ST. JOSEPH — It’s a Tuesday afternoon at Lakeland Medical Center’s emergency department. Physicians and nurses briskly make their way around the unit, treating patients and monitoring their conditions by computer.

“Pretty chill” is how Dr. Robert Nolan, medical director of the emergency department, describes the shift, with about 22 patients with complaints ranging from difficulty breathing to a swollen lip.

But staff members know that this situation could change any time, and they could suddenly be required to treat life-threatening injuries. A red phone sits nearby for calls from paramedics about incoming patients.

“We’re the one spot in the entire county that will never say no,” Nolan comments. All three of Lakeland’s hospitals are trauma-certified.

That night, the calm is broken when four men are shot in three locations in Benton Harbor and are transported to Lakeland.

Incidents with multiple victims are becoming more common. This year the hospital has seen several situations with more than one shooting victim, including three women who were shot at a party. One later died.

The night of that incident, 40 or 50 people came to the emergency department to check on the condition of the injured,  blocking the entrance to the emergency room, Nolan said.

A fire at a Benton Township motel last summer also brought multiple victims to the ER for treatment.

While emergency room professionals are seeing more violence and injury coming in from the street, they also are experiencing it more in personal assaults.

A study from the American College of Emergency Physicians, released in September, found that nearly half of emergency physicians reported being physically assaulted while at work. Of those, 60 percent had been attacked in the last year. More than a quarter of physicians had been assaulted more than once.

Nearly seven in 10 of those surveyed said workplace violence has increased in the past five years, and 25 percent said it has increased greatly.

Nolan said that working in an emergency room has become the second-most dangerous job, behind law enforcement.

According to the Bureau of Labor Statistics, 48 percent of all non-fatal injuries from occupational assaults and violent acts have occurred in a health care setting. From 2015 to 2016, physical assaults throughout Lakeland increased by 24 percent compared to 2015, according to a 2017 Lakeland newsletter.

In response, Lakeland security officers in St. Joseph and Niles began carrying Tasers in March 2017.

Inez, a bomb-sniffing dog, was brought in this year, making the rounds throughout the hospitals with her trainer, Bruce Modigell, on the lookout for explosives and bringing a soothing presence to patients, as well.

New research was done about violence in Michigan emergency rooms. One of the researchers, Dr. Terry Kowalenko, chairman of emergency medicine at Oakland University William Beaumont School of Medicine in Rochester, found that 72 percent of emergency medicine physicians in Michigan had experienced violence in the past year.

Kowalenko also found that Michigan’s ER docs are increasingly fearful about workplace violence.

Health professionals point out that this wave of violence affects patients as well as staff. More than three-quarters of those surveyed said violence had harmed patient care because of loss of productivity and increased emotional trauma and anxiety.

“When violence occurs in an emergency department, patients can be injured or traumatized to the point of leaving without being seen,” according to Dr. Vidor Friedman, president of ACEP. “It can also increase wait times and distract emergency staff from focusing on other patients who urgently require a physician’s assistance.”

Lakeland and other hospitals prepare for the inevitable traumas and other emergencies with additional training for their employees, from verbal de-escalation to techniques in restraining patients.

Charting the crisis

The American College of Emergency Physicians received 3,539 responses to its survey sent in August, a response rate of 11 percent. Michigan was one of the top 10 participating states, with 154 responses submitted.

Among the respondents, 47 percent said they had been assaulted, and another 71 percent had witnessed an assault. Of those who were assaulted, 27 percent sustained injuries.

The respondents reported that 97 percent of assaults were perpetrated by patients. The most common type of assault was being hit or slapped, while others had been spit on, punched, kicked or scratched.

Seventy percent said that the hospital security or administration had responded to the assault. The most common responses were to put a “red flag” in the patient’s chart, or to have them arrested. Only 3 percent of hospitals pressed charges when an assault occurred.

Half of the emergency room physicians reported that at least half of all assaults are committed by people believed to be seeking drugs or who were under the influence of drugs or alcohol. More that 40 percent of physicians surveyed believed that more than half of assaults are committed by psychiatric patients.

Ninety-six percent of female emergency physicians and 80 percent of male physicians say that a visitor or patient has made inappropriate comments or unwanted advances. More that 80 percent of physicians say that a patient threatened to return and harm them or staff.

Half of physicians think that increasing security is the most important thing hospitals can do to bolster safety.

