Situations that require emergency stabilization, sometimes against a patient's wishes, involve a patient stating that he or she is potentially or actually violent, suicidal, or developing rapidly progressive medical conditions causing disturbed behavior (e.g., hypoglycemia, meningitis, or other causes of delirium). Disturbances involving actual or threatened violence are the most difficult for emergency department staff. The staff, of course, fear injury or that such patients will escape and hurt themselves or others. There are always limitations in security personnel and immediately available staff. There are often limitations in the physical facility itself in regard to restraining such patients.
Violent behavior demands immediate restraint. Hospital security forces and police are best equipped and best trained to subdue such patients with the least chance of staff or patient injury. Staff in the emergency department should not attempt to subdue a patient unless they are fully trained to do so. An initial show of force (four or five male attendants) may be sufficient to induce the patient to accept physical or chemical restraint without further resistance. Under ideal circumstances, the emergency department staff should organize themselves to be able to subdue a violent person if security personnel are not immediately available. This requires training and practice. The approach to the patient usually requires five team members with one member assigned to each limb and the leader assigned to the head. When approached from different directions and grabbed simultaneously, the violent person can usually be immobilized and restrained.
Potentially violent behavior requires the summoning of adequate force and the adoption of a nonthreatening attitude by a physician and staff. A physician should never have his or her hands out when approaching a patient or make other gestures that might be interpreted as an attack. The physician should also stay distant from the patient, avoid excessive eye contact, and maintain a somewhat submissive posture and tone of voice. Ideally, the physician should stand in a location that neither threatens the patient nor blocks his or her own retreat from the room. Allowing the patient to ventilate feelings verbally is important. Setting limits on acceptable behavior and making neutral comments may diffuse a potentially violent situation. Adequate force nearby should be visible to the patient, and the patient should clearly be told that certain kinds of behavior will result in restraint.
The decision to release a patient from physical restraints should be made jointly by medical and nursing personnel on the basis of a judgment regarding the patient's condition and behavior and not as a result of the patient's bargains or threats. Restraints should be removed in a stepwise fashion, from four limbs to two, to none.
Stabilization of an actively suicidal patient requires adequate suicide precautions. All dangerous objects are removed from the patient in the treatment room. Staff members should watch the patient closely and not allow the patient to leave the examining room unaccompanied by a staff member. Some institutions have members of the security staff available to provide supervision.
Patients who are threatening or demonstrate actual or potential violent behavior should be disrobed, gowned, and searched for weapons. Seemingly innocuous objects such as belts or belt buckles can be used by a patient to inflict self-injury or injury to others. Some emergency departments have installed metal detectors to prevent highly lethal weapons from entering the department. It has been determined that other patients do not resent the use of metal detectors because they feel safer themselves.
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