ER doctors: We’re no strangers to violence but we try to de-escalate without anyone dying
In Charlottesville, Virginia, in 2020. ERIN EDGERTON/THE DAILY PROGRESS VIA AP
Our goal in managing agitated patients is clear: Use verbal de-escalation primarily and, if needed, physical restraint that avoids unsafe positions.
As emergency medicine physicians of color, we are yelled at and called profane names. We have been spat on, pushed and kicked. One patient has landed a staff member in the ICU. A patient recently had a knife in his pocket. We have routinely experienced psychological and physical trauma. But we choose nonviolent de-escalation strategies — not just because they work but because they are humane.
We are disappointed at the inconsistent use of de-escalation strategies revealed by emerging footage of black men and women interacting with law enforcement. This lack of respect for humanity has led to the loss of countless lives of black men and women. We are distressed by the continued use of force despite literature supporting nonviolent de-escalation.
In emergency departments across the country, threats of intimidation, harassment and physical and emotional trauma are prevalent. There have been several documented cases of non-lethal and lethal violence in or around EDs. Patients have made threats to us, waited in nearby hospital facilities, and returned to the ED to harm hospital staff. According to 2015 data from the U.S. Department of Labor, the rate of violence in the health care workplace is higher than any other industry.
Agitated patients need safe handling
The ED staff, especially our nursing colleagues, frequently encounters workplace violence. In a survey of over 7,000 ED nurses, from May 2009 to January 2011,12% experienced some form of physical violence, while 55% experienced both verbal and physical abuse. More recently, a 2018 poll showed 47% of Emergency Medicine physicians reporting physical assault at work, with 60% of responders reporting similar occurrences the previous year.
Physicians, nurses, technicians, and hospital security receive training to safely de-escalate agitated patients. The goal of crisis management is clear: employ verbal de-escalation primarily with physical restraint as the last resort. Nonviolent communication and similar conflict management strategies have been successful in mitigating severe levels of agitation commonly seen in the ED. Consequently, physician training programs and multidisciplinary teams have incorporated formal de-escalation training to ensure patient safety.
Training is necessary to manage our physiologic and behavioral reactions to perceived threats. As with any other responder, we experience fight or flight responses when our sense of safety is compromised. We must prioritize the safety of our patients and our team as our guiding principles even when we perceive violence or threat. Applying nonviolent communication is the first critical step in verbal de-escalation.
When unsuccessful, physical restraints are employed. This process requires adhering to clear guidance in safe positioning. Prone positioning, or placing a patient on their chest, is not safe in agitated patients as it limits the movement of the chest wall and diaphragm, which may restrict breathing leading to asphyxiation. Finally, the use of sedative medications may be administered when all else fails.
In all of these situations, we must maintain our primary responsibility for harm prevention in patients and staff. We understand and are grateful for our law enforcement officers who protect the community from violent, criminal behaviors. However, in none of our violent ED encounters do we use lethal control of the patient.
When viewing the footage of Mr. George Floyd, the overwhelming feelings of pain, trauma and anger emerge at the inappropriate use of force. Prone positioning and neck holds are known lethal forms of restraint. For 8 minutes and 46 seconds, Mr. Floyd suffered. In our profession, the words, “I can’t breathe” trigger rapid medical response. To neglect these words, as said by Mr. Floyd, while struggling in a prone position, goes beyond malpractice.
Our de-escalation tactics avoid death
His plea went unacknowledged as the officer continued to exert his authority and force onto Mr. Floyd’s lifeless body. This was no accident. Mr. Floyd’s death was a consequence of racism and abuse of power. We must not harm patients in order to keep them or ourselves safe; once we do, we cross the line between being a physician and an assailant. Just like the police, we are not above the law.
Mr. Floyd deserved better. Our communities deserve more.
In medicine, many others share these sentiments. We acknowledge room for improvement regarding health disparities that disproportionately impact black patients. Like the criminal justice system, our health care system lacks equity — as evidenced by long-standing disparities in maternal care, management of pain and cardiac emergencies, and recently highlighted by the COVID-19 pandemic. And despite standardized training in de-escalation, racial bias exists in the management of agitated patients. Notwithstanding, there are no patient care algorithms that support the use of lethal force in restraining any patient.
We acknowledge the harm that law enforcement may face. However, as EM physicians, we are no strangers to violence. We care for agitated patients from all backgrounds. In order to treat every patient with dignity, we prioritize de-escalation strategies that avoid death.
While our roles and rate of risk differ, the communities that health professionals and members of law enforcement serve are the same. Through education and the sharing of effective strategies among pre-hospital services and law enforcement, we can promote a culture of nonviolent de-escalation. Most of all, we can champion accountability in safety, efficacy, compassion and humane care for our communities. In solidarity, we must.
Dr. Onyeka Otugo is an Emergency Medicine Health Policy Fellow, Brigham and Women’s Hospital, Harvard Medical School. Dr. Adaira Landry is Assistant Residency Program Director, Assistant Professor, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School. Dr. Al’ai Alvarez is Assistant Residency Program Director, Clinical Assistant Professor, Department of Emergency Medicine, Stanford School of Medicine. Dr. Italo Brown is a Social Emergency Medicine Fellow, Department of Emergency Medicine, Stanford School of Medicine. Follow them on Twitter: @OnyekaOtugo, @AdairaLandryMD, @alvarezzzy and @gr8vision