Close to home

The Michigan study by Kowalenko and colleagues sent surveys to 1,102 emergency room physicians, and 288 were returned, for a 26 percent response rate. The findings were compared to a similar study conducted in 2005.

The percentage of physicians reporting a physical assault increased from 28 in 2005 to 38 percent in 2018. The number of those feeling frequently fearful spiked from 9.4 to 21.9 percent, and those who were constantly fearful increased from 1.2 to 8.1 percent.

In 2018, 53 percent of hospitals had security officers making the rounds throughout the facility (compared to 27 percent in 2005) and 34 percent had security staff assigned to the emergency department. Thirty percent of emergency rooms had armed officers, in contrast to 9 percent when the last study was conducted.

Half of the physicians surveyed said hospitals could improve security by adding cameras, metal detectors and increasing visitor screening.

The report found that despite increased security measures in Michigan, the problems of emergency department violence are getting worse.

“Emergency physicians across all demographics experience various forms of violence and are increasingly concerned about becoming a victim of violence,” Kowalenko said in a news release. “Despite increased risks, our research found that there is very little published on topics such as situational awareness, verbal de-escalation, self-protection techniques or weapons awareness for emergency physicians to use.”

Be prepared 

To be ready for any type of crisis, emergency rooms are required to conduct trauma trainings once a year, Dr. Nolan said.

Lakeland’s Niles hospital held its training Sept. 27. A drill at the St. Joseph ER took place earlier in the month. The Niles exercise included enacting the presence of an active shooter.

Al DiBrito, safety security manager for Lakeland Health, said the drill is “real dynamic – it’s over in five minutes.”

Once the exercise is over, staff can look at what worked and what didn’t, he said.

It also simulated an incident in which a vehicle plowed into a crowd at the Red Bud motocross event, sending 35 victims to the ER at once. Many of the “victims” were portrayed by students from Niles High School’s Professional Health Care Academy, under the supervision of RN Angie Mann.

The drill gives the students a close-up look at how an emergency department operates under the most stressful conditions, Mann said. The ER has to continue to function to treat actual patients while the exercise is taking place.

Student Gabi Trevisan was brought to the ER with a simulated broken leg and lacerations. To further add to the stress, McKenna Thompson played her 6-year-old daughter, also injured and now lost somewhere in the hospital.

Other students acted as patients who were angry that they weren’t being treated right away.

Trevisan wants to study to become a surgeon. She said participating in the drill gave her the opportunity to see how health professionals interact.

Thompson wants to become an emergency room nurse. In part, she is doing it in honor of her mother, who attended emergency medical technician training but couldn’t be hired at the time because she was a woman.

Mann, who has been with Lakeland for 20 years, said being an ER nurse “has always been tough,” but today “there are a lot more things to be prepared for.”

She remains dedicated to her profession.

“I love the quick, fast pace. There is constant change,” Mann said. “You have to be on top of your game all the time.”

Rich Matthews, Director of Safety, Security, and Emergency Preparedness for Lakeland, observed the Niles drill. Communication is the key to a successful operation, he said.

As he learned from his military experience in the National Guard Reserves, including deployments to Afghanistan and the Gulf region, “If you can’t communicate, you can’t maneuver.”

Matthews said that Lakeland is fortunate to have Dr. Nolan, who also was deployed to Afghanistan.

“Trauma-wise, that guy’s on it,” Matthews said.

He also said that Dr. Jason Hamel, head of the Niles ER, “brings a calming presence, which helps everyone else.”

Along with limiting physical injuries to staff, hospitals need to be mindful of emotional trauma, as well, Matthews said.

Medical staff members are getting more training in how to deal with patients with mental health issues, Matthews noted.

“It comes down to compassion,” Matthews said. “It sounds like a corny word, but it’s not.”

Dr. Nolan said the scheduled renovation of the ER in St. Joseph includes rooms for patients experiencing emotional and psychological problems, away from the action in the rest of the wing.

Nolan said those coming to the ER for their own treatment or that of loved ones can help by being patient and realizing that physicians treat those with the most serious and life-threatening conditions first.

And no one is likely to wait long, he added. On average, it takes 11 minutes for a patient at a Lakeland ER to be seen, he said, putting the operation in the top 5 percent nationally.

Contact:, 932-0360, Twitter: @HPMatuszak