Dangers of psychiatry- resident stabbed

[90sportsfan]

I know this probably gets over blown, but I admit, I always had a subconscious nervousness about patients before my Psych rotation. Although as we all learn, the average psych patient is not violent at all.

You all probably heard of this recent incident:

Penn Medicine doctor sues Pennsylvania Hospital after being stabbed by patient

Pennsylvania Hospital faces a lawsuit from a Penn Medicine doctor who alleges the hospital disregards the safety of its practicing physicians.

www.thedp.com

A Psychiatry resident was recently stabbed. Have any of you guys ever felt unsafe with a patient during training or practice, and what are general precautions that can prevent a very rare aggressive/violent patent?

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[michaelrack]

It's not that rare, especially when dealing with the chronically mentally ill who require inpatient treatment

 

[futuredo32]

Be careful. Read about the patient's history especially as it pertains to violence. I was assaulted by an inpatient at a hospital where I am currently working as a locums. I was speaking with the patient in an interview room. He was becoming agitated and I attempted to "talk him down". That didn't work and I started side stepping out of the room and I was almost out and the nurse came in, the patient lunged at me and had me in a choke hold and scratched me quite a bit. I froze and don't recall any of it. I listened the to the nurse tell the police officer what happened and I just repeated it. It wasn't in the chart, but later learned the patient had broken someone's arm a few years prior while inpatient. I now take someone with me (a PCT or even security ) if a patient has a history of violence or is threatening. I sit closest to the door and sit at least 6 feet from the patient. The hospital where I am working takes extremely violent patients. One was so violent in the jail and was assaulting the officers, so they dropped his bond, released him on his own recognizance and dropped him off at the hospital. I had to see him with SIX people, three PCTs and three security guards. I heard of a resident leaning in to hear a patient while evaluating him in the ED and he caused head trauma and she is permanently deaf in one year. I treat EVERY inpatient as potentially violent. I let someone on the unit know I am going to see the patient, sit closest to the door and keep my distance from the patient. I am cautious with some outpatients, especially on the first visit.

 

[nexus73]

I usually don’t do sit down interviews with people like this. Interview standing from the doorway of their room on the psych unit or ED. Patients have definitely scared me.

 

[90sportsfan]

Wow...thanks for all the candid responses! These are great practical pieces of advice. I am actually leaning towards Neuro but like Psych (and are specialties are obviously closely connected) so this is good to know. The patient who assaulted the resident was actually previously being seen by Neuro, so these are good precautions we all should take. Thanks.

 

[michaelrack]

It's hard to take precautions when a psych patient suddenly becomes agitated and runs at you from across the hall.

 

[robellis]

Patients are unpredictable similar to a wild animal, you have to be very careful and treat it as you would if you were a zookeeper taking the appropriate precautions

 

[wolfvgang22]

Always trust your gut. If your instincts make you feel uneasy or cautious, listen to them. I've flat out declined to interview a patient based on that more than once. Never been wrong. Often it's better to medicate and wait.

 

[TexasPhysician]

50% of the residents in my residency class were technically assaulted during training. Alll but 1 were assaulted in neurology cases, not psych. The 1 remaining occurred on a peds rotation. None required any medical care.

We were trained to monitor patients on inpatient for signs of aggression. When that occurs, the interview is over….or done behind a large medical student - that’s why you have them right ?

 

[nexus73]

I've many times told agitated patients in midst of psychosis that their yelling is scaring me, and surprisingly many they have been able to calm down, at least enough to interview briefly.

 

[birchswing]

Patients are unpredictable similar to a wild animal, you have to be very careful and treat it as you would if you were a zookeeper taking the appropriate precautions

I like to think they're more like racehorses and need to be handled like one.

 

[WisNeuro]

50% of the residents in my residency class were technically assaulted during training. Alll but 1 were assaulted in neurology cases, not psych. The 1 remaining occurred on a peds rotation. None required any medical care.

