A) CALMING ANGRY PATIENTS

Use body language to take charge of things. Remain polite, be professional and avoid confrontation or becoming angry or show offended. Check for your own safety first!

First calm the situation and next establish the facts of the case! Acknowledge the patients emotions. Many feel angry as a reaction to loss, guilt or fear. Say ‘I can see what made you angry’. ‘It is understandable that you should feel like this’. Focus the conversation away from the area of sad things towards positive things and plans. Emphasize any grounds for optimism and/or plans for resolving the problem.

An angry person feels lack of control. You may calm an angry patient by lowering your eye level e.g. sitting when he/she is standing or squatting next to him/her. Do not keep your arms crossed, but keep them parallel at your side, or wide. Better use open body language. Have your palms open, faced to the patient (it subconsciously shows that you don’t carry any weapons!).

THE S.A.F.E.S.T. APPROACH

Doctors often encounter patients who are threatening or exhibit violent behavior against the hospital staff, especially on the ER (A&E). Recognize the early warning signs of impeding violence such as changes in patient’s tone of voice, gestures and postures and specifically threatening words, clenched fists, loud voice, agitated movements, striking inanimate objects, fighting body posture.

Underline the causes of an aggressive, violent and/or agitated behavior. There may be an underlying treatable cause such as hypoglycemia, hypoxia, head injury, metabolic anomaly, hypothermia, distended bladder on a patient with spinal trauma (without foul bladder sensation) etc. These situations are aggravated by alcohol and illicit drug abuse.

If an aggressive and violent and/or agitated behavior occurs, then use the S.A.F.E.S.T. approach:

S (Spacing): Maintain distance from the violent and/or agitated patient. Do not touch the patient! Allow both you and the patient to have equal approach to the exit door. Ensure there isn’t any block to your escape. Note where the alarm buttons are situated.

Α (Appearance): Maintain professional empathetic attitude. Use a primary contact person to make rapport with the patient. Call the security staff or the police.

Have security staff available in order to show that you have the control of the situation.

F (Focus): Watch the patient’s hands. Is he/she holding any potential weapons? Watch for increasing agitation.

E (Exchange): De - escalate the situation by calm& continuous talking. Avoid judgmental or punitive statements or patronizing comments. Never insult the patient. Don’t be critical. Don’t try to dominate. Don’t make promises that you can’t keep. Show that you listen what the patient says. Avoid prolonged eye contact. Maintain a calm atmosphere. Avoid interruptions by other staff that may make the patients (especially the psychotic) feel threatened. A calm approach with talking and listening may prevent further aggressiveness.

S (Stabilize): the patient. Use 3 stabilization techniques to get the control of the situation.

1) Physical restraint. Once the situation permits, restrain the violent and/or agitated patient. This should be better done by a special trained security staff of the hospital (who should also search the patient for weapons).

When you use physical restraint, use the minimum degree of force to control the patient. Apply it in a rather calm manner, in order to avoid provoking further aggression. It may require sufficient staff to control the event. Restrain the patient by holding his/her clothes rather than his/her limbs. If you need to hold a limb, then hold it near a major joint to avoid any fracture or dislocation. Remove the patient’s shoes or boots. If the patient is biting, then hold firmly his/her hair! Do not apply pressure to neck, throat, chest or abdomen.

PHARMACOLOGICAL RESTRAINT

Pharmacological restraint is the last resort and should be given on the advice of a senior doctor. Emergency sedation has considerable dangers for the patient and may mask important signs of an underlying illness such as an intracranial hematoma on a patient with head trauma (that may pass unnoticed). Respiratory depression may occur and then ET intubation and ventilation may be needed. Also cardiovascular compromise (such as arrhythmias and hypotension) may occur, especially in struggling, hypoxic patients. There may also be legal implications by the patient who may feel that he was ‘assaulted’ by the hospital staff. Sedative drugs should better giver by oral rout, however this may not be possible in a violent and/or agitated patient. IV sedation has hazards including needle stick injury, however it may be considered in special; occasions.

2) Sedation. If agitation persists then give lorazepam 1 – 2 mg IV or IM or PO (orally) – (if oral rout, use 2 – 4 mg lorazepam). You may repeat dose every 30min, for max 4 doses, if needed. The maximum dose is 16 mg in 24 hours.

3) Chemical restraint. It is best achieved by neuroleptics. If the patient doesn’t respond to sedation, and/or is psychotic give haloperidol 5 –10 mg IM. In older patients start with lower dose and increase by 1 – 2 mg increments. You may repeat dose every 30 min, until the patient is more in control. However, the 1st dose of haloperodol shouldn’t normally been repeated and would be adequate.

