 Hello, I'm Dr. Louis Myers, and this is Health Care Today. We're going to talk today about a difficult subject, which is health violence in the health care setting, particularly violence directed toward health care workers. Seems that this is a growing problem, and it has led to the involvement of the emergency department and other physicians around the state and the involvement of our legislature. And we have two guests today who are going to tell us about what's been happening in recent years, and particularly over the past year. Dr. Ben Smith is with us. He's the medical director of the emergency department at Central Vermont Medical Center. Dr. Smith is with us on Zoom today, and he attended Columbia Medical School and then did his residency in emergency medicine training at Alton Denver. Also with us by Zoom is Senator Brian Collamore, a Republican state senator from Rutland. Senator Collamore has served for 10 years now in the state senate and is involved in several committees. Prior to joining the state senate, he was the general manager of a number of radio stations in Rutland. He's going to talk to us about the legislative process and how he brought this bill through the legislature in the past year. So welcome to you both. I'd like to start with Dr. Smith, who is on the front lines as both a physician treating patients in the emergency department as well as the administrator. Dr. Smith, tell us a little bit about what's been going on out there and what has changed in recent years. Sure. Thanks, Dr. Myers. I appreciate the opportunity to be here and appreciate all the work that Senator Collamore and his colleagues did around this legislation in the past year. I think as a starting point, I just wanted to mention something about the practice of emergency medicine, which is that the fact of the matter is for the emergency, part of emergency medicine has always entailed a little bit of the risk of violence. And that's unfortunate, but it's always been part of the work that we do, a sliver of risk. There are people who come to the emergency department, often come in extremes of distress of one form or another, and that's the nature of the work. And so sometimes that slips into violence, threats, or the risk of it. And that's always been a part of the work as long as I've been doing it, which is just over 20 years now between my residency in Denver and my work here in Vermont. So there's always been a component of that that we have accepted. Whether you were physicians, PAs, nurse practitioners, nurses, technicians, kind of all up and down the chain, a bit of this is a part of the work that we do, unfortunately, but it's something we accept and we learn how to manage and deal with. I think what's happened over the last, for whatever set of societal, cultural, sociopolitical reasons, over the last five, six, seven years, is really beginning even before COVID, but rapidly escalating in COVID is that the level of violence that our teams were dealing with, the level of threats of volatility dramatically escalated to the point that it has come repeatedly come close to jeopardizing the core mission and core role we play in public safety, in the safety of our communities. Emergency medicine is challenging even on a normal day. We have entirely unpredictable patient flows. Sometimes we get 20 people who show up in the course of an hour, and any one of them could have a life-threatening illness. You throw in the middle of that one or two people who are violent for whatever set of reasons that might be. It becomes very challenging in any environment and particularly sometimes in our under-resourced small rural hospitals to manage those problems to anyone's basic metric of safety. We've just been seeing that with a greatly increasing level over the last five years, and it's really continued post-COVID when I think some of us thought it might abate a little bit. Can you tell us perhaps a couple of clinical scenarios or situations that you recall that have happened just to give the viewers some sense of what it's like for you guys? Yeah, sure. It's hard to talk about because we're a proud bunch. We don't like to appear vulnerable. But you ask any of us, we have tons of stories. We think of one of our nurses who was bringing a drink to a patient who was in some significant distress, and she dropped something on the ground, bent over to retrieve it, and the patient just hauled off and kicked her in the face, flipped her back over, knocked her out. This is probably a year and a half ago. Knocked her out cold. She wakes up as her colleagues are dragging her away across the floor to get her out of harm's way. She sustained a concussion, was out for, I don't know, four or six weeks before she returned, and has some trauma as anyone would from that. She's back at work. She's a fantastic nurse. That's just one event among many. We've had, I mean, sure, Senator Caldmore is aware of the, we all are probably about the Vermont Digger story about the nurse in Rutland who was pregnant and punched in the stomach and had to be hospitalized. I know of at least two ER physicians in the state who are no longer practicing because of violence that occurred in the workplace in one case of pregnant woman who sustained an attack and another one who sustained a career-ending traumatic brain injury being punched in the head. I mean, even in the last few weeks, we've had situations in our emergency department that have been really close to unmanageable with multiple people injured in the same kind of event. If I may, when a situation like this develops, and it sounds like it can develop very suddenly, what is the response of the ER, and tell us about what you have in the way of security, what is the first thing that have obviously other ER personnel will try and help, but what gets triggered there? Yeah, so we have policies in the hospital, you know, in our instance called Code Green, there's different tiers of levels of behavioral response that we can call overhead to get various levels of support. We have a great security team. They, you know, often on over the years have been under staffed and under resourced, but the hospital's put in a lot of effort in the last couple of years to help that, which has been great. But the fact of the matter is our hospitals are under significant financial strain, as we all know, and in addition to having a workforce crisis, which certainly extends to paying security guards 24-7 to be available to