We were trained to monitor patients on inpatient for signs of aggression. When that occurs, the interview is over….or done behind a large medical student - that’s why you have them right ?

Yeah, I've done a fair amount of inpatient work, both on psych and neuro units. Never had a swing taken at me on psych units, have had a swing and other aggressive behavior on neuro units.

 

[Dave1980]

Seems like a great way to get all admin and attendings in your department to hate you and put you under the microscope. this person had better be a model resident from here on out

 

[MacDonaldTriad]

If you academically look at assaults, geriatric units are #1, closely followed by adolescent units (second mostly likely to be hit at). If you look at medicine in general, the Medicine ER residents have it the worst. We had a bad incident where the human beings who were in charge of our safety did their job, but ended in a death in our hospital. The social justice enthusiasts did their best to make change, but like all examples of public furor, the actual fruits of such efforts are difficult to measure. It seems that there is federal law that allows for firearms to be carried for all law enforcement officers any where they are except court, prisons, and locked inpatient psychiatric units. At least the last part helps. Just like our ability to hold people against their will, the safety officers have an extreme dilemma about how to deal with human rights and protect all of us. There is no good answer to this.

 

[comp1]

This happened with a neurology patient on a neurology floor. Other than the psychiatrist being a consultant, I'm not understanding why this person was called a "psychiatric patient." It can happen in any specialty, unfortunately. It can also happen in retail or many other jobs. In inpatient psychiatric units we at least anticipate and prepare for it through training.

 

[WisNeuro]

Honestly, I've had far more threats from patients/family members of patients not wanting to comply with clinic COVID and mask requirements in the past 6 months than from inpatients over my entire career.

 

[robellis]

Seems like a great way to get all admin and attendings in your department to hate you and put you under the microscope. this person had better be a model resident from here on out

Hmm

 

[SunBakedTrash]

Honestly, I've had far more threats from patients/family members of patients not wanting to comply with clinic COVID and mask requirements in the past 6 months than from inpatients over my entire career.

I think many of us have learned to tread lightly when we are sandwiched between societal privilege and illogical perceptions of discrimination.

 

[Monocles]

This is terrifying and one of my worst fears.

In adult residency we rotated at a particularly violent hospital where the administration was all around negligent in terms of trainee wellbeing. There had been faculty members brutally battered by patients in broad daylight, and during my three years there many patients had made death threats against me. Ngl but it was definitely one of the biggest contributing factors to me wanting to get out of medicine as soon as possible.

It took me years after leaving that place to finally feel comfortable going to crowded places like supermarkets, without the fear of worrying about some random homeless guy coming up behind me and slitting my throat.

 

[Taddy Mason]

I worked in psych for several years in undergrad, rotated through more than one maximum security prison in med school and residency, worked on an urban ACT team with a lot of patients with psychosis and substance use issues in a low income and high crime area, currently moonlight at a maximum security prison/forensic facility specifically for individuals with psychiatric disorders and a history of violence, and my spouse worked as a psych nurse for 6-7 years. Based on our n=2 experiences 99% of the time someone was assaulted there were clear warning signs exhibited by the assailant prior to the assault that people ignored/were oblivious to or the person who was assaulted clearly provoked the assailant (not that it justifies the attack, but it could have very easily been avoided). The instances I’ve encountered where a significant assault occurred and was largely unexpected are few and far between and tended to be on child/adolescent units (vast majority), in the ED, or on acute units in state hospitals and were perpetrated by individuals with well known histories of violence and/or impulsivity. In the ED and state hospitals a common underlying factor was lack of certain safety considerations by the facility (particularly with EDs being overly stimulating environments to begin with) and the person attacked tended to be someone with little to no training in dealing with potentially violent individuals (e.g., cleaning staff, sitters, etc.). I’ve been assaulted by patients on multiple occasions (the vast majority of which occurred on the child and adolescent units of a specific hospital while working as an aide) and with the exception of one instance with a 10 year-old patient there were pretty obvious things I could’ve done differently to avoid being hit, slapped, have something thrown at me, etc., and thus take some ownership for the fact that those incidents occurred. You don’t need to go all out and always bring security or multiple staff members with you or only see patients from the doorway while standing (obviously there are exceptions, but they are just that, exceptions). Any fear or apprehension you exhibit through your behavior can easily be misinterpreted by psychotic or cognitively altered individuals and heighten their own fear, mistrust, and apprehension and trigger them to become defensive and act on impulses. Also, as another poster noted above, simply informing a patient that their behavior or demeanor is making you uncomfortable can go a long way in diffusing potentially aggressive patients. Common sense, actively appraising a situation, and being cognizant of your surroundings goes a long way and should keep you from being assaulted or reasonably injured by a patient 99.9% of the time.

