How to manage a 49-year-old man with chronic back pain and a history of violence toward healthcare staff, who is becoming agitated after a 2-hour wait in a crowded emergency department (ED)?

Management of an Agitated Patient with History of Violence in the Emergency Department

Evaluating the patient with security on alert is the best next step in managing this situation. 1, 2

Assessment of the Current Situation

This case presents a potentially dangerous scenario requiring immediate attention:

• 49-year-old male with chronic back pain
• 2-hour wait in a crowded ED with 5-hour average wait times
• Escalating agitation (yelling and throwing objects)
• History of violence toward healthcare staff

Management Algorithm

1. Immediate Safety Measures

• Ensure security personnel are present and on alert 2
• Maintain appropriate distance and positioning (stand at an angle to the patient, not directly facing) 1
• Create a calm environment by reducing sensory stimulation if possible 2

2. Verbal De-escalation Techniques

• Designate one staff member to interact with the patient to avoid confusion 1
• Use simple language and concise sentences 1
• Introduce yourself and establish verbal contact 1
• Acknowledge the patient's frustration: "I understand waiting is frustrating" 1
• Identify patient's goals and expectations: "What would help you right now?" 1
• Use active listening techniques to show you understand his concerns 1

3. Set Clear Boundaries

• Establish expectations of mutual respect while maintaining safety 1
• Clearly communicate consequences of unacceptable behaviors in a non-punitive manner 1
• Offer realistic choices to help the patient regain control 1

4. Medical Assessment

• Once the situation is stabilized, perform a focused medical assessment 1
• Evaluate for medical causes that could be contributing to agitation 1, 2
• Consider point-of-care glucose testing 2
• Assess for signs of substance intoxication 1, 2

5. Pharmacologic Intervention (if verbal de-escalation fails)

For undifferentiated agitation requiring rapid control:

• First choice: droperidol 5 mg IM or midazolam 5 mg IM 2
• Alternative: lorazepam 2-4 mg IM 2

Why This Approach Is Best

Evaluating the patient with security on alert balances several critical needs:

1. Safety: Protects staff and other patients while addressing the patient's medical needs 1, 2
2. Medical care: Allows for assessment of the patient's chronic back pain 1
3. De-escalation: Provides opportunity to use verbal techniques before resorting to medications 1
4. Ethical considerations: Respects the patient's right to medical care while maintaining boundaries 1

Common Pitfalls to Avoid

• Calling police immediately: This may escalate the situation unnecessarily and delay medical care
• Simply explaining the triage system: While important, this alone is unlikely to de-escalate an already agitated patient with a history of violence 1
• Offering food/drink without addressing safety: This doesn't address the underlying agitation and safety concerns
• Failing to rule out medical causes of agitation, which can lead to delayed diagnosis and treatment 2
• Inadequate monitoring after administering sedative medications if they become necessary 2

Special Considerations for Chronic Back Pain

Patients with chronic back pain often face unique challenges:

• They may feel delegitimized when their pain is not immediately addressed 3
• Long wait times can exacerbate feelings that their pain is not being taken seriously 3
• The emotional component of chronic pain can intensify reactions to perceived delays in care 4

By evaluating the patient with security present, you address both the immediate safety concern while still acknowledging and preparing to address his medical complaint.