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Managing the difficult patient encounter in the Emergency Room
(The perspective of Dr Zulfikar Bux, Head of GPHC’s A&E; Asst. Prof. of Emergency Medicine)
Dr Zulfikar Bux
In the ideal world everybody gets along, and there aren’t personalities and cultural differences that make us differ in opinion. Obviously there is no such existence and it is even more complicated in emergency rooms (ER) where the environment is high-stressed and unpredictable.
Emergency physicians cannot anticipate that all encounters will unfold according to the standard expectations for successful patient-physician relations, that is, that privacy and confidentiality will be maintained and patient autonomy exercised.
Privacy, autonomy, even assessing and addressing the medical complaint itself are often not the emergency physician’s first priority in managing uncooperative patients. These Physicians are expected to maintain calm and be respectful to every patient. Often however, there are patients or relatives who are aggressive because of anger or an unstable state of mind. These persons can pose a threat to the staff and other patients in the ER and must be kept in check for the safety of all.
In most emergency departments, aides or security personnel are available to assist if the patient becomes unruly. Those not involved in the patient’s care (hospital security personnel or police officers) should be discretely placed, so that the patient is aware that they are present or nearby, but they should not intrude on the patient-physician encounter unless they are actively engaged in guarding or controlling the patient.
The physician’s first intervention is to assure the patient in a non-threatening way that, regardless of the circumstances, his or her health is the physician’s primary concern. Often physicians must maintain control of their own emotions, responding to patient anger and even abuse, calmly and un-defensively.
It is difficult to list what goes on next in sequence. The physician must determine, almost simultaneously:
· Whether the patient is likely to pose a threat of harm to him or herself – or to others.
· Whether or not a medical emergency or need exists. Whether the patient is in physical distress. Intoxicated. Psychotic. Attempting to get a prescription for narcotics.
· Whether the patient is competent to accept or refuse treatment. If not, whether someone is present who can speak as the patient’s surrogate.
The possible combinations of answers to these questions determine how the encounter proceeds. If a medical need is present and the patient is not combative or hostile and is competent to discuss and consent to or refuse treatment, the encounter resembles a traditional acute medical intervention. If medical need is present and the patient is highly combative or frenzied, with frankly compromised mental status, he or she can be restrained or sedated so that the need can be assessed and treatment can proceed. The physician may ask security personnel or police to detain or control the patient.
A patient’s decision on his or her care should make sense relative to his or her values. Refusing surgery because it is frightening, for example, may be perfectly reasonable, but not consistent with a goal of continued life. Obviously, the need to feel secure about the patient’s competency increases as the risk associated with an intervention or the refusal of an intervention increases. A psychiatric consultation may be needed. In all events, seriously injured or ill patients who refuse treatment should be given comfort care rather than turned away because of their refusal. As the distress from the injury or illness increases, and with continued encouragement of medical staff, they may change their decisions.
Given the likely physical and emotional distress of patients with emergency medical needs, their possible estrangement from routine health maintenance, and the diverse psychosocial and cultural backgrounds and expectations that converge in the emergency department, it’s small wonder that the real life “ER” offers an intense immersion course in managing difficult clinical encounters. Emergency Physicians are therefore trained and expected to be the calm minds in the midst of crisis.
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