As an aside, when talking about aggressive or assaultive patients there's a broad spectrum of behaviors in terms of actual harm and intent to harm that are simply lumped under the umbrella of "assault". There's a big difference between someone throwing a paper cup of water or taking a half-assed swing at someone v. breaking someone's nose or stabbing someone. The vast majority of what is labeled as assault in hospitals tends to more in line with the former than the latter. Also, in my experience, the majority of incidents in which patients physically attacked someone tended to occur at community hospitals.

 

[calvnandhobbs68]

Also, as another poster noted above, simply informing a patient that their behavior or demeanor is making you uncomfortable can go a long way in diffusing potentially aggressive patients. Common sense, actively appraising a situation, and being cognizant of your surroundings goes a long way and should keep you from being assaulted or reasonably injured by a patient 99.9% of the time.

I think this is a really helpful technique that is really underutilized even by people who I feel should actually understand how to keep themselves from being assaulted (ex. forensics fellows/attendings I've rotated with). Utilizing the "the way you're pacing right next to me/yelling at me/threatening me/moving around the room/etc. is making me feel unsafe/uncomfortable right now" can be very helpful both to verbalize the tension and force the patient to address at and to appraise how the patient reacts to this. If they obviously don't care/don't respond or get even more threatening, time to start evaluating an exit/wrapping things up or put an actual limit in place while having an easy exit if they don't go along with the limit. Somebody who doesn't respond to the "I'm feeling uncomfortable and would feel a lot more comfortable continuing talking if you sat down right now to talk to me" appropriately is someone who is risky to continue talking to at that moment.

Another thing I see people violating all the time is staying outside of arms length of patients who you have any inkling could potentially be violent (including when you're giving a patient who hasn't been violent any kind of unwanted news) unless you're doing a physical exam or something. I've been guilty of this myself and try to catch myself doing it. The "we're not discharging you" talk I'd bet is one of the more confrontation prone talks.

 

[Taddy Mason]

The "we're not discharging you" talk I'd bet is one of the more confrontation prone talks.

Lol, I’d have to go with the “we ARE discharging you” talk with malingering patients in the ED as being fairly confrontation prone. This is the situation I most frequently end-up asking security to accompany me when talking with a patient.

 

[thepoopologist]

I know this probably gets over blown, but I admit, I always had a subconscious nervousness about patients before my Psych rotation. Although as we all learn, the average psych patient is not violent at all.

You all probably heard of this recent incident:

Penn Medicine doctor sues Pennsylvania Hospital after being stabbed by patient

Pennsylvania Hospital faces a lawsuit from a Penn Medicine doctor who alleges the hospital disregards the safety of its practicing physicians.

www.thedp.com

A Psychiatry resident was recently stabbed. Have any of you guys ever felt unsafe with a patient during training or practice, and what are general precautions that can prevent a very rare aggressive/violent patent

This is not a risk unique to psychiatry. Its a risk that occurs when you encounter any patient who is awake, or any of their family members for that matter

Also on the psych floor we generally have a good idea of people's history and proceed with caution (all the techniques already mentioned above). Assaults still happen even despite our best efforts. The one plus we have going for us is telepsychiatry is a thing.

