Under the Knife

We must all work together to stop the violence that explodes [in] our emergency rooms.

--President Clinton, State of the Union Address, January 25, 1994

The plum-colored bruises on the left side of Pauline Hanusosky's face have healed since she was assaulted by a patient more than four years ago. But the memory lingers, still fresh in her mind.

It was a Friday at dawn when Hanusosky, the charge nurse at a hospital in north Phoenix, prepared to wrap up an uneventful 12-hour shift in the emergency department (ED). At 5 a.m., emergency technicians wheeled in a stretcher bearing a patient in his late 20s. What began as a routine assessment quickly turned ugly.

Without warning, the patient rose from the stretcher, grabbed an IV pole and swung it in circles around the room. Hanusosky hit a panic button, summoning hospital security. Within minutes, six people had restrained the patient on a bed. Just as things seemed under control, the patient thrust his head backward, hitting Hanusosky's face. The nurse lost consciousness and suffered a severe concussion and internal facial bleeding.

During the next week, Hanusosky received calls at her home from co-workers, urging her to file an assault charge. But she knew that assaulting a health-care worker was a misdemeanor and the offender would be on the streets in less time than it would take for her to fill out the paperwork.

"It made me feel like a human target," Hanusosky says. "There was no legal recourse. I just had to sit and take it."

In the past decade, 106 health-care workers have been murdered in hospitals around the nation. Assaults like the one that happened to Hanusosky have become commonplace in health-care settings, threatening the safety of workers and patients alike. Hospitals, once considered havens, are now grappling with a chronic problem of violence that has spread within their own walls.

* In 1990, a distraught family member entered the ED of a small community hospital in San Diego and opened fired on the staff, killing a nurse and injuring an emergency medical technician (EMT).

* In 1991, the husband of a former patient fatally shot a nurse and held the maternity ward hostage at Alta View Hospital in Salt Lake City, Utah, after his wife received a tubal ligation.

* In 1993, a man seeking narcotics stabbed a patient-care technician (PCT) in the arm at John C. Lincoln Hospital in north Phoenix. The incident helped spark a new state law making it a felony to attack a health-care worker.

* In 1993, a Chicago man stabbed an emergency nurse with a syringe loaded with his own HIV-positive blood.

* In 1993, three physicians were shot at Los Angeles County University of Southern California Medical Center by a patient who thought the waiting times were too long in the ED. One of the victims is now a paraplegic.

* In 1993, a man who had just been treated at a hospital in Michigan City, Indiana, began shooting in a hallway outside the ED, wounding two security guards and a visitor.

* In 1995, a Mesa, Arizona, woman shot up a nurse's station at Valley Lutheran Hospital, injuring a nurse and an ambulance driver.

Emergency workers are especially prone to assault. Round-the-clock exposure to the public makes workers vulnerable to the intoxicated, the disenfranchised, the gang member or the addict seeking narcotics. The number of violent incidents is staggering. At 127 teaching hospitals recently surveyed by the American College of Emergency Physicians (ACEP), 80.3 percent reported staff injury because of violence in the ED over a five-year period and 7 percent described acts of ED violence resulting in death.

By the end of last decade, the Occupational Safety and Health Administration issued voluntary safety guidelines for health-care facilities, where two thirds of all workplace violence occurs. The guidelines were intended to help hospitals and health-care workers handle violent patients and visitors and to improve security measures.

Although some Arizona hospitals have beefed up security in recent years and have provided aggression-control education programs for staff members, their efforts may be lacking. Health-care workers and prosecutors say that Arizona's 1994 law making it a felony to attack a health-care worker is often rendered useless because of a loophole in the statute. And hospitals are often reluctant to press charges because they fear bad publicity.

Allan Morphett, a risk-management specialist for Farmers Insurance Group who conducts national seminars on hospitals' liability, says more needs to be done. "Arizona is under the federal mandates of OSHA, but everybody is like an ostrich with their head in the sand. They just ignore the problem of violence until something happens."

