Author: Dr. Rohini R

What can doctors do when patients are agitated?

Most doctors and other healthcare professionals are not confident or unable to manage patients and their relatives who are tense, restless, uncooperative, and show other signs of agitation and anger. This can often escalate to verbal abuse and physical violence against hospital staff and vandalisation of the hospital. Younger doctors are at a higher risk of facing violence because they are often the first to see a patient. Younger doctors also lack the appropriate skills required to prevent and manage violence. Learning these skills are as important as gaining medical knowledge, unfortunately it is not part of the medical curriculum.

The First Step Is To Identify And Categorise Agitation

Categorising  the level of agitation can help handle the situation better. It is important to identify the signs or agitation quickly, react quickly and appropriately. Agitation is categorised into:

• MILD: Mildly agitated patient and relatives are able to converse, are cooperative without being disruptive or a danger to hospital staff. They seem restless, irritable, argumentative, defiant, use inappropriate language and keep pacing. 
  
• MODERATE: Moderately agitated patient and relatives are disruptive, mainly towards the hospital but not a  danger to themselves or the hospital staff. They escalate to verbal threats and show increased motor restlessness. This is a high risk situation and can easily escalate to physical violence if not managed properly.
  
• SEVERE: Severely agitated patients and relatives are dangerous to all. Everyone around them is at immediate risk. They assault doctors, other hospital staff and damage property. 

What To Do If Patients And Their Relatives Are Agitated?

Once you have identified and categorised agitation, you need to react quickly and efficiently depending on the level of agitation. Effective and respectful verbal de-escalation techniques will go a long way in managing mild to moderate agitation. 

De-escalation for Mild to Moderately agitated Patients and relatives 

Verbal de-escalation is usually effective in mild to moderately agitated patients and relatives. It is not as easy as it sounds. It requires a calm and deliberate approach which requires training and practice. Some key point for effective de-escalation include environmental and self- awareness. Only one person should be delegated to speak to the agitated patient. If there are many relatives, consider taking the patient with ONLY one family member to a separate room or have the other relatives leave the premises (if they are willing to without a fight). Make sure you take at least one person along with you inside and have a security guard or other colleagues wait out side the room. Verbal de-escalation works best when you are able to speak the patient’s native language. This gives the patient and their family the confidence that you are on their side and not an outsider. Whoever is assigned to speak to the patient should be able to speak the patient’s native language, or ensure they are with someone who can. Shut the door, ensure the room is quiet room, take a minute or two to modulate your own emotional and physiologic responses, remain calm, avoid staring at them, looking angry, clenching your jaw, teeth grinding or smiling excessively (this can trigger anyone that is already very angry), avoid clenched fists, and having your hands visible, do not cross your hands in front of your chest, keep them by your side or under the table if you are sitting. You may now begin to speak when everyone in the room has calm down.

The SAVE mnemonic outlines scripted responses that may be helpful when faced with a violent patient:

• Support: “Let’s work together…”
• Acknowledge: “I see this has been hard for you.”
• Validate: “I’d probably be reacting the same way if I was in your shoes.”
• Emotion naming: “You seem upset.”

Do not state the obvious by saying things alone the lines of “calm down”, “I am a doctor”, “you have no right to speak to me this way”, “be respectful to me”, “I will have you kicked out”, “I have other patients to attend do”, “I don’;t have time for this. Saying “Calm down” could be the most triggering of the lot. 

“Code White” for Moderately and Severely Agitated Patients and relatives

Consideration should be given to calling a “code white”  or any colour set by the hospital for patients and relatives who are an immediate threat to you, other staff and the property. There are pitfalls to this. One is that, if  they are mild to moderately agitated, they can become more agitated and immediately when they hear the announcement, begin assaulting staff and damaging property. Consider a way of  calling a concealed code, directly to security and other hospital staff, instead of using an announcement system. We need to keep in mind that in a country like india, the security are old, frail men, who are not armed and your colleagues may exit the building when you call a code instead of coming to you to help. We have all seen the videos of doctor being assaulted, nobody comes to help. At this stage, verbal de-escalation will not work. You need to decide what to do.  What can you use to protect yourself? What do you haven you? Pepper spray? A scalpel? A stick? An IV stant? A Swiss Army knife? Protective firearms? You are on your own at this point. Assess the number of people in the room, your own fitness level and decide what to use to protect yourself. It is recommended that you take self-defence classes as soon as possible. This is an another important skill for doctors to have 

Using Safe and Effective Physical Restraints

There are several debates as to whether physical restraints should be used at all in the management of the agitated patient. If you are going to use physical restraints, the goal should be to use them only as a last resort while getting a chemical restraint (sedative) ready which should take no longer than five to 15 minutes. However, this would work only if the patient is agitated with just one relative present who you can manage, or if the other family members believe that the patient is being unreasonable and agrees with your decision to restrain them. If there is more than one relative with the patient and they are also agitated and against you, trying to restrain the patient can escalate to assault. 

Running away when you sense violence?

This does not solve the problem. If the patient and relatives have come with vengeance and the intention to be violent, they will be violent. If they can’t find you, they will attack other doctors and staff they see and damage property as well. In fact, the fact that they can’t find you will make them assume you are irresponsible, don’t care enough and trigger them further. You may have escaped temporarily, but you have not solved the problem, you have put others in danger and it doesn’t take long for people to find your address. However, if you are present in the situation and by using effective de-escalation techniques, if you are able to diffuse the situation, you may actually gain the trust of the patient and their family forever. 

In conclusion 

The law/ hospital management system/ security system/ medical education system/ the public/ lack of unity amongst doctors etc. will not change today, tomorrow or even the next decade or two. However, you may face agitated patients/ family and violence on a regular basis. Meanwhile, you are on your own, especially at the junior most level, you will be the first responders and need to defend yourself. Remember that the seniors will not always come to your rescue or teach to you the skills required to prevent manage such situations.

So, what can you do?

• Learn how to communicate effectively to prevent agitation 
• Learn effective de-escalation techniques
• Ensure you carry something to protect yourself 
• Take self-defence classes (this would help outside the hospital too, especially women)
• Support your colleagues 
• Understand your legal rights