a methed out patient pull out a butterfly knife on me. The 5'2" tiny female security guard bolted to get to a phone to call for backup, leaving me alone with this dude. Luckily she left her metal clipboard, which I picked up to defend myself had the guy decided to charge me..... Luckily, I was able to talk him to put it down just in time for the rest of the security guards to get there....The police came by code 3 and arrested him. Needless to say, I quickly "medically cleared" the guy and he was taken off to jail....
That is one thing I liked about Yale ER is that the security guards were certified police officers and were armed. They searched all psych and questionable folks on arrival to ensure that they were not armed....

 

[ang19]

Does anyone ever worry about being physically hurt, besides needle sticks and other exposures, while working in the ER?

Is this a realistc concern, that violent and angry patients may try to hurt the ER doc?

i am not a er doc, i am a nurse and i think it is more of a concern for us because we have to actually handle the patient. i have never been hurt, but i do know nurses that were choked and assaulted other ways by violent patients when trying to draw blood or give haldol. i will not go into a room to do patient care on these type of patients if i don't feel safe with at least 3 security guards at my side. i do know a doc that was kicked pretty hard in the groin and end up going home at the end of the night because of the pain. you try to do the best you can to take care of these patients, but no amount of money is worth getting physically harmed over.

 

[roja]

2 and 5







2 and 5




2 and 5

 

[Sessamoid]

i am not a er doc, i am a nurse and i think it is more of a concern for us because we have to actually handle the patient. i have never been hurt, but i do know nurses that were choked and assaulted other ways by violent patients when trying to draw blood or give haldol. i will not go into a room to do patient care on these type of patients if i don't feel safe with at least 3 security guards at my side. i do know a doc that was kicked pretty hard in the groin and end up going home at the end of the night because of the pain. you try to do the best you can to take care of these patients, but no amount of money is worth getting physically harmed over.

I agree. I think the ED should have Haldol-loaded dart guns for these kinds of patients.

For the dangerous and altered patient that needs to be hospitalized, the other option is paralyzation and intubation. I've intubated more than a few trauma and overdose patients due to concerns about my staff's safety as much as the patient's.

 

[Jeff698]

Yeah, Sessamoid!

Clearly, any patient that is so combative that the staff fears for their safety also has a serious inability to protect their airway. Fortunately, we can help with that.

Take care,
Jeff

PS, I'm still pretty attracted to the idea of just sending in Christiana's Thor.

 

[docB]

i am not a er doc, i am a nurse and i think it is more of a concern for us because we have to actually handle the patient. i have never been hurt, but i do know nurses that were choked and assaulted other ways by violent patients when trying to draw blood or give haldol. i will not go into a room to do patient care on these type of patients if i don't feel safe with at least 3 security guards at my side. i do know a doc that was kicked pretty hard in the groin and end up going home at the end of the night because of the pain. you try to do the best you can to take care of these patients, but no amount of money is worth getting physically harmed over.

We don't have the right to back out of a dangerous situation. If the pt winds up injuring himself we're gonna get sued. The lawyers don't care how dangerous, intoxicated or outright stupid a pt is.

On a related note I get lots of people who come in and say "I'm afraid of needles. You'll have to hold me down." I refuse to do this unless the problem is life threatening. I tell them that it is an unacceptable risk to the staff and the pt to hold someone down for a minor illness. I had a woman who brought in her 28 year old, mildly ******ed son with a dental abscess. I wanted a CBC and some IV Abx. She said "OK, but you need to get 12 paramedics to hold him down because that's what it took last time." So I handed her a script for po Abx and some pain meds and showed her the door.

 

[ERMudPhud]

On a related note I get lots of people who come in and say "I'm afraid of needles. You'll have to hold me down."

Why do they always have tatoos and piercing? I always tell them, "I'm not going to tie you down if you want to get better you're just going to have to learn how to deal with it"

In terms of the original question. I've never been attacked but I'm pretty good at keeping an eye on people and restraining them before it gets to that point. The closest I ever came was a meth addict who stuck his hand in his pocket and claimed he had a box cutter. I just had everyone stand out of reach while one of the nurses went to call the police. Then he took his hand out of his pocket to mess with his IV so I jumped on him before he could put his hand back in his pocket. After that everyone else piled on. I also remember a huge bouncer I took care of in the ICU after a suicidal benzo overdose. When he woke up the next morning the first thing he said was "I'm leaving and you can't stop me" I didn't confront him but instead said OK and left the room. I then rounded up every young male worker I could find in the hospital. Our security guards were little old retired guys so I walked into his ICU room as he was disconnecting himself from the foley with more than 12 guys (nurses, PT's, RT's, janitors) and said, "You need to be tied down. You can lie down or we can do it for you." He carefully counted us all up, thought about it, and then went back to bed with his arms in the right position for restraints.

I do have to say that I knew I married the right woman when I saw my <120 pound wife throw a perfect ankle tackle on some 6 ft tall drunk as he tried to run out of her ER.

 

[ang19]

We don't have the right to back out of a dangerous situation. If the pt winds up injuring himself we're gonna get sued. The lawyers don't care how dangerous, intoxicated or outright stupid a pt is.

On a related note I get lots of people who come in and say "I'm afraid of needles. You'll have to hold me down." I refuse to do this unless the problem is life threatening. I tell them that it is an unacceptable risk to the staff and the pt to hold someone down for a minor illness. I had a woman who brought in her 28 year old, mildly ******ed son with a dental abscess. I wanted a CBC and some IV Abx. She said "OK, but you need to get 12 paramedics to hold him down because that's what it took last time." So I handed her a script for po Abx and some pain meds and showed her the door.

you are absolutely right. i know we are all taught to use the least restrictive device possible to protect the patient and staff, but i have seen many, many times when it took 6 or 7 staff members to get a patient under control who was severely manic or drugged. i know an ED doc who is being sued because a patient claims that he now suffers from carpel tunnel syndrome and emotional distress from being in 4 point restraints. this is the same patient who spit in the ED docs face and kicked a pregnant nurse in the abdomen. he was well sedated in the end with ativan and haldol so i don't now how he even remembers anything. we all know the carpel tunnel claim will be thrown out but it is truly amazing what health care providers have to deal with to prvodide effective care to patients.