Anyway I'm glad the psych resident shined a really bright light on it because hospital administration loves to keep things like this quiet. Physician suicide, overwork, pay cuts are other topics they love to avoid talking about. I'm sure the C-suite execs are livid about the lawsuit and figuring out a way to retaliate against the psych resident for not accepting that getting stabbed is part of the job.

 

[90sportsfan]

These are such good tips. As someone interested in Neuro, where it seems like potential assaults can be even more common, I will definitely be using these precautions going forward. I especially like the suggestions of simply letting a patient know if they are making you feel uncomfortable, reviewing the EMR for any red flags, and keeping appropriate distance and/or having people with you with certain patients. These are the types of intangible, patient care things they should teach all medical students because any practicing physician should have this knowledge. Thanks for all the great input!

 

[WisNeuro]

Pro tip, be over 6 feet tall, with a background in wrestling, with some training in boxing and jiu jitsu. That usually helps feel more at ease in these situations.

 

[TexasPhysician]

These are such good tips. As someone interested in Neuro, where it seems like potential assaults can be even more common, I will definitely be using these precautions going forward. I especially like the suggestions of simply letting a patient know if they are making you feel uncomfortable, reviewing the EMR for any red flags, and keeping appropriate distance and/or having people with you with certain patients. These are the types of intangible, patient care things they should teach all medical students because any practicing physician should have this knowledge. Thanks for all the great input!

It is quite tough with many Neuro patients to see it coming. The most common type of assault that I’ve seen is physicians moving in closer to hear an elderly Neuro patient with dementia. Physicians let their guard down thinking 80y/o grandparent with 15 grandchildren in the room must be sweet and loving. Placing your head that close to a patient places you in a vulnerable position.

 

[deleted1100659]

In outpatient the risk is substantially less than inpatient/ED i would assume but overall..

1. Know the patient and be aware of any hx of violence/potential for it

2. Always maintain safe distance, when patients move too close, respectfully ask they remain in an area. If that fails, and theyre too close, your safety is priority over interview

3. In ER/inpatient I never do an interview sitting down

4. Keep patient in LOS at all times

5. Control your access to exits

6. read body language/verbal tone, watch for shifts

7. ANYONE can turn violent

8. any verbal aggression, I end the interview and come back. Patient gets to sit and wait. No one likes waiting. operant conditioning.

9. Control the interview, don't come off timid, unsure, worried. Project confidence. Even if its false confidence, people tend to be more amendable if you assert yourself in the proper way.

 

[Splenda88]

Always assume most (not only psych) patients are violent. We are in tough business in which most people have unreasonable demands.

 

[nexus73]

Luckily physicians get paid well and aren't dumped on with boatloads of regulatory nonsense and poorly functional EMRs so they have time and energy to just be the heroes we need them to be.

 

[90sportsfan]

This is terrifying and one of my worst fears.

In adult residency we rotated at a particularly violent hospital where the administration was all around negligent in terms of trainee wellbeing. There had been faculty members brutally battered by patients in broad daylight, and during my three years there many patients had made death threats against me. Ngl but it was definitely one of the biggest contributing factors to me wanting to get out of medicine as soon as possible.

It took me years after leaving that place to finally feel comfortable going to crowded places like supermarkets, without the fear of worrying about some random homeless guy coming up behind me and slitting my throat.

Geee.....sorry you had that experience. Yeah it is a little scary dealing with patients. I think primary care, EM, and Psych/Neuro are kind of on the front line of potentially difficult patients. I have a few classmates looking at Radiology in large part because they don’t want to have to deal directly with patients, and the baggage they can bring.

 

[Splenda88]

Geee.....sorry you had that experience. Yeah it is a little scary dealing with patients. I think primary care, EM, and Psych/Neuro are kind of on the front line of potentially difficult patients. I have a few classmates looking at Radiology in large part because they don’t want to have to deal directly with patients, and the baggage they can bring.