help us out in these circumstances. But what happens is we will activate those resources and we'll get people that kind of swarm to the area. But the reality is, you know, depending on what time of day these things happen, we may or may not have enough resources to safely deal with that situation, you know, depending on the staff who are on it at any given time. And so we have an array of options. So we then, you know, carefully circumscribed and very highly regulated series of events. We can restrain people, we can apply involuntary medications if they are in the throes of, you know, a mental health crisis or something of that sort. If they're not and they're being violent, thanks to this legislation that was passed, we can now have the police remove them. And that had been a bit of a challenge, which is, I think, probably surprising to many viewers. Yeah, but why don't you explain? What was the policy across the state before this recent legislation? Okay. And Senator Collamore, please jump in if I get this wrong. There was a widespread, there was a widespread perception, there was a widespread feeling amongst law enforcement, and unless they had visualized directly these incidents, that they charges could not be filed. And I'm sure I'm probably not getting this quite precisely right, Senator, but. And what that meant that what we were experiencing frequently, and the idea is we would have these violent episodes by the time that the law enforcement arrived, it would sort of have cooled down or resolved. And the patient may, you know, if they were in the, they would basically say, well, we're going to issue a citation. You have to appear in court in a few days and would leave, but that person would remain in the emergency department. And so that was obviously very challenging for us to manage and often unsafe. And I want to be really clear. Law enforcement is, is working under their own enormous stressors from top to bottom these days. And we have great sympathy for and honor the work that they do. And I think they're, they're in many of the same situations that we are as far as resource being strapped for resources and the ability to deal with these situations. So I don't want to be clear that I'm not blaming law enforcement for this, but there was, they I think often felt that their hands were tied in their ability to help us. And so the legislation that the senator helped to enact gives them some more tools to help us. And in certain cases, remove people from healthcare settings when the danger has become too great. And that's been, we're going to talk with Senator Cullinmore in just a moment, but let me go back. You mentioned the security and workforce challenges, et cetera. Obviously we're having trouble even hiring police officers who are come in at a, you know, a higher salary than I'm sure than hospital security. What kind of training do hospital security get? Cause they're the ones are going to be putting hands on in many cases and helping restrain patients. Do you have any idea of what kind of training they get and where, where they're being hired from? Sure. Yeah. Where they're being hired from, some of them are former law enforcement. Some of them, you know, there's a, there's a wide variety of people who, who are hired into that field. They get very specific training that is tailored for the healthcare environment. The program that our hospital uses, which I think is fairly common around the state is called evade. And it combines, it's, I think run out of Dartmouth, although I probably shouldn't say that. I don't know the exact details of it, but it can, combines training in the physical elements of, of necessary, unfortunately, occasionally necessary for restraint of, of, of volatile patients with, with extensive training in de-escalation, body language, all those kinds of things, trauma informed care that, that we want our people to be bringing to those circumstances. So they, they have very extensive and prescribed training for this before they're, before they become active in the healthcare setting. Let me ask you this. You mentioned at, at the beginning in your introductory remarks that this accelerated during COVID and then has continued. You know, we, we are hearing across the country in different industries. For example, airlines where there seems to be an increase in unruly and violent passengers and other situations during COVID and after. Do you think this, I mean, in your own opinion, do you think this is part of a trend that, that somehow the societal dysregulation is increased and we're just seeing some of that in the emergency department as well? That's an enormous question. I think the short answer is yes. Yeah. That would be a whole nother conversation we could spend a ton of time on. But I do think we, yeah. There is something, there is something about our culture in the last couple of decades. I think that has resulted in this, but I, you know, I think the other thing that, that has to be said, and this was a difficult part of the conversation last year in the legislature and sort of remains an open question. But there is a general increase in the volatility of, and sort of incivility in our society. And the ER is ground zero for that 100%. But with these violent episodes, and this is, this is very hard to talk about Dr. Myers, but there is an overlap with our stroke, patient struggling with mental health and substance abuse. And it's very hard for us in this state, I think in particular to talk about, because we have very open and free and, and generous approach to patients who are struggling with these issues as we should. And, and, and a deep concern about stigma. And that is all in very, very appropriate. But I think we, we as a state need to carefully, cautiously figure out how to talk about that tiny, sliver of patients who are struggling with some very severe mental illness or very severe substance abuse problems who do have violence as a part of their illness. It's a tiny subset, but it is a, it is a very real thing. And we seemed as a state to have a, a lot of difficulty talking about that forthrightly. And I think it comes from a good place because we don't want to stigmatize and, and, and that makes a ton of sense. But I think we've made a lot of progress with the bill last year, but I think we still have a little of ways to go. That is thoughtful. And, and we're going to come back to that. I want you to stay with us. I'm going to turn to Senator Cullamore