The 24-hour security dispatch center at Samaritan Health System on 12th Street and McDowell Road looks like the cockpit of the Enterprise. A cluster of monitors flashes images from the corridors and stairwells of SHS' four hospitals, while a row of computers monitors fire alarms, distress signals and ED lock-down systems. The $300,000 unit, the only one of its kind in the Valley, was installed three years ago in response to an escalation of violent incidents.

Don Borgadus, director of security at SHS, is confident the bank of blinking lights will reduce the number of assaults against emergency workers, which has increased at all four Samaritan hospitals in the past five years. (At Desert Samaritan Medical Center in Mesa, the number of hours security personnel spent in the ED rose by 160 percent last year.)

"At Desert Sam, we see a lot of methamphetamine cases in which people become violent and require physical restraint," says Borgadus. "At Good Sam, you see more of the knifing and shooting victims. Two years ago, we had a lot of rival gang shootings where you get gang members from opposing sides in the same ED."

The violence is concentrated in Level 1 trauma centers, which have sufficient staff and equipment to treat serious injuries such as penetration traumas caused by guns or knives.

"We get the stabbings, the shootings, the psych patients--all the worst cases in the city come here," says Tom Pernot, the security manager at John C. Lincoln Hospital in north Phoenix. "Unfortunately, violence is a problem here. You see the worst side of people in the ED. People don't want to be here. They're waiting, getting tests, poked and prodded. You've got a lot of anger, you've got people who might have been convicted of a crime and you've got family members who are upset 'cause something happened to their relatives. The ED is a very emotional place."

Lincoln has installed bullet-resistant glass on the front of the ED and often hires off-duty police officers to roam. "One thing we have here is real good cooperation from the police," Pernot says. "We give them free doughnuts and coffee in the emergency room, so they're here all the time."

Each of the Valley's five Level 1 trauma centers--Lincoln, Good Samaritan Regional Medical Center, Maricopa Medical Center, St. Joseph's Hospital and Medical Center, and Scottsdale Healthcare (formerly Scottsdale Memorial Hospital)--has round-the-clock security officers and panic buttons in the emergency department, as well as lock-down capabilities on all doors leading into the treatment area.

Maricopa, a county hospital that ministers to 2,000 traumas per year, of which 25 percent are penetration traumas, deploys security officers armed with guns, Mace and handcuffs in the ED. All of Maricopa's security officers are trained marksmen and many are ex-police officers, a necessity since the hospital houses Station 41, a secured area for prisoners requiring health care.

Although a quarter of trauma patients, their families and friends carry handguns and other weapons, according to an OSHA report, metal detectors have been excluded from security programs in Arizona, given that they're costly--estimated at more than $100,000--and require 24-hour monitoring.

In other states, metal detectors have proven effective in controlling weapons. Henry Ford Hospital in Detroit, Michigan, reported that in the first six months of its screening operation, 33 handguns and 1,324 knives were confiscated.

The catch, says Pernot, is metal detectors won't prevent someone from assaulting an employee with an IV pole or a scalpel, or punching or sticking an employee with a needle.

Drew weighs 72 pounds, has piercing amber eyes and razor-sharp teeth. A 7-year-old German shepherd, he's the senior canine in a security program that was instituted at all four Samaritan hospitals six years ago.

Drew's handler, senior officer Tom Knowles, is loading blanks into a small black revolver in the parking lot at Maryvale Samaritan Medical Center in preparation for a training exercise. Drew is all wags and smiles.

Knowles passes the gun to canine officer Frank Lopez, who bolts toward a parked pickup truck and pretends to break into the truck. Drew tenses his withers, draws his ears forward and rolls back his upper lip.

Knowles yells, "Pakhum!" (the German word for "attack") and Drew torpedoes toward Frank and clenches his jaws around the shield, shaking his head from side to side. Lopez fires off a round of blanks, but Drew won't let up. Then Knowles commands, "Oust!" and Drew retreats as if he were being reeled in by an invisible string.

"Our crime statistics have decreased every year on the property at all four hospitals since we got the canines," says Knowles, who's trained attack dogs for 26 years. (Knowles recently left Good Samaritan for a security job at John C. Lincoln Hospital.)

