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I started my 12-hour shift in the emergency department (ED) at 1900

hours. It was a busy night, and I was in triage. We were fully staffed at the start of the shift. At approximately 2330 hours, the computer charting system went down. This resulted in a backup of patients in the triage area. I let the patients know about the situation and assured them they would be seen as quickly as possible. I thought that the worst-case scenario was that I would do paper charting. I was all alone in triage after shift change at 2300 hours. At 2345 hours, our computer system charting came back online, and we processed most of the patients in the waiting area. At 0300 hours, two nurses went home at the end of their 12-hour shifts. We were down to five nurses, with a patient ratio of 5:1. The charge nurse and a security guard were in a room with a patient on a "psych hold," so we were pretty busy. No patients were in the waiting room at that time, and knowing what the workload was like, I went to the back to help out.


At approximately 0310 hours, emergency medical services (EMS) brought in a patient who had been in a fight. I took the report and settled him into a room close to the nurses' station. The patient was an East Indian man, and I noted that he had a swollen nose with lacerations and no active bleeding and that he was intoxicated. About 5 minutes later, another patient arrived with alcohol intoxication. Because triage was slow, I stayed to help get the second intoxicated patient processed. The charge nurse assigned that patient to a room isolated from the main area, into which we could not see into very well from the nurses' station. I thought that this was not a good idea, but because EMS had already put him in the bed, I did not say anything.


The patient was sleeping. I measured vital signs and noticed dried blood on his nose and mouth, a swollen nose, and a slightly swollen left eye. I could smell alcohol on his breath. I was taking the report from EMS when the primary nurse came into the room. EMS reported that the patient had sustained his injuries by falling in a parking area. At that point, the patient woke up and said that he had been jumped, beaten, and kicked in the face. The patient was agitated and argued with EMS about what had happened. The situation was getting out of control. We tried to calm the patient by assuring him that we believed his statement. At this point, the primary nurse also became uncomfortable with this patient's being in an isolated area while intoxicated and angry. She asked the charge nurse to relocate him to a room with better visual access from the nurses' station. In the meantime, she started to help the patient get into an examination gown. I went back to the station to finish up paperwork on the first patient.


After a few minutes, I started to wonder what was taking the primary nurse so long and then realized she needed help transferring the patient to the new room because she was small, and the patient was pretty big. She had the patient ready to transfer. She manned the head of the stretcher, and I was at the foot. It was difficult to maneuver in the small area where the beds are very close together, separated only by a curtain. As we were maneuvering the stretcher, the curtain was about to brush across the patient's face. The primary nurse caught it in time and apologized, but as she did, the stretcher bumped into the one in the next bay. I apologized again to the patient. The primary nurse jokingly said, "Be careful, this is a human being on the stretcher."


I laughed at the situation and the playful tone in her voice. The patient reacted by stating, "Do you think it's funny?" I was about to explain myself when he lunged to kick me in the abdomen. I dodged the kick and was about to call the police when the patient pulled off his gown and jumped off the stretcher to attack me. He was cursing and extremely agitated. He moved toward me with an unsteady gait because of his highly intoxicated state. I was concerned that the patient would fall to the floor. As I moved to protect him from a fall, he kicked me in the thigh. The patient continued to kick and punch me. I could have defended myself, but the nurse in me who was concerned for his safety kept me from lashing out. I kept thinking that it is my job to help patients and not to harm them. All I could do was to dodge the patient's punches and kicks while I backed away.


The unit clerk, a physician, and a police officer all grabbed the patient and tried to get him under control. After a struggle, the patient was cornered, and the officer was able to handcuff and subdue him. At that point, his wounds were reassessed, and the police filed a report. When the case came up, I did not press charges. My main concern was that this patient would retaliate against me or my family. I had suffered some bruises, but for me it is just a part of the job. This kind of thing happens on a daily basis in our ED. We later found out that the patient who attacked me had also caused the injuries of the first intoxicated patient who had come in.


Questions


1. What "triggers" for violence can you find in this scenario?


2. What interventions were used to deescalate the situation?


3. What environmental safety measures are described?


4. What other safety measures would you recommend?

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