Healthcare workers and their employers are to some extent “enabling” an epidemic of violence by not reporting attacks and pressing charges, the president of the American College of Emergency Physicians (ACEP) warns.

“Healthcare workers tend to underreport because we are there to take care of people,” Vidor Friedman, MD, FACEP, said recently in San Diego at the annual ACEP meeting. “We don’t want to create more of a problem than already exists, but we are enabling the issue to a certain extent. It’s not just healthcare workers. It is also the institutions that we work at.”

Friedman spoke at a press conference about an ACEP violence survey1 that netted responses from 3,539 emergency physicians, which represents about 11% of the group’s membership.

“Among those physically assaulted, 70% of emergency physicians said that their hospital administration or security responded to the assault,” the survey authors found.

The responses by hospital and security included placing a behavioral flag in the patient’s chart (28%), and arresting the patient (21%).

“Among those who gave ‘other’ responses (42%), many indicated that the hospital’s reaction was simply to remove or restrain the individual,” the report states. “In some cases, the hospital responded to the assault but did nothing at all.”

Hospital security pressed charges in 3% of assaults. In only 6% of assaults, the hospital administration advised the emergency physician to press charges.

“I’ve been assaulted three times in 30 years,” Friedman said. “I know that is not a lot, but every time it happened my hospital asked me not to press charges. I don’t know anywhere else people work where the institution would ask you not to press charges if you were assaulted.”

This suggests that only the more severe incidents make their way into the news and public awareness, with many physicians not reporting and hospitals advising them not to press charges if they do.

Vile Threats

Friedman described a harrowing encounter with an agitated, drunken man who came in for treatment after just being released from a 10-year stint in prison.

“He was a pretty intimidating-looking guy, and he threatened to stab me,” he said. “We appropriately restrained him, which only increased his agitation. The fourth time he said he was going to kill me, he said he was going to put an ice pick through my heart.”

After treatment, the patient was discharged and police escorted him to the city limits. Friedman had trouble sleeping for a week. In survey results, 83% of emergency physicians said a patient has threatened to return and harm them.

“This is the kind of thing that healthcare workers are unfortunately exposed to,” he said.

Patients also are exposed to violence and may be injured themselves, and the incidents prolong wait times and distract clinicians from patients who need care.

“We’re not saying that every ED in America needs to have a metal detector up front, but this needs to be something that your institution takes seriously,” Friedman said.

In the survey results on needed interventions, 49% of respondents said increase security; 18% said establish, communicate, and enforce clear policies; 10% said report incidents to the police; 9% said reduce public areas in the ED; and 9% said increase ED staff.

Overall, 47% of respondents said they had been physically assaulted at work, with 60% of those saying they had been attacked in the past year. (See survey highlights in this issue.)

“Nearly half of emergency physicians report being assaulted at some point in their careers,” he said. “Almost three-quarters have personally witnessed others being assaulted.”

Nearly seven in 10 say violence has increased in the past five years, with 25% reporting it has increased greatly, he added. If there is a ground zero in the national epidemic of healthcare violence, it is the ED.

“The results are quite troubling,” Friedman said.

“Emergency physicians are reporting that violence in emergency departments is increasing. It’s harming not only physicians and nurses but also patients and the care that is being provided.”

In results by gender, 96% of female ED physicians said they had been subjected to inappropriate comments and unwanted advances. Perhaps more surprisingly, 80% of men reported similar incidents.

A variety of physical transgressions included being spit on, punched, or kicked, with 27% reporting they were injured in the attack. This is primarily patient-to-worker violence, with 97% reporting patient assaults. In addition, 28% of assaulted workers said they were attacked by patient family members or friends.

“If you think about it, in some states and jurisdictions it is more dangerous working in the ER than being a police officer,” Leigh Vinocur, MD, an emergency medicine physician in Belcamp, MD, said at the ACEP press conference.

ED conditions are a recipe for violence, as caregivers try to minister to patients who may be emotional and volatile, she said.

“People come in hurt,” Vinocur said. “They are at their worst — frightened and vulnerable. Family members are also frightened and vulnerable, and there is stress.”

In this sense, EDs face common societal problems of guns, gangs, and domestic violence, all pressurized by injuries and pain in a crowded environment.

“We have a shortage of beds, and sometimes, we are boarding psychiatric patients for days, waiting for them to get treated appropriately,” she said. “It’s leading to overcrowding in the emergency department.”

The opioid crisis and other substance abuse issues mean that many incoming patients may be impaired and potentially violent. The survey found that 50% of respondents estimated that half of all assaults are committed by people who are seeking drugs and may be under the influence of drugs or alcohol.

“I know that firsthand,” Vinocur said. She described an attack by an opioid overdose patient who flew into a rage after being administered an antidote.

Part of the problem was that a responding clinician incorrectly administered the antidote before the patient was secured, and as he quickly recovered, he became threatening and violent, she said.

“He shot up [in the bed], still a little groggy, but then started screaming and yelling that we ruined his high,” she said.

The patient suddenly grabbed Vinocur by the throat and began choking her.

“I tried to grab his fingers around my throat and tried to pull them away,” she said. “At one point, I couldn’t talk or scream. I thought I was going to pass out. Then I felt his grip loosen. He ripped a necklace off my neck — cut my neck. That was the last time I wore jewelry on shift.”

Other healthcare workers were able to assist her and restrain the patient.

“I had those strangulation marks on my neck and broken blood vessels in my eyes for a couple weeks after that,” she said, comparing such situations to clinicians overseas working in war zones.

“ER physicians that are on the front lines and taking care of people are being caught in the crosshairs of violence,” Vinocur said.


  1. Marketing General Inc. ACEP Emergency Department Violence Poll Research Results. September 2018:1-25.