A 37-year-old man comes to the emergency department for evaluation of back pain. The patient was seen 2 days ago in the emergency department for similar pain symptoms and was discharged on naproxen. Medical history is significant for asthma, hepatitis C, and opioid use disorder. Temperature is 37.2 C (99 F), blood pressure is 138/92 mm Hg, and pulse is 104/min. The patient is irritable while his vital signs are being taken and angrily says to the nurse, "That medication I got was useless. My pain is now 10 times worse." His speech is very loud, filled with expletives, and disruptive to patients in adjacent rooms. His fists are clenched. Which of the following is the most appropriate next step in management of the patient interview?

Question

A 37-year-old man comes to the emergency department for evaluation of back pain.  The patient was seen 2 days ago in the emergency department for similar pain symptoms and was discharged on naproxen.  Medical history is significant for asthma, hepatitis C, and opioid use disorder.  Temperature is 37.2 C (99 F), blood pressure is 138/92 mm Hg, and pulse is 104/min.  The patient is irritable while his vital signs are being taken and angrily says to the nurse, "That medication I got was useless.  My pain is now 10 times worse."  His speech is very loud, filled with expletives, and disruptive to patients in adjacent rooms.  His fists are clenched.  Which of the following is the most appropriate next step in management of the patient interview?

Quizplus · Accepted Answer

11ec25c8_d768_8279_bc81_e1b55a5b07ac_MD0003_00 This patient is showing multiple signs of increasing agitation (eg, irritable demeanor, loud speech, cursing, clenched fists), which could escalate to violent behavior. He is angry about his recent treatment in the emergency department and could pose a threat to staff if he feels his current needs are not being met. Emergency department staff must be alert to verbal and nonverbal signs of escalating agitation and take steps to minimize safety risks to other patients and staff. The most appropriate approach is to listen attentively to the patient's needs during the interview after arranging for security personnel to be standing nearby should the patient become violent. In addition, the door should remain open so staff is not trapped behind a barrier with the patient. Seating should be arranged so that the physician (not the patient) is seated closest to the exit to facilitate escape. Objects that can be used as weapons should be removed from the room. A panic button or agreed-upon code word can be used to alert security. (Choice A) Closing the door and asking the patient to calm down places the physician at increased risk. Asking a patient to calm down can be perceived as condescending and have the unintended effect of making the patient angrier. A closed door makes escape more difficult. (Choice B) Although it is appropriate to set limits that verbal abuse and violent behavior are unacceptable, threatening to withhold treatment is likely to be experienced as confrontational and may further escalate the situation. (Choices C and D) Informing the patient that he will be restrained or that security personnel will be called will likely make the patient feel that his needs are being ignored, leading to further agitation. These statements may be perceived as confrontational and threatening and provoke the patient to act out violently so as to exert some control and prove himself. It is safer to first try to engage the patient with a nonconfrontational approach and have the restraint team or security personnel nearby in case further intervention becomes necessary. Educational objective: Emergency department staff should be alert to verbal and nonverbal signs of escalating agitation and impending violence (eg, irritable demeanor, loud speech, cursing, tense posture, pacing, clenched fists). Management techniques include interviewing the patient with the door open to facilitate escape by the clinician and a system for alerting security personnel standing nearby. References: Violence in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/27836151)

A 37-Year-Old Man Comes to the Emergency Department for Evaluation