The clinically excellent clinician prepares before intervening to de-escalate patients who may be behaving aggressively.
Mr. T towered over my attending. His eyes glared with rage as he fumed about not having enough food provided to him in the hospital. Admitted two days earlier with poorly controlled diabetes, Mr. T was 32-years-old, 6 feet 6 inches tall with a muscular build, and weighed over 260 pounds. It seemed physical assault and an uncontrolled violent crisis was imminent.
My attending continued to speak in a calm, tranquil, and monotone voice as he explained to Mr. T the severity of his illness, as well as management recommendations. He did not maintain eye contact with Mr. T, so as not to provoke him further. My attending simply continued to explain the team’s plan with the hope that Mr. T would comply.
Listening closely, empathizing, and repeating back Mr. T’s points of frustration diffused his anger. After several minutes, Mr. T’s demeanor softened, the anger in his voice waned, and the Incredible Hulk transformed to Bruce Banner (soothed).
A difficult encounter
Besides anecdotes, my experience with aggressive and violent patient encounters was limited to this experience; I never received formal teaching on de-escalation techniques. Fast forward to my years as an attending—I had the occasional frustrated and angry patient, but never experienced a violent encounter until a year ago.
I was called by nursing to see a patient admitted for COPD exacerbation who insisted on leaving the medicine floor to smoke. When I arrived, the patient was visibly upset and getting ready to walk out of his room. As I attempted to talk with the patient to understand the situation, he struck me several times in the face. We called security, but the staff and I were ill equipped to stop the assault. Because of the severity of his COPD, he eventually tired out and stopped punching.
Unprepared for patient violence
Despite many years of clinical practice, I was no more prepared to de-escalate or intervene during violent/aggressive patient encounters than when I first started medical school. My REACTIVE rather than PROACTIVE response that day resulted in the physical assault.
How to prepare for patient violence
Disaster Preparation for violent/aggressive patient encounters is essential to protect patients and staff from adverse outcomes. Akin to gowning up before entering a patient’s room on isolation with Clostridioides difficile infection (CDI), providers must take the necessary precautions to protect themselves and others prior to evaluating a patient who is angry.
Gathering as much information before interacting with a patient who is behaving aggressively and finding out what (if anything) has helped to de-escalate violence in the past for the particular patient is crucial.
Have security on-site
Taking several minutes to think of a strategy (the right words to say, being cognizant of one’s body language), and having security on-site before entering the patient’s room is key to de-escalating.
Similar to leaving patients’ room with CDI (ungowning and washing hands), debriefing the patient and staff is critical to ensure the situation remains limited, controlled, and monitored for resolution.