Guns, gangs terrorize urban trauma centres

Physicians decry security cuts after spate of shootings devastates Toronto

By Evan Dyer

There's a plastic bag of weapons on emergency physician Paul Brad-ford's desk. Dangerous weapons. "I've got stuff like a machete, throwing knives." All of them were taken from patients by staff at the Hotel Dieu-Grace Hospital in downtown Windsor.

Now Dr Bradford uses the arsenal to fight his own battles with hospital administrators.

"We got concerned because we had so many weapons piling up that we started using the photocopy machine. We'd just plunk the weapon on the photocopier and take a picture of it." But Dr Bradford still keeps the bag. "I take it to the meetings when they're talking about cutting security. It tends to put an end to that discussion pretty quickly."

VIOLENT TIMES
Violent crime is on everyone's minds these days. In a case that shocked the country, Hotel Dieu-Grace was the scene of a murder-suicide by one of the hospital's own physicians — anesthetist Marc Daniel, 50, stabbed his former girlfriend, 37-year-old nurse Lori Dupont, in one of the OR recovery rooms. After she applied for a restraining order, the hospital provided her with a security escort to and from the parking lot. Although Dr Daniel had his hospital privileges suspended for a short time, the hospital decided there wasn't sufficient evidence from Ms Dupont's complaints to fire him.

The case coincided with a spate of shootings in Toronto, as well as the high-profile campaign to prevent US rapper 50 Cent from coming to perform in Canada because of the glorification of guns in his lyrics. An embattled Paul Martin stood up and took notice, promising a summit on gun violence in Toronto.

TIGHT SECURITY
Violence is an unfortunate fact of life for Dr Bradford and the staff at Hotel-Dieu Grace, which not only has private security guards, but also pays the Windsor police department to provide protection. There's no way of knowing whether Lori Dupont's death could have been prevented by better security (details about the security response to the attack have not been released), but the tragedy doesn't make the budget cut proposals any more convincing.

"We have several code white incidents a day," says Dr Bradford, using the hospital term for an out-of-control patient. "The police have made about eight arrests in our emergency department in the past six months. This year they've called for back-up on six occasions."

"Things like nurses being spat on we don't really even count," says Dr Bradford. "You work in emergency, that's part of the job. But we're seeing an escalation, just as we're seeing an escalation in serious penetrating traumas among patients. It seems that more of our patients think they need to be armed."

Statistics confirm that hospitals are getting rougher. Physical assaults against Ontario hospital workers increased more than 60% between 1999 and 2003, according to figures from the Workplace Safety and Insurance Board. And in British Columbia, nurses now lead all other occupational groups including taxi-drivers and police officers — in the number of workplace injuries due to acts of violence.

EDs: VIOLENCE-MAGNETS
Emergency departments service a disproportionately high number of people who are mentally ill or marginalized. Many of their patients arrive at the hospital under the effects of alcohol or drugs; others are distraught or hysterical. Some have already been fighting and are pumped up with adrenaline and aggression.

Sometimes it's the people accompanying the injured who lose control. Many can't or won't understand the concept of triage; when a person who has been waiting for hours sees a late-arrival receive immediate assistance, they interpret it as queue-jumping or favouritism.

But security guards aren't only there to protect staff from patients, says Dr Howard Ovens, director of the Schwartz/Reisman Emergency Centre at Toronto's Mount Sinai Hospital.

"The number one reason we call security is still to protect patients from themselves, to keep watch on those who are potentially suicidal. The second most common reason is when we have a patient who is intoxicated or confused, perhaps because of dementia, and who we're worried might start acting out or elope. Only after that do you have what I'd call the criminal, competent person who becomes violent merely because, for example, they're tired of waiting."

ZERO TOLERANCE
Dr Ovens says hospitals have a duty of care even towards those patients who lash out at others, if they are clearly not responsible for their own actions.

Nonetheless, there are growing calls from some in the profession for a less tolerant approach to belligerent patients.

The Royal Ottawa Hospital, the main psychiatric treatment centre in eastern Ontario, reported 94 "patient action incidents" last year. Unions have taken the position that psychiatric conditions are no excuse for violence, and demanded that each assault be reported to police by hospital administration (rather than leaving it up to the individual victim). The hospital insists that assaults are not tolerated, but union leaders have continued to complain about "an expectation that somehow it just goes with the job".

BEYOND RENT-A-COPS
In practice, says Dr Bradford, there's often little incentive for making a criminal complaint. "You end up penalizing yourself through loss of your time, while the patient is typically someone who has very little to lose anyway, and just says 'I was drunk'."

Dr Bradford says hospitals need to put the emphasis on controlling violent individuals before they can harm others. He says that not only means a security presence, but one that is well-trained and mature enough to know how to calm, rather than inflame, an agitated patient. He also says that to be convincing, the security presence must be credible.

"People tend to laugh off our white-shirted security guard. They know there's not much he can do; it's like 'Stop that or I'll take your name'. But there are also armed police in this hospital, and when they walk up to someone, that person usually quiets right down."

Dr Ovens agrees that security in EDs is not a job for the average private security guard working for close to minimum wage. "It can't be just any security, but people who are well-trained, who know how to defuse a situation instead of escalate it. And that's usually enough. Most of the time, all you need is a juice and a sandwich and someone to set some boundaries."