Arguably one of the best specialties in medicine. I am saying that as an IM doc. Patient interaction is overrated as >50% of them don't care about their health.

 

[Mad Jack]

I had one violent patient in my residency, the guy sent three staff members to the hospital. He had intellectual disability and it was completely unprovoked, it took three security guards to subdue him and one ended up taking several blows to the head in the process. If we didn't have good security, guaranteed someone would have died, and there was no opportunity for de-escalation (he just ran into the nursing station when it was open and started trying to punch nurses). It's a rare thing, but it happens. There was an attending at a local hospital that was beaten quite badly with a coat rack by a patient, and I knew a resident that made the mistake of wearing a tie that was nearly choked to death when a patient grabbed it and pulled it through a door (thankfully security had a knife and freed him, but if they weren't there he would be dead).

Never let a patient be between you and the exit. Always stay outside of arm's reach, and the more concerned you are, the further away you should be. Be aware of all objects in the room, with a focus on potential mechanisms of injury. If a patient starts to get aggressive don't attempt to defuse the situation unless you are confident in the endeavor, as a lack of confidence will often feed aggression. When in doubt, bring someone along that you trust and that also won't be a liability if things go south. Never forget that you can always conduct another interview but that you've only got one life and act accordingly. No ties. If your hair is long, keep it up.

There's a few dozen other things I can't think of right now, but these immediately came to mind. There's certain patient populations that can be more dangerous, but you never know someone's history and should always be on guard to some degree.

 

[When is graduation again?]

I know this probably gets over blown, but I admit, I always had a subconscious nervousness about patients before my Psych rotation. Although as we all learn, the average psych patient is not violent at all.

You all probably heard of this recent incident:

Penn Medicine doctor sues Pennsylvania Hospital after being stabbed by patient

Pennsylvania Hospital faces a lawsuit from a Penn Medicine doctor who alleges the hospital disregards the safety of its practicing physicians.

www.thedp.com

A Psychiatry resident was recently stabbed. Have any of you guys ever felt unsafe with a patient during training or practice, and what are general precautions that can prevent a very rare aggressive/violent patent?

I would caution against the boldest sentiment. I forget where I read this, but most studies that show those results combine data from all psychiatric patient populations including mild depression and anxiety, which far outnumber people with SPMI. The people you see in in-patient settings, especially with substance or psychotic illness, are more likely to be violent than the general population. But they're also more likely to be victims of violence. Bear in mind, that that's a relative claim. In absolute terms, the risk you will be assaulted are low, but not negligible. I attached an article from Sweden tracking the relationship between hospital discharge after set time intervals and acute forms of risk.

That said, I agree with everyone else. There are usually signs that a patient is becoming agitated. If the situation seems unlikely to be defused, walk away and try again later. If you feel uncomfortable in a situation, that's probably a sign that you should proceed carefully.

 

[robellis]

I would caution against the boldest sentiment. I forget where I read this, but most studies that show those results combine data from all psychiatric patient populations including mild depression and anxiety, which far outnumber people with SPMI. The people you see in in-patient settings, especially with substance or psychotic illness, are more likely to be violent than the general population. But they're also more likely to be victims of violence. Bear in mind, that that's a relative claim. In absolute terms, the risk you will be assaulted are low, but not negligible. I attached an article from Sweden tracking the relationship between hospital discharge after set time intervals and acute forms of risk.

That said, I agree with everyone else. There are usually signs that a patient is becoming agitated. If the situation seems unlikely to be defused, walk away and try again later. If you feel uncomfortable in a situation, that's probably a sign that you should proceed carefully.

Agreed that statement that keeps getting thrown around is pointless, like yes psych patient may more likely be victims but they are also more violent than average so those things are not mutually exclusive and also are kind of common sense

 

[90sportsfan]

Agreed that statement that keeps getting thrown around is pointless, like yes psych patient may more likely be victims but they are also more violent than average so those things are not mutually exclusive and also are kind of common sense

Yeah, that's true. I should have clarified. I think you'd be more likely to encounter a violent patient in a pool of psych patients (vs. the general population), but I meant the average psych patient you encounter is probably not likely to be violent. But that's not entirely true as a lot of factors, such as practice setting, specific patient population, etc. play into the equation. So I agree, it's probably not the most accurate statement to make.

