EPTS, p

COMPONENTS AND CONF!GlJRATKIII

(Expletive Deleted) Shouter

Roger Johnson, MD, LLB* C/eve Trimble, MD**

Denver, Colorado

e management of the verbally abusive and uncooperative emergency

I psrtment patient is discussed. The authors recommend the use of asenable therapeutic restraint to allow examination and treatment.

f

signed form stating that the patient left the emergency department ainst medical advice does not protect the physician or hospital in a $practice suit. Four cases describing the handling of verbally abusive ICents and the subsequent outcomes are reported.

TRODUCTlON 1 klany noises characterize the emer- ;ncy department and are an inti- Bte part of the world of its practi-

I ners. The wailing of a mother ose car-struck child just has been

bounced dead is a sound that eli- Iheartbreak and prompts the most

ned emergency physicians to their ears. These same ears

up, perhaps subconsciously, to rbled babble of the cerebrovas- accident victim, the slurred

usness of the alcoholic, the ogenic shrieks of the teenie- the fearful fantasy of the

I- rector, Emergency Medical Services,

6 @i- General Hospital, Denver Colo-

!“rmerly with the Department of Emer- $ Medical Services, Denver General %l. Denver, Colorado

?Qted at the annual ACEPiEDNA ent& Assembly in Washington, DC, Iember, 1974.

Roger Johnson, MD, Hospital, W. Eighth and

okee, Denver, Colorado 80204.

I@ July/August 1975

acute schizophrenic, and the howl of a perfectly sane man with a dislo- cated joint. These auditory clues pro- vide insight into the therapeutic needs of the emergency department’s patients.

Yet there is one sound that attracts the emergency department staff only by its repulsiveness, that of the pa- tient who crosses the sanctified threshold of the emergency depart- ment and strikes out with verbal abuse. That same sagacious crew, who expertly handled the other acous- tic experiences, suddenly forgets to re- trieve the history of injury and trans- portation but proceeds straightway to admonish the combatant, no long- er a patient, that if he utters (exple- tive deleted) one more time, they will have his (expletive deleted) hauled to jail.

This particular scene is repeated daily in busy emergency depart- ments. The singularly important les- son here is that no patient presents himself with the sole purpose of shout- ing four-letter Anglo-Saxon expletives in an attempt to shock female staff or to announce his aspiration for ma- jor political office. All too many of

these patients may be suffering from cerebral hypoperfusion as a result of shock, from acute metabolic disturb- ance such as hypoglycemia or poison- ing, from traumatic central nervous system injury, or from an excessive level of a drug (especially alcohol). Any of these conditions may be con- comitant with, and mask, serious in- jury. Emergency staff must give such patients the benefit of the doubt by as- suming that their behavior is an ex- pression of serious physiologic stress until proven otherwise.

Medicolegal Aspects

This situation brings two medicole- gal principles into sharp focus - the first being that of “reasonable thera- peutic restraint” and the second be- ing the merit of the so-called “against medical advice” form. These concepts often merge in the type of patient under discussion and frequently pre- sent an either/or choice. That is to say, when the physically and verbally abu- sive patient presents, should he be tied to the bed and treated against his expressed wishes, or should he be challenged to sign a prepared form and left to his own devices?

Emergency personnel often fearful- ly regard the first approach as a form of assault and battery for which they may later be held accountable. Reluc- tance to physically restrain a patient against his will is natural, as even the Constitution confers the right to be left alone, supposedly the right most valued by civilized man. Con-

Volume 4 Number 4 Page 333

sent doctr ines have s t ressed tha t the in ten t iona l touching of another per- son wi thout his au thor iza t ion is ille- gal - - a ba t te ry .

However, the Commiss ion on Medi- cal Malpract ice found the doctr ine ot~ informed consent imposes an unrea- s o n a b l e r e s p o n s i b i l i t y upon t h e physician. ~ This would obviously ap- ply to the emergency se t t ing where therapeut ic r e s t r a i n t is not only man- da tory but, often, perfect ly defensible

An "aga ins t medical advice" form does no t s u b s t i t u t e for r e s t r a i n t . Whi le the acquis i t ion of a s igna ture seems easy, c lean and legal, in fact, it is a fa lse s e c u r i t y b l a n k e t for the emergency staff.

