Violence in the Emergency Department

Clinical nurse consultant Paul Mateos has just finished a night shift at Townsville University Hospital’s emergency department when he’s asked to describe the violence and aggression he sees from patients on a daily basis.

He doesn’t mince words.

“Last night we had a young woman overdose and a major trauma case come in, so it was very busy and very intense,” he said.

“I had a family who was desperately upset and a trauma victim whose life was about to change dramatically and all of this was against the background of a bellowing patient brought in by the police violently drunk, drug-affected and abusive,” he said.

In other words, it was a typical day at work.

Mr Mateos has worked in Townville University Hospital’s ED since 2001 and says violence has been an escalating issue for the past five years.

“The level of violence has been steadily increasing; the way that people express themselves at the moment has probably become a much more physical, emotional, and, therefore, violent act when they find they can’t control their emotions,” he said.

“The disinhibition is a combination of substance use and an inability to control their emotions because of stress, mental illness, or a change to their normal functioning brought about by the drugs.”

In more than 90,000 presentations a year to Townsville University Hospital, around 14,000 are related to drugs and alcohol.

About 400 of these patients are admitted to an inpatient bed.

Mr Mateos said it was clear Townsville had issues with alcohol and amphetamines, in particular.

“Not only are people acting violently because of the drug abuse, there are also patients in the ED who have been in car accidents, have fallen off their motorbikes, or had an episode at home when they’ve unbalanced and fallen, causing a serious injury to their head, spine, or neck.”

Emergency department deputy director Dr Natalie Ly said a typically violent presentation was the patient brought in by the police.

“This someone who is brought in as an involuntary patient in the care of police and ambulance, because of the violent and aggressive behaviour they have displayed in the community,” she said.

“This may be in the context of  drug or alcohol, or where there is a question about a mental health or  medical condition that may be contributing to the presentation, and so they are brought to the emergency department for medical assessment,” she said.

“We will often then see a spectrum of verbal and physical abuse directed at our administration, nursing, medical, support staff and security officers from someone we are trying to help.

“Ideally the person’s behaviour can be deescalated, but at times the person is so heightened these attempts are unsuccessful. 

“At this point, the clinicians are required to make decisions about the patient’s ability to make their own choices, the medical need for treatment and the safety of everyone in the ED. 

“This may lead to the patient being restrained and sedated for necessary medical assessment and treatment, or discharge with security or police escort out of the emergency department,” she said.

Dr Ly said examples of patient violence could include throwing objects, smashing doors, running at walls, spitting, biting, punching, kicking, threats with weapons, and flinging human waste.

“It’s not unusual, it’s not uncommon and it happens way too often.”

According to Dr Ly and Mr Mateos, the emergency department is also a place where heightened emotions translate to challenging behaviours.

“Working in emergency you probably see people on their worst day, at their most scared, at their most vulnerable but within that you see people who, for various reasons, simply can’t negotiate and explain what it is that they want in a normal way,” Mr Mateos said.

“Typically, people want us to do things faster or give them drugs which descends into yelling and screaming unacceptably at the staff.”

Dr Ly wants the community to know that the Townsville emergency department, like EDs around the country, is currently seeing higher volumes of presentations.

She also wants the community to know that staff are doing their best.

“Our staff triage and prioritise care based on medical urgency,” she said.

“They will attend to the most unwell first, and this may mean that if you have presented with a non-time-critical problem, when we are very busy, you might need to wait a few hours before a doctor can see you. 

“Please be patient with us.”

Despite the challenges of working day in and day out with people who can be aggressive and violent, both Dr Ly and Mr Mateos say they wouldn’t work anywhere else.

“In amongst all that difficulty, in emergency you have the opportunity to do some really important, life-saving work,” Mr Mateos said.

“When that happens it’s incredibly personally and professional rewarding.

“Even though I’m working with violent people who can be very difficult, at the end of that process I think most staff are hoping they’ve been able to do something to help their patients and it won’t be an end point for them.

“Maybe we can assist that patient with their immediate situation and put them in touch with someone who can help them longer term.”

Dr Ly said that while violence and aggression happened frequently in emergency, it wasn’t the bulk of the job.

“Yes, violence happens too often in emergency but there are more than 100 doctors and 180 nurses working on a rotating roster so not everyone is encountering every act of aggression,” she said.

“Some shifts you can have a shocking run of luck and see much more violence and aggression than anyone should in an eight-hour period.”

Dr Ly said emergency department staff would always do their best to look after everyone who presented.

“We will do our best for you but if you are violent or aggressive you are risking your safety, our safety, and the safety of others around you, and this behaviour will not be tolerated.

“Safety of our staff and patients is our number one priority,” she said.

Mr Mateos said communicating with emergency staff was key.

“Help us understand where you’re at without being abusive and violent; we’d very much appreciate it and we’d be much better equipped to help you.”

The Townsville Bulletin is partnering with Townsville University Hospital to take you behind the scenes of one of Queensland’s busiest emergency departments. Meet the people who care for our community and share in their stories and challenges in looking after more than 90,000 people a year who come through their doors injured, sick, drug affected, scared, dying and all in need of help. Come behind the curtain for a unique perspective on emergency medical care in the 21st century.

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