"The dog changes every scenario. One day a lady who had a heart attack was brought in by ambulance with three of her sons. The fourth son was at a bar getting drunk. The doctors stabilized mom and transferred her from the ER to the special-care unit. By this time, son No. 4 came in to see mom and the other three explained he couldn't see her. A fight broke out and they were yelling, swearing and punching in the hallway. Drew and I got the call and went up to where they were fighting. I yelled, 'Stop or I'll send the dog!' You've never seen eight arms and eight legs move so fast.

"Dogs also have a calming effect," adds Lopez. "At Good Sam, we had a psych patient in the ER beating up on a doctor and a nurse. I went up with my dog, Bahd [also known as Badass Hospital Dog], and the guy forgot all about beating anybody up, leaned down and hugged the dog."

In 1994, the year after Pauline Hanusosky was assaulted, Arizona became the first state in the nation to raise the penalty for assaulting a health-care worker or an emergency medical technician from a misdemeanor to a Class 6 felony. The bill was introduced by the Arizona chapter of the Washington-based ACEP, but it was shot down by the Senate more than once before becoming a law.

"Our philosophy was simple," says ACEP member Dr. Todd Taylor, an emergency physician at Good Samaritan. "On the grand scale of things, how many times do you hear about an assault occurring at a police station? Never. Why? Because you'd have to be deranged to perpetrate a crime at a police station. That was our attitude about the ED. It's supposed to be a safe haven for someone who is down on their luck, ill or injured, and anyone who violates that should be penalized."

Taylor and another ACEP member, Dr. Patrick Connell, were also concerned that hospitals were minimizing incidents to deflect a negative image. "We all know stories about health-care workers being physically threatened or assaulted by a patient," Connell says, "but several years ago, we knew we'd get stonewalled when we did anything about it. The hospital administrators wanted the violence kept quiet 'cause it was bad publicity."

Police did little to encourage hospital workers to hold attackers accountable. "Several of our nurses had been assaulted and the police just blew it off. One had been punched by a patient. They said if we booked the perpetrator they'd come back in less than 24 hours with a submachine gun, so just ignore it."

Connell remembers a time when hospital emergency departments were practically immune to violence. When he began his medical practice at Maryvale 22 years ago, the janitor doubled as a part-time security officer.

"Sadly, we have evolved to where they are no longer hallowed healing places. The number of weapons and violence has escalated tremendously to the point where we now need trained, professional security forces," Connell says.

"I work in a part of town where there is a lot of violence in general," he says. "People are subject to gun violence and domestic violence and you end up with a lot of people impaired by drugs and alcohol. There's a climate here that is ripe for violence. Physicians, nurses and techs are particularly vulnerable. In order to effectively deal with patients, you have to get physically close to examine them. You don't know who they are or if they're armed."

Connell was recently threatened by a gang member whose buddy had suffered a chest wound.

"I was told, 'If anything happens to Homeboy, you're history.'"
Connell says half the assaults at Maryvale have been committed by family members. "They become frustrated with the system. Often they don't realize that we help people in the order of how serious their illness is, that we'll care for the person with a heart attack before someone who's been waiting three hours with a sore throat. Or they have unrealistic expectations of what we can provide them with and lash out when those expectations aren't fulfilled."

The availability of narcotics also poses a safety threat. Connell says he sees people on a daily basis looking for drugs.

"They'll go from ED to ED. Some are very creative. They'll say, 'My dog ate my prescription' or 'I came here for the weekend for my aunt's funeral and forgot my medicine.' I've had people threaten me if I didn't give them what they wanted."

In November 1993, a vicious incident occurred at John C. Lincoln Hospital which sent a shudder throughout Arizona's medical community. The assault happened at 4:30 on a quiet Sunday afternoon.

Marc Wayne Bachard, a 37-year-old patient-care technician, was gathering equipment from a cabinet on the sixth floor to draw blood from a patient, when he noticed a tall man (later identified as Nicholas Conn) in his mid-20s, wearing dirty blue jeans and a bloody denim jacket, approach the nurses' station.

