Doctors on Alert

From the Oregonian, June 23, 1994 – not available elsewhere online.

“A man just came in,” a frightened secretary told Dr. Elmore E. Duncan, “carrying a gun.”

That June morning in 1985, the psychiatrist was in the hall, picking up his mail. “I think we’d better get out of here,” he said as, confused and afraid, he began rounding up patients and staff.

They were heading out the door when they heard the shotgun blasts.

Duncan’s partner, 41-year-old Dr. Michael J. McCulloch, lay dead in his office, shot in the head and body by a longtime patient who had threatened to kill him.

Something else died that day in the Portland psychiatric community: the denial that it could happen to them. The hands of a patient could harm them, as they had McCulloch and, four months earlier, Dr. Brian Buss, who was clubbed to death at Salem Hospital.

Monday’s shootings of a psychiatrist , psychologist and bystanders at Fairchild Air Force Base hospital in Spokane are cold reminders that caregivers and hospitals are as vulnerable to violence as any other person or place in America.

“It used to be that physicians and hospitals were pretty much protected,” said Dr. Michael P. Resnick, a psychiatrist for 20 years and director of psychiatric education at Providence Medical Center. ‘A hospital was like a church. Nobody would expect somebody to go in and shoot up a hospital.”

But Portland hospitals have become wary. They bristle with surveillance cameras. Emergency room nurses at Oregon Health Sciences University work behind bulletproof glass. Security guards carry chemical Mace and handcuffs. At the Portland Veterans Affairs Medical Center, when the most troublesome patients arrive, they are surrounded by a welcoming committee of staff and security guards.

But what can a hospital do to protect itself against someone who is bent on killing?

“Little if anything,” said Russell Colling of Denver, one of the nation’s leading authorities on hospital security.

Colling said hospitals were at a disadvantage in controlling access to people with guns in their hands and killing in their minds. Hospitals have less control over who comes and goes than, say, a manufacturing plant.

“A hospital is more like a library,” he said. “We are inviting the public in — just the same as a department store might.”

More likely, hospital workers will find their violence in the form of patients who are wildly intoxicated with drugs or alcohol. Or from distraught visitors who think not enough is being done for sick or injured relatives. Or from gang members seeking to even a score.

Words, body language

In Portland and elsewhere, hospital officials are learning that words and body language may be the most powerful weapons in defusing violence before it begins.

Barbara L. Glidewell, patient advocate and ombudsman at Oregon Health Sciences University, routinely talks with furious patients and relatives. And she’s been physically threatened more than once.

Just by coincidence, she convened a group of 30 nurses, physicians and security workers at OHSU on Wednesday — just two days after the Fairchild killings — to discuss a coordinated approach to avoiding hospital violence.

“You have people who come to the emergency room who demonstrate malevolent or dangerous behavior,” she said. “How do we identify dangerous behavior before they get through the triage door? Each of us have our own methods. But we want to deal with this in an active manner rather than a reactive manner.”

Glidewell said that while hospitals have fire and earthquake drills there is no widespread training on how to handle threats from people.

“What happens when a person walks into a nursing unit and brandishes a gun?” she asked. “Does everyone know what to do?”

A designated talker

Ideally, staff members should quietly leave the area to reduce the amount of stress for the disturbed person. Someone should be designated to talk to the person while others quietly call for help.

“If you’re prepared for fires you should be prepared for Uzis,” she said.

Glidewell hopes to adopt a system similar to one used by the Portland Veterans Medical Center.

Dr. David J. Drummond, chairman of the center’s committee on violence, said 200 of the hospital’s 30,000 patients have been classified as potentially violent and have electronic flags attached to their records.

Dr. William R. Dubin, former chairman of an American Psychiatric Association task force on violence toward clinicians, cited a 1988 report from the Department of Health and Human Services, which studied 418 hospitals in a one-year period and found they reported 2,118 assaults, 63 rapes, 551 bomb threats and 72 arsons.

Incidents probably on rise

He said studies suggest 40 percent of all psychiatrists have been assaulted by patients sometime in their careers, and almost everyone had been threatened at least once. No one keeps track of such incidents, but his sense is that they are increasing.

“We live in a very violent society and that violence has spilled into medicine,” said Dubin, who now is acting medical director of Belmont Center for Comprehensive Treatment in Philadelphia.

Although psychiatrists are allowed to breach doctor-patient privilege and go to the police if they feel there is any danger of the patient harming himself or others, they tend to delay in hope of treating the patient, Dubin said.

He warned that psychiatrists should take precautions if there are warning signs, such as uneasiness on their own part or a history of violence on the part of the patient.

“We stay in the role of the healer too long,” he said. “And then we tend to get into very dangerous situations.”

Resnick, the Providence psychiatrist, doesn’t hesitate when he has any safety concerns. “There are some people I would see only in an emergency department,” said Resnick, who works in an unmarked office, keeps an unlisted phone number, quizzes patients about their access to weapons — and takes all threats seriously.

“Threats indicate a basic breakdown in what should be a positive relationship,” he said. “They indicate somebody’s impulses and feelings are out of control.”

Seen as an adversary

Another piece — beyond the disturbed emotions or distorted expectations of a minority of mental patients — is psychiatrists ‘ increasing role in assessing patients for legal or insurance reasons or, as in the Spokane situation, to determine fitness for a job. Such patients might see a psychiatrist as an adversary rather than a partner in solving a problem.

A jammed system also plays into the mix. Voluntary hospital beds for seriously mentally ill people are in short supply, says Dr. Joseph D. Bloom, head of psychiatry at Oregon Health Sciences University. “Oregon had 5,800 people in mental hospitals in the mid-’50s, and now we have less than 1,000,” including forensic patients. Bloom expects to see more conflict between patients and doctors if managed care’s economizing squeezes out longer-term therapy.

But, as several doctors noted, they have company when it comes to workplace risks. “A lot of professions dealing with the public are going to have this kind of problem,” said Daniel S. McKitrick, executive director of the Oregon Psychological Association.

“With or without mental illness,” Bloom agreed, “we have a high level of violence in this country.”