Working in the emergency department can be dangerous. It is a stressful place for everyone. Many patients are impaired from drugs and alcohol. Mentally ill patients frequently end up in the emergency department. Gun shots have even been fired while I was working in my emergency department.
I have been an emergency physician for over thirty years. During that time, I have been yelled at and threatened. I have been spit at several times, once right in the face. But I have never been physically assaulted – until recently, when I was actually knocked down by a patient. I was not injured but I was surprised at how much this bothered me. I realize the older I get, the more at risk am to being assaulted. Also, to do well in a high-risk environment, one has to kind of fall back on the “it can’t happen to me” defense. Once it has happened to you, it is harder to effectively use that. I was really shaken by this. Enough that it contributed to my decision to retire, a bit earlier that I had planned to. It was important enough that I want to tell you about it.
Staff alerted me that a patient having a seizure had just arrived. He was being wheeled into the room the same time I entered. I saw a healthy-looking young man, about twenty years old, sitting up in the wheel chair. He was clearly faking having a seizure.
For some reason, faking seizures is a pretty common way for people to try to gain attention. Some of them are pretty good fakes but an experienced emergency physician can often tell, at a glance, the patient is not really having a seizure. I shared my impression with my staff. That allowed them to relax and move ahead with stuff like getting vital signs and attaching the patient to the monitor. I went to take care of another patient while all of that was being done.
When I went back into the room, the patient was behaving normally. His brother-in-law was with him and helped give me the following history. The patient had just come from another hospital where he was admitted to intensive care, a breathing tube was passed down his throat and he was treated with multiple medications to get him to stop seizing. The patient and his family were unhappy with his care so they signed him out and brought him to our hospital in the neighboring city. The patient complained, “All they did was just knock me out.” He admitted he had not been taking his seizure medicine before he had the seizure that took him to the other hospital.
I started with his vital signs and a physical examination, which were normal. To evaluate someone who is having seizures, I might have ordered blood tests, a urine drug screen and a CT scan of the brain. However, since he had just come from another hospital, I thought testing might have already been done. I asked the patient for permission to request records from his previous visit, thereby avoiding unnecessarily repeating tests.
Before too long, the report was faxed over from the other hospital. It was pretty amazing. He had arrived having seizures and had been given several medications to stop them. None worked. As a last resort, the patient was paralyzed and put under general anesthesia. A breathing tube was passed into his windpipe and he was placed on a ventilator. All laboratory testing was normal, as was the CT scan of his brain. Up in intensive care, they let him slowly wake up then pulled the breathing tube out. He promptly refused further treatment, signed out against medical advice and left the hospital.
Within a couple of hours, he was back in their emergency department, seizing again. Once more, he was given medications to stop his seizures. They repeated all of the labs and the CT scan. When no medications stopped his seizures, they decided to paralyze and intubate him again. Before they did, he stopped seizing, refused further care, and signed out against medical advice a second time. That’s when he came to our hospital. So, in the last twenty-four hours, the patient received two complete seizure work-ups. All was negative.
Seizures are hard on the brain. Someone who has been seizing a long time usually does not wake up right away. It could take hours before returning to normal mentation. For him to stop seizing, wake up and immediately walk out of intensive care made me wonder if he had been faking all along. Regardless, he was not having seizures in my department. All he needed to do was go home, take his medicine and follow up with his doctor.
As is my habit when discharging someone, I went into the room and sat on a stool at the foot of the gurney. I calmly explained what I learned and why there would be no reason for us to do any additional testing or provide him with any treatment. As what I was saying began to sink in, he started hollering and swearing at me. He stood up, called me several nasty names, pulled off his monitoring pads and yanked the IV out of his arm.
He announced he was leaving and I could see he was in no frame of mind to listen to me anymore. So, I stood, moved to the door and pulled it open for him to go. As he walked by me, he took a big swing at my head. Reflexively, I pushed the door into him to protect myself. The door knocked him back and kept his roundabout swing from landing a blow. He quickly recovered and came back swinging, knocking me down onto the gurney. Fortunately, his brother-in-law jumped between us and pushed him back against the wall, giving me a chance to roll off the gurney onto the floor. I then scrambled out the door on the other side of the room.
I was not injured but I was shaken. I am sure he would have hit me if I had not been able to use the door to protect myself and if his brother-in-law had not been there to hold him back.
I can’t help but think he was a troubled person. I assume everything that happened at the other hospital as well as his assaulting me as I tried to give him discharge instructions were as a result of underlying mental problems. It makes me wonder how long it will be until he attacks someone else and whether that person will be as lucky as I was to escape serious injury.
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