Neuroleptics have SEs (side effects) such as seizures, neuroleptic malignant syndrome and extrapyramidal symptoms. Be aware of these SEs. Neuroleptic malignant syndrome is characterized by fever, anorexia, muscle rigidity, extrapyramidal signs, severe dyskinesia, and low level of conscious and autonomic dysfunction (tachycardia and hyperthermia). In hyperthermia on neuroleptic malignant syndrome treat with dantrolene 1mg/kg rapid IV, which can be repeated – according to response – up to a cumulative maximum of 10 mg/kg (consult a senior doctor). Also cooling and bromocriptine (a dopaminergic antagonist) may help.

Allow sufficient time for the above drugs to act, before giving any further doses. As sooner as the situation allows monitor HR, BP, RR (respiratory rate), T (temperature), ECG, SpO2 (oxygen saturation), ABGs (arterial blood gases), CXR (Chest X’ Ray) and take blood and urine for CBC/FBC (complete/full blood count), blood glucose, urinalysis, blood urea nitrogen (BUN), creatinine & electrolytes, LFTs (liver function tests), toxicology screening etc.

However the above drugs are sedatives and may compromise respiration, so ensure when using them that are available adequate resuscitation facilities, including mechanical ventilation! The purpose of the sedation is to calm the patients and not leave them unconscious!

CONSIDER UNDRLYING CAUSES

There are many causes of aggressive behavior such as hypoxia, head injury, hypoglycemia, metabolic abnormalities, smugglers, alcohol and recreational drugs abuse or withdrawal, infection, medications (overdose, side effects, interactions with other drugs or alcohol), MI (heart attack), TIA, stroke, endocrinical disturbance, thyroid disease, cancer, epilepsy and malnutrition (e.g. thiamine, vit B12, nicotinic acid).

T (Treatment): Once the patient is calmer, initiate treatment based on the patient’s symptoms. If he/she refuses treatment, then you may need to treat him/her involuntary in order to insure his/her safety, the safety of the hospital’s staff, and the safety of the rest patients and visitors.
After the episode of verbal or physical violence record full notes on the patient’s files, report the event to your senior attendant and to the police (if appropriate).
When dealing with the violent patient, do not purposely avoid him/her or treat him/her differently, because this may provoke further aggression.

Further information on www.nice.org.uk/pdf/cg025quickrefguide.pdf

B) APPENDIX: MENTAL EXAMINATION TESTS

I) Mental – cognitive examination test
(6 CIT, cognitive function examination, Kingshill, 2000)

Ask		Answer/score
‘Which is the year ?’		Correct 0, Wrong 4
‘What is the month?’		Correct 0, Wrong 3
‘Remember the following address ‘John Brown 42 West Street, Bedford’.’
‘What time is it?’ (approximately to nearest time)		Correct 0, Wrong 3
‘Count back from 20 to 1’		Correct 0, one mistake 2, more than 1 mistakes 4
‘Mention the months of the year but referring them with opposite sequence’ (i.e. December, November etc.)		Correct 0, one mistake 2, more than one mistakes 4
‘Mention the phrase I said before to remember’		Correct 0, one mistake 2, two mistakes 4, three mistakes 6, four mistakes 8, all mistake 10

Maximum total score 28.
Score
0–7 no important cognitive impairment.
8–9 possible important cognitive impairment, possible dementia. Admit the patient.
10–28 Severe cognitive impairment, strong possibility for dementia. Admit the patient.

See also www.kingshill-research.org

II) MINI MENTAL STATE EXAMINATION (MMSE)

a) Orientation (totally 10 points)

What is the year, season, day, date, and month? (5 points)

Where are we: country, county, town, hospital, floor/ward (5 points)

b) Registration (totally 3 points): name clearly (that the patient can hear!) and slowly (allowing about 1 sec to say each) 3 unrelated objects e.g. ball, car, man. Allow 1 second to say each one. Then ask the patient to repeat all 3 after you have said them. Give 1 point for each correct answer. The first repetition determiners the patient’s score.

c) Attention and calculation (totally 5 points): ask the patient to take 7 from 100, and again, total of 5 times. Give 1 point for each correct answer. Stop after 5 answers (93, 86, 79, 72, 65).

