Yelling, screaming and ducking the cranky triaged patients

  1. In our tiny hospital in the sticks I triaged a woman for dental pain who had just come from another ER three towns away. They didn't give her the meds she wanted so she hitchhiked to us. she was loud and demanding, and got more so over the next 30 minutes. Security was called, and when she took a swing at him she was told to leave the facility.

    So...my question is since everyone is required to have a medical screening exam if they present to triage, under what circumstances do other ERs consider a patient's behavior unacceptable and tell them to get out. If you don't kick them out how do you handle them without having everyone else waiting realize that the way to be taken back immediately is to be loud and demanding?
    •  
  2. 33 Comments

  3. by   widi96
    We have a particular patient that was a frequent flier who walked in one day demanded pain medications, morphine to be exact. He had a little bag in his hand and claimed he had a gun and was going to kill one of our nurses and a doc, both of whom were right in front of him.
    We have been told since that time, if, once he gets out of jail, he decides to come back to the ER, we must treat him like any other patient, but security may be present at all times.
  4. by   sanctuary
    I think that if the initial assessment determines that the c/o is not life threatening (tooth pain), no one could fault you for releasing the patient to the street. However, lawers will sue over anything, so Chart, Chart, Chart.
    Last edit by sanctuary on Mar 25, '07 : Reason: spelling
  5. by   TrudyRN
    Quote from widi96
    We have a particular patient that was a frequent flier who walked in one day demanded pain medications, morphine to be exact. He had a little bag in his hand and claimed he had a gun and was going to kill one of our nurses and a doc, both of whom were right in front of him.
    We have been told since that time, if, once he gets out of jail, he decides to come back to the ER, we must treat him like any other patient, but security may be present at all times.
    I hope your ER has a bullet-proof door that you control so you can decide who gets to come in and when. If this guy shows up, keep him outside until Security is present, I'd say. and they need to strip search him, it sounds like, to make sure he isn't packing. What is the world coming to? Seriously, your Admin needs to protect you guys.
  6. by   TrudyRN
    Quote from canoehead
    In our tiny hospital in the sticks I triaged a woman for dental pain who had just come from another ER three towns away. They didn't give her the meds she wanted so she hitchhiked to us. she was loud and demanding, and got more so over the next 30 minutes. Security was called, and when she took a swing at him she was told to leave the facility.

    So...my question is since everyone is required to have a medical screening exam if they present to triage, under what circumstances do other ERs consider a patient's behavior unacceptable and tell them to get out. If you don't kick them out how do you handle them without having everyone else waiting realize that the way to be taken back immediately is to be loud and demanding?
    Not sure but you could be in trouble for letting her be run off. What does your Manager say?
  7. by   justme1972
    I'm glad I saw this post....

    My psychology professor is a Psychologist that specializes in drug and alcohol addiction and we just got finished covering behavioral evidence of drug addicts...he said they are the ones that typically go into an ER or a DR's office and always request a specific drug, and refuses to take any other...if she was truly in pain, she would have been happy to take anything as long as it ended the pain...if she's an addict...that's probably why she did something as risky as hitch-hiking.

    To those that are currently working...what do you do with someone like this that comes into the ER and you have a good reason to suspect that drugs and not pain is the reason for the visit.
  8. by   EDValerieRN
    Thankfully, my ER and supervisors are fantastic about this. We'll kick 'em out if they need it. I myself have kicked out two patients, one who told me he was going to kill me, and another that was generally acting an arse in the waiting room, going into other pt's belongings, that sort of stuff. He cursed me a lot, too.
    Our management also stands behind us if we ever choose to press charges... One nurse was hit in the mouth, and the patient was arrested and charges were filed. Management supported the nurse wholeheartedly... I was suprised some hospitals don't have the support we do.

