Zero Tolerance

My friend ScrubOne suggests that my next post will be on this. Who am I to argue with such wisdom?

“A deluge of abusive drunks is straining Wellington Hospital’s emergency department, clogging its systems and demoralising staff to such an extent that at least one doctor is considering leaving her job.

“Nurses say they dread night shifts at the department and have told of constant verbal abuse and occasional physical assaults, damning research by Otago University reveals.”

After nearly 30 years working emergency departments, the MacDoctor’s initial thought on reading this article was the über-sympathetic “harden up, ladies”. After all, drunken idiots at two in the morning are what emergency medicine is all about. Being verbally abused by 18-year-olds who have spent the entire day exterminating their few remaining brain cells is, of course, the joy of every ED staffer’s life. What would we do with ourselves, at that time in the morning, if we didn’t have some moron trying to spray us with his/her blood? How else could we get to practice suturing moving lacerations?

All sarcasm aside, my next thought was why do we tolerate it? Surely, in any other situation, if a person was screaming at you to go away and trying to beat you off, would you not consider that they did not really want your help? Consider that the law determines that a drunk person is still responsible for their decisions. If you get into a car and drive drunk, you cannot argue that you were out of your mind at the time. Why is this seen differently in an emergency department?

I suspect it is because we forget that we don’t have a duty to provide care, we have a duty to offer to provide care. People have the right to refuse. And bouncing around the ED waving their fists would be prima facie evidence of a patient’s refusal of care. Instead, we nobly attempt to provide care to an uncooperative adult. Technically, this is assault. Consider:

““They always swear at us. I’ve been hit once by a drunk patient but that was because I was trying to sew up his head.””

Indeed. From the drunk patient’s point of view the doctor was attempting to stick needles in his head for no reason. It it unsurprising that he leaped to his defense. Not that I am blaming the doctor for this. She was doing her best for her patient. But combative drunks are notoriously ungrateful.

Take it from an old hand at this. If a drunk patient is unco-operative, there is always a nice, quiet jail cell where they can go and rest until they have  slept off the booze. Suturing up a wound the following day does not produce as nice a result as immediate closure, but so what? The patient has indicated to you that s/he would like a lousy-looking scar by their very combativeness. Unless you have very strong reasons to suspect a dangerous head injury, or some other life-threatening problem, in the drunk person, there is no need to provide any medical service that might put you or your nurses in harm’s way.

Zero tolerance works. The regular drunks soon learn that an emergency department is not an extension of the pub, where they can carry on brawling. For the younger ones, waking up in a police cell is not a pleasant experience for them. And if staff do get assaulted, they should make sure they lay assault charges without fail. Part of the problem in our EDs is the staff let minor assaults slide as “part of the job”. But this merely sends the message that this sort of behaviour is acceptable and emergency staff are just “part of the brawl”. We need zero tolerance for all forms of aggression in the emergency department (note: this does not, of course, include the truly mentally ill – although the police are often invaluable in restraining such people so that we can sedate the patient properly)

Part of the patient bill of rights says that they should be treated with respect, but respect is a two-way street. If you are aggressive and rude, expect to wake in a cold cell in pain and with scant sympathy in the offing.

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