 

[Sessamoid]

On a related note I get lots of people who come in and say "I'm afraid of needles. You'll have to hold me down."

I've never had that request, ever. Weird. I've had people ask me to "knock them out" for a procedure such as laceration suturing. Never had anybody ask me to tie them down. At least not in the ER.

I've had a couple patients that just wouldn't hold still enough to make suturing safe that I just ended up either stapling or leaving to close by secondary intention. I'm not putting myself at risk just to close a laceration. If they can't hold still, screw 'em.

In my experience, some of the biggest needle weenies are really muscular guys and heroin addicts.

 

[docB]

I've never had that request, ever. Weird. I've had people ask me to "knock them out" for a procedure such as laceration suturing. Never had anybody ask me to tie them down. At least not in the ER.

I've had a couple patients that just wouldn't hold still enough to make suturing safe that I just ended up either stapling or leaving to close by secondary intention. I'm not putting myself at risk just to close a laceration. If they can't hold still, screw 'em.

In my experience, some of the biggest needle weenies are really muscular guys and heroin addicts.

Yeah, I get lots of people who say "You'll have to knock me out." So I take an IV pole and beat them unconscious (Whoops, I'm losing my grasp of fantasy vs. reality again). So I do what you do. I tell them it's not indicated and let them go on their way.

BTW I also get some really stoic pt's from time to time. I had a guy last week who split his chin. I numbed him up and put a drape over his face and sutured him. I asked him several times how he was doing and he always said fine. I finished and took of the drape and he was bright red and covered in sweat. He felt the whole thing! I'd have been more than happy to give him more lido. I felt like crap over than one.

 

[Febrifuge]

BTW I also get some really stoic pt's from time to time. I had a guy last week who split his chin. I numbed him up and put a drape over his face and sutured him. I asked him several times how he was doing and he always said fine. I finished and took of the drape and he was bright red and covered in sweat. He felt the whole thing! I'd have been more than happy to give him more lido. I felt like crap over than one.

Last week, I helped with two little kids who (along with their mom) had CO poisoning. I held the forearm still for each of 'em while they got IVs. Even on the kid where the RN had to chase the vein around for a minute, there was no crying, no whining, and no yanking back the hand. They didn't even complain about boredom after the rest of the day in the HBO chamber.

I decided everyone else is a total wuss compared to those kids.

 

[canuck MD]

A while back I went on a ride along with paramedics (1 guy, 1 girl; average build). They got a call for a post ictal patient. He was treated, put in the ambulance and started to become VERY aggressive. The female medic was trying to put restraints on him and he just swung and knocked her out (for only a few seconds). The male medic stoped the ambulance and we both jumped into the back. The patient took a swing at the medic so I (6'7, 340lbs ) just jumped on him, put all my weight down and sat on his head. The medic finally got restraints on him and the police arrived a few minutes later and escorted us to the hospital...the medics decide to put a c-collar on the patient just in case I injured him...

 

[Sessamoid]

I (6'7, 340lbs ) just jumped on him, put all my weight down and sat on his head.

Wow, you must..... nah, it's just too easy.

 

[grouptherapy]

Last week, I helped with two little kids who (along with their mom) had CO poisoning. I held the forearm still for each of 'em while they got IVs. Even on the kid where the RN had to chase the vein around for a minute, there was no crying, no whining, and no yanking back the hand. They didn't even complain about boredom after the rest of the day in the HBO chamber.

I decided everyone else is a total wuss compared to those kids.

anyone else here use lido, before inserting an IV if there's time and no allergy

 

[Febrifuge]

Topical lido? Because otherwise, from a nurse/ tech point of view, you'd just be sticking them twice. It's not the actual needle-stick pain that's the problem. It's the presence of the needle in the room. A 22ga IV, inserted properly and quickly, is no big deal for a kid who isn't already psyched out about it.

 

[grouptherapy]

no, intradermal injection of lido using a 27 ga needle (just like a PPD). i use a a bent insulin needle and introduce enough lido just underneath the skin to produce a wheal (<0.1ml). then i stick them with the 18 ga or whatever i want; they don't feel it. it's a great technique if they have bad veins and you know you have to fish or if you're teaching a med student with no experience. also works with sissy gangbangers

 

[mikecwru]

We don't have the right to back out of a dangerous situation. If the pt winds up injuring himself we're gonna get sued. The lawyers don't care how dangerous, intoxicated or outright stupid a pt is.

On a related note I get lots of people who come in and say "I'm afraid of needles. You'll have to hold me down." I refuse to do this unless the problem is life threatening. I tell them that it is an unacceptable risk to the staff and the pt to hold someone down for a minor illness. I had a woman who brought in her 28 year old, mildly ******ed son with a dental abscess. I wanted a CBC and some IV Abx. She said "OK, but you need to get 12 paramedics to hold him down because that's what it took last time." So I handed her a script for po Abx and some pain meds and showed her the door.

How big/bad was this friggin' dental abscess?

mike

 

[docB]

How big/bad was this friggin' dental abscess?

mike

It wasn't too bad. I like to get a CBC and use IV Abx on people I think are unreliable. If they come back and the CBC is worse it gives me some data to use to get them admitted for an outpt failure and the IV or IM blast ensures compliance for at least the first dose.