 

[hallowmann]

I've had a lot of verbal threats (killing, cutting throat, etc.) thrown at me, racist comments etc. I've been hit or scratched a few times, but usually by a kid lashing out or a patient with dementia for whatever reason that I'm trying to prevent from doing something harmful to themselves until restraints can be secured. The violent psychotic patients or acutely intoxicated ones get plenty of distance, a calm voice, and limited dialogue if it's not going anywhere but escalation.

It happens, but it's rare, and to be honest, I've been more threatened by patients on medical floors without the cameras, staff, restraints readily accessible, and more things that could be used to harm you than is typically available on the inpatient psych units.

 

[deleted1100659]

What really annoys me is in my area, police are extremely hesitant to get involved when a psych patient is aggressive or makes threats, even if the patient is obviously 100% competent. Ive seen too many malingering aholes continually get away with bad behavior that I have limited desire for ER psych.

 

[futureapppsy2]

Honestly, violence can happen in any specialty (heck, you can be that nephrologist who got in that literally fistfight with a cardiologist over patient care) for reasons of illness, stress (sickness/injury is inherently very stressful), addiction/drug-seeking, perceived poor treatment, family grief, etc. I would be interested to know if there's been any research looking at assault rates of physicians and other clinicians by patients--I'd guess EM would rank highly and maybe pain med, in-patient psych, critical care, and primary care. When these current writing tasks are a bit more managable, I'd like to look into it.

Also, can we maybe not refer to patients as akin to animals? There's a long history of treating disabled people, especially people with psych disabilities, as subhuman, which has lead to pretty horrific abuse, and it makes my skin crawl a bit to perpetuate that.

 

[birchswing]

Honestly, violence can happen in any specialty (heck, you can be that nephrologist who got in that literally fistfight with a cardiologist over patient care) for reasons of illness, stress (sickness/injury is inherently very stressful), addiction/drug-seeking, perceived poor treatment, family grief, etc. I would be interested to know if there's been any research looking at assault rates of physicians and other clinicians by patients--I'd guess EM would rank highly and maybe pain med, in-patient psych, critical care, and primary care. When these current writing tasks are a bit more managable, I'd like to look into it.

Also, can we maybe not refer to patients as akin to animals? There's a long history of treating disabled people, especially people with psych disabilities, as subhuman, which has lead to pretty horrific abuse, and it makes my skin crawl a bit to perpetuate that.

Thank you.

I was hoping my racehorse comment (a direct quote from the news recently that was used to reference a famous person with mental illness) was picked up as disapproving satire in reference to the other post referring to patients with mental illness as wild animals.

I can't appreciate the dangers psychiatrists feel that they face, but when you take on the whole the dangers patients with mental illness face from diabetes, drug dependency, or cardiac arrhythmias, and so on, well, it's another way to look at it. It's not entirely safe for anyone involved.

 

[Mad Jack]

What really annoys me is in my area, police are extremely hesitant to get involved when a psych patient is aggressive or makes threats, even if the patient is obviously 100% competent. Ive seen too many malingering aholes continually get away with bad behavior that I have limited desire for ER psych.

There's ways to get them involved. Getting the number of the local DA can be helpful

 

[Mad Jack]

Honestly, violence can happen in any specialty (heck, you can be that nephrologist who got in that literally fistfight with a cardiologist over patient care) for reasons of illness, stress (sickness/injury is inherently very stressful), addiction/drug-seeking, perceived poor treatment, family grief, etc. I would be interested to know if there's been any research looking at assault rates of physicians and other clinicians by patients--I'd guess EM would rank highly and maybe pain med, in-patient psych, critical care, and primary care. When these current writing tasks are a bit more managable, I'd like to look into it.

