Not What I Signed up For

Alice Ma, MD
Professor of Medicine in the Division of Hematology and Oncology at the University of North Carolina School of Medicine in Chapel Hill

Last month, while at a mandatory conference at our hospital and idly checking my email, a note from my nurse caught my attention: “Dr. Ma, can you call me now or let me know where you are?” I replied, “In a meeting – I’ll let you know when the session lets out.”

My nurse’s next message really caught my attention: “Local law enforcement has been called.” I escaped from a group activity and called back my characteristically calm and unflappable nurse.

A series of phone calls from a long-term patient of the hemophilia center had raised the alarm. Brenda, the center’s highly experienced nurse, and Curtis, our well-trained social worker, filled me in: “We just couldn’t get him calmed down, and we think he’s threatening to hurt you.” Okay. “He’s in his car driving and isn’t answering our calls any more. We don’t think you should be alone, and we wanted to make sure you weren’t in clinic late and coming out to an abandoned parking lot.” Great.

The patient was upset about the copay for his monthly narcotics, the winter weather, the poor heat and insulation in his girlfriend’s apartment, his unemployment, and his lack of disability insurance – for which he apparently blames me. He also has an anger management issue, and depression, and he’s been fired from work for assaulting people who “got in his face.”

As a child, he had a heart murmur and received disability benefits. He no longer has a heart murmur, and he blames me for documenting this. Because he equates his lack of a heart murmur with his lack of disability, he went from faulting me for cosigning a resident’s “no M/R/G” note to accusing me of writing the disabilities board to say his application should be denied.

Brenda and Curtis explained to him that this wasn’t true, and that no adult patients with hemophilia get approved for disability on their first application, and that he should reapply after keeping a log of his bleeds and joint pain. He could not be reasoned with.

Curtis found it hard to keep up with the patient’s disorganized ranting, but several phrases stood out: “Make an example of her. … Get people’s attention. … Mass shooting.” And, my personal favorite: “If I could, I’d come and blow the b—- up.”

Apparently, he’s been angry with me for a decade. This was news to me, since I had arranged a monthly clinic visit schedule for him so we could track his bleeds and pain, thereby helping him with his disability documentation.

Luckily, that day it was threatening to snow. In North Carolina, not even a potential mass shooter wants to be out on the roads in bad weather. He turned around and went home.

A few hours later, I was driving to a previously arranged dinner while thoughts were scurrying around my head. What would I do if the patient pulled a gun in clinic? What if he was by my car, or waiting at my home? Golly, my colleagues would have to cover a bunch of calls and clinics for me if I were dead or wounded.

I found little solace when I told others about my experience.

My mother – ever unsupportive – asked, “Why do you always get yourself into these situations?” Not helpful, Mom.

The husband of a trainee offered to loan me a handgun. Gulp. Should I think about getting a gun?

I turned to the internet next. I looked up “handgun classes near me.” A facility located in the same shopping center as my nail salon offered handgun training. Their website proclaimed “Violence as a second language.” They offered classes titled “Defend Your Castle” and “Urban Warfare 1.” I hesitated; I’m not certain I want to be fluent in violence.

Note to self: There’s a real opportunity to market handgun safety to academicians. Call it “Handgun Training for Squeamish Liberals.” I’d have signed up for a class like that, but all I found was “Boom: Introduction to Firearms.”

After careful consideration, I concluded that a handgun was NOT for me, since I really didn’t think I could shoot a hemophilic patient. And, firearms are forbidden in clinic, so even if I bought a gun, I couldn’t bring it to work. I settled on ordering pepper spray and a Taser from Amazon.

Now, what to do about the patient, his hemophilia, and his boiling rage? On the one hand, he has specialized health-care needs that are best served at our center. Could we mandate that he be actively engaged with mental health care as a condition of treatment? Could my partner see him in clinic when I’m not there? Yet on the other hand, he might go off the rails and decide to follow through on his threat. How do we keep our other patients and health-care providers safe, while addressing the needs of this patient?

Serendipitously, while I was wrestling with these questions, I ran into Arlene Davis, JD, a terrific colleague and co-chair of the University of North Carolina (UNC) Hospitals Ethics Committee. Yes! I clearly needed an ethics consult. Soon, I was at a meeting with representatives from our ethics committee, legal department, and hospital police. I learned that we should have called the hospital police at the first threat so that officers could have patrolled our off-site clinic and that we could implement a behavioral contract mandating the patient undergo regular mental health care as a condition of receiving hemophilia care at UNC.

The hospital police contacted the patient to inform him that threats against his providers would not be tolerated. He denied making threats, while simultaneously making more threats, and then he called the hemophilia center to make even more threats. We are in the process of dismissing him from our care; he will be given a list of other hemophilia providers, and two months of prescriptions during the transition period.

Violence against health-care workers is rising, though suffered most by nurses, and mostly in emergency-room or psychiatric settings.1 In 2015, a surgeon was murdered by the son of a patient at Brigham and Women’s hospital. In 2017, an Indiana man murdered his wife’s doctor after he refused to prescribe her opioids. Our health system is experiencing an uptick in the number of patients threatening harm to providers. Many come from drug-seeking patients; most come from patients with untreated or undertreated mental health disorders.

I have no answers for this problem, but I know that my interaction with a potentially violent patient has taken a toll on my sleep, my interactions with other patients, and my feelings of personal safety.

I wonder how many others have had a similar experience?


Reference

Jacobson R. “Epidemic of violence against health care workers plagues hospitals.” Scientific American. December 31, 2014.

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