“the word on the street is that Emergency Departments keep a lot of drugs.  Drug seekers know this.  They also know that it is easy to walk into an open-access Emergency Department and demand drugs, even if it takes the use of violence to get what they want.”

Violence in the Emergency Department, Patricia B. Allen

During our ER/ED violence audits the "Violent Drug-Seeker" is frequently mentioned as the cause of the most dangerous type of violent incident seen in the Emergency Department.  In fact, during one observation visit we conducted, a drug-seeker visited the ER and attacked a doctor and a security guard, resulting in a dislocated shoulder for the security guard.   Our discussions with both frontline and management-level team members reveals that this is an all-too-common occurrence and one which presents the most serious circumstances. Hospitals soon learn to ‘get the word out’ that the ER is NOT a place to come and get drugs.  While difficult to measure, it appears that this strategy has some effect in reducing presentations by drug-seekers at the ER. Drug-seekers will still present at the ER looking for drugs and when refused by staff, some will resort to aggressive and intimidating behaviour, possibly escalating to violence.   Ordinarily, the security team at a hospital would be tasked with removing these individuals from the hospital premises, however as noted in some of our previous posts, the security teams at some hospitals are ineffective and/or not empowered in this regard. Without an effective show of force by police or security, the nursing and clinical staff will be the frontline defence against the drug-seeker’s behaviour.   Training in physical intervention and restraint will give the staff ample tools which can be deployed for the purpose of protecting themselves or denying access to certain parts of the building.   However, as mentioned above, nursing staff will need motivation and support to undertake this high-risk tasking. A point to note is that from a ‘system’ point of view, resorting to the use of the nurse/clinical staff to control this criminal behaviour is almost certain to result at some time in a serious injury or worse. When a highly motivated drug seeker (male, 30-45yrs old, uninhibited and physiologically aroused) commits an act of violence on a motivationally-challenged female nurse whose psychological and physical level of preparedness for physical violence is much lower, the physical and emotional challenges for her will be huge. Security Staff and Police should be the main point of defence when a drug-seeker is identified within the ER. Furthermore, it is apparent that drug-seekers who present at Emergency Department are frequent offenders in this regard.  For this reason, information-recording and sharing protocols which utilise database technology could easily enable staff to be alerted to the presence of a previously-violent ED client when they present.

A violence reporting program in the Portland, Oregon, VA Medical Center identified patients with a history of violence in a computerized database. The program helped reduce the number of all violent attacks by 91.6% by alerting staff to take additional safety measures when serving these patients.

---------------------------------------------- Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant.  He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict.  www.dynamis.training