Also, can we maybe not refer to patients as akin to animals? There's a long history of treating disabled people, especially people with psych disabilities, as subhuman, which has lead to pretty horrific abuse, and it makes my skin crawl a bit to perpetuate that.

There was a study a few years back which I'm too lazy to look up that showed ER staff are the most likely to be assaulted by patients and behavioral health staff are the most likely to be killed by them. Most assaults occur on-unit/in the ER, while most murders occur in outpatient practices or at the clinician's home. Young, male patients with a history of psychosis and access to firearms were the typical profile of individuals committing homicide.

 

[mistafab]

Before any new psych med student rotated with me, I would give them a talk on safety and security on the unit. I covered a lot of self-defense and vigilance ideas like knowing your position in space, keeping maximum POV, minimizing flanks… etc.

The variance in student behavior after this talk was astounding. Some students are completely clueless how dangerous their decisions on the unit were. Luckily none of my students were ever assaulted, but again this was by luck and not training or systemic safety nets. Most MDs are clueless in general when it comes to street smarts in any general way.

 

[MedMan80]

Had an antisocial patient trash our unit and computers and came face to face with me in the nursing station when I was in training, i was so lucky i didn't get punched..should've played the lotto that day.

 

[NickNaylor]

I had a delirious patient punch a neurosurgery resident who was seeing the patient with me in and then get me in a headlock. Ultimately had to be tackled in the bed. Had another guy intoxicated on PCP chase me around the ED for a bit after I asked him what kind of contact he had with his kids.

Agitation/aggression definitely happens. The best thing you can do is to be careful around patients that have a history of being aggressive and "reading the room" appropriately. I generally find myself more concerned about patients with antisocial traits and those that are acute intoxicated than I am with most patients that are manic and psychotic.

 

[trixter888]

Psychotic patient in residency who would "always come to the appointments with knives." Admin told me it was okay, and to "get used to it." As soon as patient showed me his knives during our first appointment, I got security to escort the patient out. We have to have our own boundaries.

 

[mdphd123j]

What happened to the resident at Pennsylvania Hospital is absolutely horrible… and, as a medical student, reaffirms my selection of psych as the specialty I would not touch with a 10-foot pole. Hope I like surgery😐

 

[Stagg737]

A Psychiatry resident was recently stabbed. Have any of you guys ever felt unsafe with a patient during training or practice, and what are general precautions that can prevent a very rare aggressive/violent patent?

Yes, as an intern I had an antisocial patient basically take a swing at me after he'd sobered up from PCP use who had to be subdued by security. Calling security before engaging with him was probably one of the smartest things I've done in residency. I also had a couple patients become very verbally aggressive and physically threatening during my outpt CMHC time, one in particular was pretty bad. This was the only time I really felt like I was in danger as the support staff/security was poor. Thankfully, that clinic was dropped from our program, but has confirmed that I will not be working at a CMHC anytime soon.

Agree with most of the above so won't add too much. Just use common sense, 99% of the time it's fairly easy to tell if you can sit down with a patient or if you need to stay standing near the door. Intoxicated patients, especially those on PCP, meth, or hallucinogens should be automatic red flags to be cautious with. Have a low threshold to walk away if patients make threats. Always keep your distance from patients (especially on eval) until you know safety is not an issue. Make sure the environment is safe and safety protocol is good, do not be afraid to point out problems or safety concerns. Finally, do NOT take a job where you feel your safety is not prioritized. You may have to see dangerous patients, but you should know that the risk is being minimized and appropriate precautions are being taken.

These are such good tips. As someone interested in Neuro, where it seems like potential assaults can be even more common, I will definitely be using these precautions going forward. I especially like the suggestions of simply letting a patient know if they are making you feel uncomfortable, reviewing the EMR for any red flags, and keeping appropriate distance and/or having people with you with certain patients. These are the types of intangible, patient care things they should teach all medical students because any practicing physician should have this knowledge. Thanks for all the great input!