    EMTALA only goes so far... if I feel as if my safety is at risk, it's the last thing I'm worried about. I'm glad my boss agrees.
    Last edit by EDValerieRN on Mar 25, '07 : Reason: Spelling
  9. by   BULLYDAWGRN
    A friend and co-worker of mine was verbally abused and threaten one night in the er by a pt. They called security and did the paper complaint form, tx'd the pt and d/c'd. A few days later my buddy saw the pt in a super walmart. Followed the guy out to his car and cussed the guy out, then got into a little tussle with the fella. Anyway my pal beat the guy pretty good. The funny thing is later that eve while my pal was at work the pt came back to the er for tx on a laceration above the eye that my friend gave him, it was a big hoot for everyone, like score one for the good guys..
  10. by   PANurseRN1
    I wouldn't recommend doing that. Not only are you risking your job and your license, your taking your life in your hands. People are wack jobs.
  11. by   Medic/Nurse
    Cranky is one thing, yelling and screaming are attention getting tactics and when "rewarded" they do reinforce BAD BEHAVIOR. But, maybe I have a room full of potential "victims" to think about - so I'm not sure there is ONE RIGHT ANSWER.

    Come on in with a weapon and DEMAND drugs - well, they are yours.
    I'll empty the Pyxis and offer you a saline lock (for your convenience) as long as YOU GET OUT THE DOOR AND MY STAFF STAYS SAFE!

    There are things worth risking your life for - THIS is NOT one of them.

    I will not STOP any patient from WALKING OUT. I will document the whiz out of it, but STOP YOU - NO!!!!

    As for patients being refused care. I have in 16 years known of a couple of facilities that have sent letters to the PROBLEM PATIENT outlining expectation that they are ONLY WELCOME to seek TRUE LIFE THREAT EMERGENCY CARE at the facility. These have been patients that have clearly exceeded any ability for the facility to create a safe environment - not frequent flyers, but a very few that have been VIOLENT. Is this risky for the facility? Maybe, but to what degree must a facility go to mitigate RISK to staff, other patients? I say let the LAWYERS sort it out, if necessary. DARWIN had a few things right!

    Is there any way to absolutely STAY SAFE?
    NO.

    I think that we are living in a more violent society - so I'm not surprised that ED violence is increasing. I can name many incidents of firearm discharge in the ED in the past 5 years - AND several of these were with the POLICE in ATTENDANCE (a couple of fatalities in VA - police, security guard and one patients SO). Scary. Just goes to show - NEVER let your guard down.

    I will be aware, alert, have a plan (or three), escape route, call security, call the police or if necessary DO WHATEVER I have to do to PROTECT myself, staff and other patients.

    But other than AWARENESS and GOOD PLANNING - there are limited solutions. Just be aware - trust the "sixth sense" - avoid escalation with ANY patient...but, really there are limitations.

    Do I feel better behind bullet proof glass? Sure, in some situations.
    Will I call security/police "for a feeling"? Yep, in a heartbeat.

    I do believe that SOMEONE who is INTENT on hurting you is not EASILY STOPPED. I just try to be consistent in the quest for safety. I'd rather explain why I exercised too much caution as opposed to too little.

    Stay SAFE!
  12. by   JRapha'sRN
    Quote from widi96
    We have a particular patient that was a frequent flier who walked in one day demanded pain medications, morphine to be exact. He had a little bag in his hand and claimed he had a gun and was going to kill one of our nurses and a doc, both of whom were right in front of him.
    We have been told since that time, if, once he gets out of jail, he decides to come back to the ER, we must treat him like any other patient, but security may be present at all times.
    We have a frequent flyer similar to yours. Ours was found with weapons on him (after making threats to staff) and now cannot even be triaged until Security pats him down. We still had to see him, though. He was arrested and is now in jail after pulling a gun while in a hotel. He's still in jail.

    Unfortunately, I think the ER sees many of these patients each week, we just can't identify all of them. I just try to implement things I learned back in school on our psyc rotation--always keep a clear path to the door! Every once in a while I get a very weird gut feeling with a patient and am even more vigilant, but it's something to keep in mind at all times.

    Back to the original topic: I think we have to see everyone. I'm not sure what our management would do if we kicked a patient out of the waiting room.
  13. by   TazziRN
    We cannot deny anyone an MSE, but we can delay it until the staff and patients/visitors are safe. If someone were to act up like that and I/we could not reason with them, the cops would be called to reason their way. If the pt still did not see it our way and refused to calm down, the cops would escort them from the premises. We are not denying an exam, we are making sure of our own safety.
  14. by   mamalle
    document and get my OT police officer to handle the issue. its not worth getting myself hurt or worse. If they decide to calm down then we can proceed.. I love having a cop but it took a nurse being held hostage for 11 hours with a razor to her throat to finally get one in our ER..

close