Alternatively, if the patient can’t make the above calculation, spell the word WORLD backwards, giving 1 point for each letter in the correct order e.g. dlrow =5 points, dlorw =3 points.

d) Recall (totally 3 points): ask the patient to recall the 3 objects previously stated. Give 1 point for each correct answer.

e) Naming (totally 2 points): show the patient a watch and ask him/her what it is. Repeat for a pen or pencil.

f) Repetition (totally 1 point): ask the patient to repeat the phrase ‘no ifs, ands, or buts’. Allow 1 trial. Score 1 point if the repetition is completely correct.

g) Three – state command (totally 3 points): ask the patient to follow these instructions: ‘take this paper in your left hand, fold it in half and put it at the floor’. Give the patient a piece of paper and score 1 for each state completed correctly.

h) Reading (totally 1 point): write on a paper the phrase ‘CLOSE YOUR EYES’ and ask the patient to read and obey what it says (‘read this sentence and do what it says’). Score 1 point if the patient closes his/her eyes. Give no points if he/she simply reads the sentence loud.

i) Writing (totally 1 point): ask the patient to write a sentence on a piece of paper. Don’t dictate any sentence and not give any example. Correct grammar, punctuation and spelling aren’t necessary.

j) Copying (totally 1 point): ask the patient to copy the following design. All 10 angles must be present and 2 must intersect. Ignore mistakes from tremor or rotation of the diagram.

The MMSE maximum total score is 30. The MMSE score will vary by age and numbers of years in education (decreasing with advancing age and increasing with advancing schooling). The median score is 29 for people with 9 years of education, 26 for 5 – 8 years of education and 22 for 0 – 4 years. Scores less than 23 indicate mild cognitive impairment, scores less than 17 moderate and scores less than 10 severe cognitive impairment.

ΙII) THE ABBREVIATED MENTAL TEST SCORE (AMTS)

1) Date of Birth: ‘What is your date of Birth?’

2) Age: ‘How old are you?’

3) Time: ‘What time is it?’ Correct to the nearest hour.

4) Year: ‘What year is now?’ The hospital patient may often lose track of the day or month, but not the year.

5) Place: ‘Where are we?’ or ‘What is this place?’.
The name of the hospital/ clinic/ surgery.

6) Head of state: ‘Who is the Prime Minister/President/Monarch of the state at the moment?’
A specific name is required, not a generalization such as ‘the Queen’.

7) World War 2: ‘What year did the second world war start?’

8) 5 minute recall: tell the patient an address (e.g. ’42 West Street’) and ask him/her to repeat it back to ensure that he/has heard it correctly. Ask the patient to remember it. Five minutes later ask the patient to recall the address. The patient must remember the address in full to score a point.

9) 20 -1: Ask the patient ‘Count backward from 20 down to 1’.
Patients may need an explanation here ‘Like this: 20, 19, 18, and so on’.

10) Recognition: Ask the patient ‘What job do I do (correct answer: doctor). Point a nurse and ask ‘What job does this man/woman do (correct answer: nurse).

Both must be correct to score a point.

The abbreviated mental test score (AMTS) has total score 10 points (1 point for each correct answer) is a test of cognitive function and impairment. A score equal or less than 6 suggests poor cognition, acute (delirium, acute confusional state) or chronic (dementia).

This test colerates with the more detailed Mini Mental State Examination (MMSE) mentioned above.

NOTE ON THE ABOVE MENTAL EXAMINATION TESTS

Deaf, dysphasic, depressed and un – cooperative patients and those who don’t understand English will also get low scores on the above cognitive function tests!

The above mental examination tests help on the differential diagnosis between dementia and acute confusional state. The last may be caused by infection, drugs, metabolic causes, alcohol/ alcohol withdrawal, hypoxia, MI (heart attack), TIA, stroke, endocrinical disturbance, head trauma, thyroid disease, cancer, epilepsy, malnutrition (e.g. thiamine, vitamin B12, nicotinic acid) and illicit drug abuse.

Dementia has a more long term history and has not fluctuations.

REFERENCE

1. Stone C.K., Humphries R.L., Current Diagnosis and Treatment in Emergency Medicine, McGraw Hill - LANGE, 6th edition, 2008. mcgraw-hillmedical.com

2. J.P. Wyatt, R.N. Illingworth, C.A. Graham, M.J. Clancy, C.E. Robertson, 3rd edition, Oxford Handbook of Emergency Medicine, Oxford University Press. www.oup.com

3. Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008. www.oup.com

4. D. Richards, J. Aronson, Oxford Handbook of Practical Drug Therapy, Oxford University Press, 2008 www.oup.com