• Rosalind Kaplan, MD

Adding Tragedy to Trauma

Last week, a healthcare worker at Thomas Jefferson Hospital in Philadelphia shot and killed one of his colleagues. I only know what the university told me (I teach at Jefferson's medical school), pretty much the same as what was in the news. The shooter, a Certified Nursing Assistant, entered the hospital in scrubs with body armor underneath, presumably using his legitimate employee ID to get past security. He had multiple guns, including and assault rifle. The police believe he was targeting the other Nursing Assistant. He then escaped in a U Haul vehicle, but was chased by police. He shot two police officers and then he was shot by police. The policemen and the shooter are expected to recover.

When I first heard, in the middle of the night, that there was an 'active shooter' in the hospital, I assumed it was an angry patient or visitor. It didn't occur to me that it could be a medical worker. I think that's because healthcare workplace violence is most often perpetrated by patients, family or other visitors. In 2019 before Covid, studies on healthcare workplace violence showed that over 60% of nurses and doctors had experienced violence, either physical (21%) or non-physical (around 40%, threats and other verbal assault). It was most common in hospital or emergency settings. While there is not yet hard data on such violence since the pandemic, anecdotally, this has worsened, and healthcare workers in the US and many other countries have been the targets of more assaults, both verbal and physical. Many of these have been related to covid restrictions, or frustrations over covid testing and treatment, including patients angry at their diagnosis or that of relatives, or wanting untested treatments such as hydroxychloroquine or ivermectin.

I have had a fair share of experience with violence in the healthcare workplace in my 30+ years as a physician. As a resident working in the emergency department, I was kicked, hit, and even bitten by patients, many of whom were intoxicated or in withdrawal from drugs or alcohol. Later in my career, a delusional patient once brandished a knife at me in medical clinic, and another patient once held me hostage in an office, wedging himself between me and the door, and claiming to have a bomb in his gym bag. He believed that another doctor in the building was trying to poison him, and that he was protecting himself; I was able to de-escalate the situation and he left without harming me. I have been yelled at, cursed at, and threatened more times than I can count over the years. And recently, in an urgent care setting, a patient became enraged that we didn't have an MRI scanner, which caused her to verbally assault me, throw her mask at me, and spit at me.

Like most healthcare professionals, I have come to accept these situations as 'part of the territory.' We deal with people at the worst moments of their lives, when they are helpless, frightened, sick, and sometimes incoherent. The last thing I want to do is compound someone's troubles by calling the police or refusing care. I try to de-escalate, to soothe, to ease pain and distress when possible. If necessary, hospital security or help from a colleague is the next step, unless I truly feel in danger. Luckily, I have not been seriously injured in any of these situations. But I am always wary, and watch for early signs of trouble when a patient is new to me. I try be cautious, and I have always depended on the healthcare team to help me stay safe.

That's why it's so especially unnerving to see a medical worker go after another medical worker. The other professionals around us are supposed to be our safe haven, but in this case, a coworker was the biggest danger. It's tragic, and frightening to think that this could be the next disaster in healthcare.

We all want a reason. We want to say that the shooter was mentally ill. And perhaps he was. But, according to the American Psychiatric Association, studies of workplace violence

show that, while psychiatric problems probably play a role, the more frequent triggers of workplace violence are personal stressors, strongly negative feedback at work, and a feeling of shame or humiliation.

Healthcare workers have been experiencing serious burnout over many years, and there was already a sense of crisis in the healthcare workplace before Covid. But with Covid in the picture, healthcare workers are under tremendous stress and duress. Overworked, understaffed, under fire from angry patients, and, in many cases, pushed to the wall by financially struggling healthcare systems, every doctor, nurse, and ancillary professional I know is struggling right now. There is a severe nursing shortage, and between Covid and the backlog of care that Covid caused for many other medical problems, everyone on hospital and emergency healthcare teams seems overwhelmed. There are unprecedented levels of depression and anxiety amongst nurses and doctors. Add a few personal stressors to that, and it seems a recipe for disaster.

I witnessed a melee between two staff members during one of my work shifts recently. It was precipitated by a shortage of Covid protective equipment. They argued about whether one of them was going to perform a job function without full PPE and the argument escalated into a much angrier, more personal confrontation. One of the employees became extremely emotionally distraught. By the time a manager could successfully intervene, patient care was suffering and other employees had to perform their job functions while the dispute was settled.

There was no physical violence, but it wasn't far from that point. In my three decades in the medical profession, I had never seen such blatant dysfunction in the middle of patient care.

I certainly hope that violence between healthcare workers does not become more commonplace. Perhaps last week's events were a one-off, an extreme situation that won't occur again. But I worry that it won't be the case unless some of the pressure is relieved in healthcare environments. Telling healthcare workers to meditate or do yoga is not the answer. It wasn't the answer to burnout before Covid and it surely isn't the answer now. Medical institutions need to do some serious investing in the well-being of their employees, offering mental health assistance, better salaries for lower-paid employees like Nursing Assistants, and administrators who are supportive rather than punitive. We shouldn't wait for another episode like last night to make changes.

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