Case Reports

T h e d e p r e s s e d e x p l e t i v e shout - er. A 22-year-old man, s t ruck by an automobi le , was b rough t by ambu- lance to a large ci ty hospi ta l emer- gency d e p a r t m e n t . He was awake , a ler t , sober, and, in i t i a l ly , coopera- tive. However, when the surgical resi- dent proposed performance of an ab- dominal lavage to diagnose suspected in te rna l injury, the pa t i en t suddenly became exceedingly be l l igeren t and verba l ly abusive. He refused any fur- ther examina t ion and demanded his c lothes so t h a t he could leave. Be- cause of th is behavior , severa l s taff m e m b e r s b e g a n c h a l l e n g i n g h i m wi th the ~ 'against med ica l advice" forms. However, an exper ienced resi- dent reques ted the counsel of the med- i co l ega l a d v i s o r , who o r d e r e d re- s t r a in t and t r e a t m e n t of the pa t i en t aga ins t his will. The abdomina l t ap was negative• The pa t i en t was then admit ted , in res t ra in t s , to the surgi- cal in tens ive care un i t for observa- tion.

I t was l ea rned shor t ly the rea f t e r t ha t he had a t t emp ted suicide by step- p ing in front of an automobi le . He was then t rans fe r red to psychia t r ic in- pa t i en t t r e a t m e n t for his s i tua t iona l depression.

T h e h a l l u c i n a t i n g e x p l e t i v e s h o u t e r . A 15-ye~/r-old y o u t h be- came wildly u n m a n a g e a b l e after in- gest ing an unknown quan t i t y of LSD. His older b ro ther took h im to a small , p r iva te emergency depa r tmen t . Be- cause of his loud abus ive l anguage and bizzare behavior , the police were called and asked to t ake the pa t i en t

Page 334 Volume 4 Number 4

to the c i t y - c o u n t y hosp i t a l , w h e r e there were "faci l i t ies to manage this k ind of a pat ient ." No t r e a t m e n t was rendered and the pa t i en t was s imply kept from leav ing un t i l the police ar- r ived. Then, he became very qu ie t and cooperat ive, so the officers did not place h im under a menta l hea l th hold.

While the police officer was furnish- ing i n f o r m a t i o n to the a dmis s ions clerk a t the c i ty-county hospital , the p a t i e n t q u i e t l y s l i p p e d ou t of the emergency depa r tmen t , wa lked t en blocks to a downtown office building, and jumped th rough a window to his death. His family sued the hospi ta l for not p reven t ing the dea th by re- s t r a in ing the pat ient .

T h e h i p p i e e x p l e t i v e s h o u t e r • An unkempt , long-hai red 23-year-old man was admi t t ed to a smal l hospi- t a l ' s emergency d e p a r t m e n t follow- ing a ser ious automobi le accident. He was uncooperat ive and loud in his ver- ba l abuse. When presented with the rout ine consent form, he stated: "I 'm not going to s ign any (expletive de- leted) paper; I j u s t wan t to get the (ex- plet ive deleted) out of here." The odor of alcohol was noted on his b r e a t h and o b s e r v e r s b e l i e v e d h i m to be under the influence of drugs.

Al though he pe rmi t t ed a reported- ly carefu l neuro log ic e x a m i n a t i o n , his verbal abuse cont inued and he up- set the ent i re emergency staff. Since he made no physical complaints , the examin ing phys ic ian concluded, with- out x-rays, t ha t there was noth ing ser- iously the ma t t e r wi th him. He was hu r r i ed ly d ischarged and was carr ied to a car by friends, as he was unable to walk unaided. Severa l hours la ter , because of numbness in his ext remi- ties, he was t a k e n to a different hospi- ta l where he ¢vas found to be quad- r iplegic. X-rays revea led a f rac ture and sub luxa t ion at C-6 and C-7. He la te r filed a successful lawsui t aga ins t both the e m e r g e n c y phys i c i an and the hospital .