"Do you have any meds on this floor?" Conn asked a nurse, his long, brown hair revealing watery, bloodshot eyes and a thin, unshaven face. When the nurse asked who the medication was for, Conn replied, "It's for me," whereupon he attempted to open a locked drug case.

Suddenly Conn became aware of Bachard, who was standing behind him, still searching through a cabinet. Surprised and agitated, Conn whirled around, reached into his boot, produced a six-inch carving knife and stabbed Bachard in the right arm, piercing the bone above the elbow. One of the technicians yelled, "Oh, my God, Marc's been stabbed!"

A nurse followed the assailant, who ran down the hall. As she passed the elevators, someone (allegedly Conn) struck her on the head and she lost consciousness.

Conn escaped (he was found later in a neighbor's backyard) and Bachard was wheeled to the ER with the blade still lodged in his arm.

The perpetrator was charged with five felonies and is serving a seven-year sentence. But knowing that Conn was in jail didn't make Bachard feel any safer.

"It was like being in a nightmare," recalls Bachard, who's going on his sixth year at Lincoln. "For an entire year after it happened, I carried Mace with me while I was working. I was constantly looking over my shoulder."

A week after the incident, Bachard was called by an ACEP member, who asked him to appear before the Senate. When ACEP members caught wind that Senator Mark Spitzer was spearheading the bill they had been lobbying for, they rounded up health-care providers who had been assaulted to give their testimonies.

Spitzer says Bachard's case drove him to sponsor what was then a controversial bill. "It just barely squeaked by," Spitzer says today. "People said, 'Why should these folks get more protection than anyone else? If I get assaulted walking down the street, why is that a misdemeanor?' Hospitals are a place of healing, and the health-care givers who work in them deserve more protection. Four years ago, when assaulting a health-care worker was a misdemeanor, the police would blow it off, like it was a pushing match in a bar."

Among those who testified were Bachard, Hanusosky and Dusty Sullivan, an emergency nurse who gave chilling testimony.

Having worked the night shift in trauma centers for 25 years, Sullivan has been assaulted on more than one occasion--she's been choked, and held at both gun point and knife point--but one particular incident made her feel violated more than any other.

The offender had been discovered molesting bodies in a mortuary. When confronted, the man became incoherent and was brought into the emergency room. Sullivan, then the head of the emergency department at Maricopa Medical Center, tried to inject him with a tranquilizer. The patient bit off a chunk of her flesh from her forearm, leaving a scar the size of a nickel.

Sullivan didn't report the incident to the police--it occurred prior to the passing of the felony law--since she knew there was little chance the man would be held accountable.

The underreporting of violence is typical, according to an OSHA report. Many ER workers and their supervisors regard violence as part of the job, some fear retaliation and often an excessive amount of paperwork is required for reporting an incident.

Besides, says Don Borgadus, hospitals often choose only to focus on those assaults resulting in injury. "There are dozens of incidents in which emergency staff members have been scratched, kicked and pushed, but we don't report those because they're not serious," Borgadus says. "The ones you report to the police are those in which employees require medical follow-up."

The only incident Sullivan reported was one in 1990 that drew the attention of the Phoenix Police Department's Riot SWAT team. While a patient's family and fellow gang member stormed the emergency department to see a gunshot-wound patient, they pushed one nurse to the ground and shoved another nurse against a wall. They threatened to kill her if she did not allow them into the trauma room.

"As you can see," Sullivan says, "we work with the dregs of society in a lot of cases. Emergency medicine is more than plumping pillows and smiling."

An hour after midnight on April 15, 1994, the day the bill was passed, Dr. Patrick Connell saw a health-care worker being threatened by a patient. "A big, angry man was standing over a tiny triage nurse, threatening to punch her out if he didn't get what he wanted. I said to him, 'Sir, I'm Dr. Connell and I just want to remind you that as of one hour ago, assaulting a nurse is the same as assaulting a police officer.' That stopped him right away."

These days, Connell looks to the law for protection, but only to a limited degree.

"Legislation is only a piece of the puzzle," he says. "I view it as more of a deterrent than as a measure to punish people."

