Dr. Raviteja Innamuri
Christian Medical College-Vellore
As post-graduate trainees at the department of psychiatry, we had a well-known dictum-
“When a patient assaults:
The attender – give a timeout
The postgraduate – give a parenteral tranquillizer
The attending consultant- physically restrain!”
Though this sounded very superficial and biased, we quickly began to realize its practical value as each situation often indicated a different degree of impaired judgment, requiring more intense intervention to diffuse the situation!
Every occupation carries with it an occupational hazard, some conspicuous, while some inconspicuous! Radiotherapy, for example, exposes both its clients and its professionals to radiation that needs a constant check, serially monitored with the assistance of TLD badges. But say, varicose veins for Surgeons due to their prolonged standing is often neglected and say, the psychological burden, particularly for mental health professionals is very abstract to measure. However, the unpredicted and unforeseen is the physical abuse of doctors by their clients. Some intentional, while others, unintentional.
Unintentional physical abuse is not uncommon as thought. The first time I experienced it was during my internship when a woman in labour almost cracked my knuckles with a tight squeeze while her little one made a grandiose entry! The last time I experienced physical violence was as a postgraduate trainee when an adolescent under psychosis kicked me while trying to restrain him (as part of the behavioural therapy). My head of the unit, Dr. Deepa sweetly asked if I would feel bad the same way if the same patient was intellectually disabled or was having a seizure. This reframing of a situation is what led us to move forward and help many more such violent patients. Dr. Tanay Maiti remarks that the few papers available show that violence among people with serious mental illness is twice that of the general population and is an under-recognized occupational hazard among mental health staff.
Several guidelines are available to assess (e.g. violence/ aggression assessment checklist), verbal de-escalation strategies (project BETA), acute tranquilization techniques using chemical restraints (injection haloperidol/lorazepam etc), or in worst cases using physical constraints. Verbal de-escalation strategies mastered with practice often become a tool for the management of agitated patients. These include respecting personal space, not being provocative, establish verbal contact, be concise, identify wants and feelings, listen closely to what patient is saying, agree or agree to disagree, lay down the law and set clear limits, offer choices and optimism, debrief the patient and staff.
Be it any serious mental illnesses such as psychosis or severe mania or medical conditions such as dementia, another poorly recognized entity is the physical and psychological abuse of their caregivers often contributing to caregiver burn-out. This needs to be frequently monitored and assisted to ensure the health of both the client and their efficient caregivers. Recognizing their efforts, suggesting cognitive and behavioural strategies to promote acceptance, taking regular breaks, lifestyle modifications including diet and exercise, building support systems can go a long way!
Remember, intentional and unintentional can often blur borders in this blame game especially when one’s cognitive faculties are in question. This has often put professionals of the legal system, ethics, medicine and forensic in dilemma. Always remember that even a poisonous snake might not have attacked until we have acted with fear or malicious intent. With practice, staying calm and following above guidelines can save all from a punch or two! Good luck and God save us from both intentional and unintentional abuse.
P.s. In recent times, we are increasingly talking about rising violence against healthcare workers (including The Lancet)! While I deeply regret the situation as a medical professional, I sometimes feel that poor skills in breaking bad news or failed negotiations in a doctor-patient relationship can also contribute to this worsening scenario. If this is so, we are not the victims anymore and the violence displayed by our clients is a fruit borne, unintentional.