In my experience, the patients with the highest risks of aggression are those who are intoxicated and delirious. Severe dementia can be a huge risk as well, but this is a relatively small demographic for me. I've only had 2 patients (the two above) who were not encephalopathic or intoxicated that I felt threatened by, and they were both clearly very antisocial with flags/warnings in their charts.

If your residency is not teaching this, they're failing you. I think med schools are less focused on this, but agree that it should be part of orientation for the psych rotation and I regularly do this day 1 before we see patients.

Pro tip, be over 6 feet tall, with a background in wrestling, with some training in boxing and jiu jitsu. That usually helps feel more at ease in these situations.

We actually just had a very large, muscular, ex-military resident graduate who looked like he would fit in an MMA ring more than a hospital. I actually sometimes used him as a gauge for patients' insight, as no one in their right mind would physically threaten him, lol.

What happened to the resident at Pennsylvania Hospital is absolutely horrible… and, as a medical student, reaffirms my selection of psych as the specialty I would not touch with a 10-foot pole. Hope I like surgery😐

Any specialty where you're seeing acutely ill or disgruntled patients will have this risk. You'll see plenty of encephalopathic/intoxicated patients on the med floors, that includes post-surgical patients. If this is actually a reason for you to avoid psych you may just want to skip the patients altogether and just go for radiology or pathology. As above, 99% of the time and more using common sense will keep you safe. Don't be oblivious and you've already minimized your risk.

 

[hamstergang]

What happened to the resident at Pennsylvania Hospital is absolutely horrible… and, as a medical student, reaffirms my selection of psych as the specialty I would not touch with a 10-foot pole. Hope I like surgery😐

Are you taking about the case from this thread, in which it was a neuro patient who got violent? Your dislike of psychiatry based on this seems misguided.

You can still not like us for other reasons, though.

 

[calvnandhobbs68]

What happened to the resident at Pennsylvania Hospital is absolutely horrible… and, as a medical student, reaffirms my selection of psych as the specialty I would not touch with a 10-foot pole. Hope I like surgery😐

😆 cool story bro

Ever hear of the surgeon who got shot by the disgruntled patients family?

https://www.cnn.com/2015/01/20/justice/boston-hospital-shooting/index.html

 

[birchswing]

What happened to the resident at Pennsylvania Hospital is absolutely horrible… and, as a medical student, reaffirms my selection of psych as the specialty I would not touch with a 10-foot pole. Hope I like surgery😐

This thread makes me wonder about what really happened when I woke up from anesthesia—I've only had general anesthesia once, for a surgery. At the time, I was told I punched a nurse in the nose, but I was told it in a joking way. I assumed I was just flailing around, but I wonder more and more if I was actually violent. From my dad's description, he was called in because I was having trouble coming out of anesthesia. He said the surgeon and anesthesiologist were nowhere in sight and there were a group of nurses around me. They told me the punching part in a way that made it sound like a joke, and I thought it was an accident, but I don't know now. My first memory was of my dad saying my name over and over again and finally realizing that I was there. It was very odd. I was sure they hadn't done the surgery and something went wrong when I finally came to. But apparently there was an hour that I am missing. I was extraordinarily weak for over a week afterward, and when I told the surgeon, they said it was from pathological exertion. Apparently my sister comes out of anesthesia the same way. I've looked back on the meds I was on for both antibiotic coverage and for anesthesia, and I don't know how anybody wouldn't be a bit crazy on that combo.

But I remember my dad's biggest impression was that all the actual *doctors* made themselves scarce and relied on both the nurses and him to help me.

They had no trouble making me unconscious. That was the easy part. I feel like there was an hour or so I was in limbo coming out and they were deciding whether to keep trying to bring me out or sedate me more because I can see in the records even as I was coming out they were giving me more Versed, probably for the agitation. But again, I remember none of it. Just hearing my name being called and being sure they had aborted the surgery.