T h e p o l i c e - h o l d e x p l e t i v e s h o u t - er. A 19-year-old m a n was brought to a large ci ty hospi ta l emergency de- p a r t m e n t by the police after being ar- r e s ted for d r u n k e n n e s s in a pdbli~ place and caus ing a dis turbance. Al- though he was in handcuffs , when first contacted by the in te rn he was so phys ica l ly uncooperat ive tha t he had

to be fur ther res t ra ined . He Was ve~ bal ly abusive and referred to the start in the most basic s t r ee t venacular :'t very cursory examina t i on was d,~tq no x- rays were taken , and the Pahee ,.v.h,

sent to ja i l . After being found pa" ~' w a s

alyzed the next morning, he Was re'l.~ t u r n e d to the hosp i t a l . Cervical rays revea led a C-5 and C-6 fractur dislocation.

U p o n q u e s t i o n i n g s e v e r a l day s l a t e r , the i n t e r n a d m i t t e d that he was so angered by the pat ient ' s abu, s iveness tha t he " jus t wanted to get r id of him." His examinat ion , in real. i ty, had been incomplete. The avail. ab i l i ty of a puni t ive j a i l ing was t~ convenient to pass up. This patient al so filed a successful l awsui t again the hospital .

DISCUSSION

The first two cases exemplify h0~ one suicide was aver ted and another al lowed to happen. In the lat ter two cases, p e r m a n e n t i n ju r i e s resulted from the emergency s ta f f s failure t~ I exer t necessary the rapeu t ic restralnl in response to a pa t i en t ' s offensive h~ havior. When a l awyer is defendlnga physic ian 's act ions in a malpractice case, obsceni ty on the par t of the pa t ien t would not jus t i fy improper re lease from the hospi ta l . To prove thlb I point, in the voir d ire examination (se lection of the jury) , the plaintiffs a torney would probably ask each p0 I t en t i a l ju ror the following:

Q u e s t i o n : '~Does the word 'fuck'~ ~, t ha t you will be unable ~1 upset you

r e t u r n a verdict based upon the e~, ]

dence?"

• ' ~ " " e 0 Q u e s h o n : Does the p lamtf f fsus 1 t ha t word excuse the doctor from praq t ic ing careful medicine?"

A ju ry even tua l ly will be selected fr0~ those answer ing no to each•quest~0~

This j u ry will agree, in advance, t~ r e tu rn a verdict based solely upon th~ evidence, l i t e r a l l y p romis ing to lg nore exple t ives wherever used in thl t e s t i m o n y . In fac t , t h e patient' swear ing could have a favorable l~

*It is the opinion of the authors that re~,] ers who are offended at this specific lnc] sion might well find themselves m dang1 of being intimidated in the clinical settl~ and thus be vulnerable to committing1 same errors described in this article

July/August 1975 J ~ [

!!, Airing a t r ial if proper ly ex- ¢~ ]~y his attorney. Also a signed, i t e u , , • inst medical advice document

further s t rengthen the plain- case The fact tha t the pat ient

~1': --arently performed an act that ~d a~ins t his legal and medical in- }s.~ = ould be p resen ted as evi- [nce of the unsound condition of the Lient An illegible scrawl, in no [~ res'embling his usual signature, ~ld only reinforce the view that the Itient was incompeten t to refuse atment-

lsychological stress often provokes 0spital i n p a t i e n t to s ign ou t nst medical advice• This action is culmination of a progression of be-

h a v i o r a l c h a n g e s r e l a t e d to fear, anger, psychosis, unrecognized trans- ference reactions, impasses with staff, unmet dependency needs, and family difficulties. 2 The inpatient 's threa t to sign out must be viewed separately from what is encountered in the emer- gency setting• Here the "sign out" is mos t f r equen t ly the s t a f f s t h r e a t against an uncooperative patient.

CONCLUSION

The entire emergency heal th team must shed their personal sensitivi- ties to the vulgar and combative pa- t ient and approach tha t individual with the supposition tha t he is ser- ious ly ill or in jured un t i l p roven

otherwise. Physical res t raint should be used to the degree necessary, re- gardless of the patient 's consent, to as- sure complete and thorough evalua- t ion and t r e a t m e n t . The "aga ins t medical advice" form probably has lit- tle valid purpose in the practice of emergency medicine.

REFERENCES

1. Informed consent to treatment. Report of the Secretary's Commission on Medical Malpractice, Department of Health, Edu- cation and Welfare, p 29, January 16, 1973.

2. Albert HD, Kornfeld DS: The threat to sign out against medical advice. Ann In- tern Med 79:888-891, 1973.

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