Unfortunately, its effectiveness in deterring violent crime has been minimal. Few people are aware of the law. Some hospitals have posted a sign in the ER stating it's a felony to assault a health-care worker, but others shy away from the negative publicity.

"Hospital administrators don't want the public to think they're coming to a place that's potentially violent," says Connell.

To make matters worse, the law has been ineffective in punishing offenders.
Even though the presumptive sentence for a Class 6 felony is one year for a nondangerous offense and 2.25 years for a dangerous offense, ever since the law was instituted in 1994, not a single felon has served the full term.

One possible explanation is a clause in the law which creates a gray area for prosecutors. It reads, "The provisions . . . do not apply if the person who commits the assault is seriously mentally ill . . . or to persons afflicted with Alzheimer's disease or related dementia."

"That clause takes a lot of teeth out of the law," says Dusty Sullivan, "because it doesn't address people who are mentally or chemically impaired, making them not responsible for their actions."

Don Borgadus agrees. "It's not an easy statute to prosecute under for a simple assault," he says. "If a patient is coming in on a gurney and is high on meth and kicks a health-care worker, you wonder if they'll ever be prosecuted. We had one case at Desert Samaritan in the last 18 months where a doctor was assaulted, and one at Maryvale where a nurse was assaulted, and both victims pressed charges. But it's tough to have that law enacted on anybody because often the people committing the violence are totally out of control and don't know who they are and what they're doing."

Consider the case of Jean Dooley. At 2:50 p.m. on February 13, 1995, the 73-year-old woman left room 503 on the fifth floor of the Valley Lutheran Hospital in Mesa, where she had been recovering from a hysterectomy. She was carrying a .38-caliber Smith and Wesson revolver.

Holding the gun directly in front of her with both hands, the heavy-set, gray-haired patient fired a shot at an ambulance driver named Douglas Proce from 10 feet away. The bullet entered the right side of his abdomen, ripping out a chunk of his small intestine and part of his colon. Proce and the nurse in charge of Dooley's care, Andy Salonic, ran for cover inside the linen area behind the nurses' station.

As Proce crawled about the floor, trying to regain his footing, Salonic saw Dooley slowly walking around the nurses' station while deliberately firing the gun. "She was very focused and intent on what she was doing," he later told police.

Salonic ran down the hall into room 512 where another one of his patients stood in the doorway with an IV attached to his arm. The nurse detached the IV and pulled the patient into the bathroom, at which point he realized he had been shot in the back.

Prior to the shootings, Jean Dooley had been under psychiatric care and had been prescribed Librium. Then, in the days leading up to the shootings, Dooley heard voices and experienced paranoid delusions that her husband was trying to kill her.

Just after the shooting, she was overheard saying to her husband, while security officers restrained her in a chair, "I know I got you, I was aiming for you. I want to kill you. If I killed two people, I don't care if I killed two people, I'll take an insanity plea."

Which is exactly what Dooley did. Nearly two years after the shootings, charges against Dooley for attempted murder and aggravated assault were dropped. Dooley claimed her actions were guided by heavy doses of painkillers prescribed by her doctor. Indeed, between her surgery on February 10 and the shooting three days later, she had been given cocktails of morphine, Demerol and Percocet. Four hours prior to the shooting, she was administered 75 milligrams of Demerol.

Her defense attorney, Jeffrey Ross, said the drugs knocked Dooley off the deep end, making her temporarily insane. Prosecutor Jim Rizer argued that she knew what she was doing, which was to kill her husband.

Since Dooley had been "involuntarily intoxicated," meaning she had taken prescription medicine according to her doctor's orders, the prosecutor's case didn't hold up. And the felony law, which exempts those who are "mentally impaired," failed to protect the two health-care workers who suffered serious injuries as a result of the shootings.

Bill FitzGerald, a spokesperson for the County Attorney's Office, says, "We felt that we prosecuted that case successfully, but the decision on retrial was the jurors felt that the medication she was under could have caused her to act the way she did. Each case rises and falls under its own set of circumstances. It's hard to prosecute all cases under the law that was written.

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Leigh Silverman