now. Senator Cullamore, when did you start to hear about this problem? When did it sort of come onto your radar? I know there's so many other issues you deal with in the state Senate, but how, how did this come into your attention? Well, thank you very much again, Dr. Myers for having me here. And I want to just begin by telling Dr. Smith how appreciative I am of his position on all of this and how grateful everyone should be about the work that goes on each and every day in our emergency rooms across the state. There are very special breed of people who work there. I was approached by a lobbyist from the hospital association at a legislative breakfast. I believe it was last fall at the Rutland Regional Medical Center. And then when the legislature reconvened, I did speak with Senator Sears, he's chair of the judiciary committee and Senator Lyons, who's the chair of health and welfare in the Senate. So they together put a bill for it, and I can explain the process of how that happens in just a second, but the bill had a number on it, S-36, and it became Act 24 once the governor signed it into law. And again, we can go over some of the provisions of the bill, but Dr. Smith was correct when he said this was a non-witness misdemeanor offense. And so often in the emergency rooms, as he correctly pointed out, what happens a lot of times when patients who are suffering from severe mental crisis interact with the workers there, it does have a tendency to get heightened in terms of verbal abuse, but also physical abuse. So we tried to fashion something that would deal with both of those, and as he also correctly mentioned, I think that we're going to have to take another look at it once we reconvene again in January. So how does a bill happen? There are 150 House members and 30 senators. Any one of those 180 people can ask to be on a bill that's drafted by the Legislative Council. We have a group of lawyers that work in essence for the legislature. They put a bill together, it's put on the floor, and then the Lieutenant Governor and the Secretary of the Senate in our case decide what committee it will be referred to. In this case, S-36 was referred to the Judiciary Committee, which has comprised of five people. They took testimony on it and finally took a vote on it and brought it forth to the floor where it was voted on. And then that bill goes across to the other body, the House, and they do the same thing. It's referred to their light committee and testimony taken and it goes to the floor. And if both houses pass it, then it goes on to the Governor who signs it or doesn't if he chooses to veto it. And it becomes law usually by July 1st of that year. So that's what happened here. And I don't know whether you need any more explanation. Can you tell us? Yes, sure. Tell us this. I'm sorry. Tell us specifically then what S-36 or Act 24 stipulates. Yeah, it's an eight-page act. So I can't get into it. Well, I could, but we'll probably be here a short enough time that I won't be able to. But in essence, it adds a category of healthcare worker in a hospital and then a person providing emergency medical treatment. Those are the two categories that were added to existing language entitled 13, which has to do with crimes and criminal procedures. So it allows an officer who has probable cause to believe a person has committed or is committing a misdemeanor outside the presence of that officer to either issue a citation or arrest that person. And in the instance of the hospital, remove that person from the emergency room. It does add two other provisions to it, criminal threatening and disorderly conduct or engaging in fighting or in violent tumultuous or threatening behavior. So it doesn't have to be a physical assault. It could be encapsulated with someone threatening someone or in essence, engaging in disorderly conduct. And what happens is they, if they violate that, they could be arrested and imprisoned for not more than two years or fine, not more than $2,000 or both. So how does it work in a hospital or other like a convenient medical facility when the law enforcement officer is not present at the time that this happens? Well, when they are responding to a crime committed by a patient, an authorized representative of the hospital will disclose to the law enforcement officer the following information before the officer can remove the patient from the hospital. The information, it's sufficient to confirm whether the patient is stabilized, has been evaluated or is awaiting inpatient care and then any other information that will be necessary for the purposes of safely taking custody of the patient. And the law enforcement officer, by the way, cannot do that unless the administrator or whosoever acting as the authorized representative of the medical facility says that they have in fact been stabilized. And so that's how that works. And we will have two studies done, one by the Vermont program for quality and healthcare and one by the Department of Public Safety that will go over all the data that's been collected by those two entities to see whether this is working well or whether we need to make further refinements to the statute. So these are misdemeanor, they're classified as misdemeanors, not felonies. So even grievous bodily harm would still come under misdemeanor? Well, again, that would depend on the citation that was issued. It could be both if, or one or the other if there's a serious injury, that could be a felony. Okay. So just to go back, Dr. Smith was talking in more general terms after I asked the question about society and have we seen a change in recent years in terms of dysregulation? What are your thoughts on that? You've been in the Senate for 10 years and you've been in community for even longer, obviously. I don't think there's any question about that and I sympathize with, again, with the folks that work in the emergency rooms across the state. They have a very tough job. So does our law enforcement community. I think there has been an increased and marked instance of disruptive behavior. You mentioned the airline industry, which is also going through problems with that. I also have to be an ice hockey official. And so what used to be sort of okay behavior where people yelling and screaming about a particular call you made, sometimes now rises to the level of people waiting at the gate or waiting in the parking lot after a game to have a further discussion with you. So I don't think there's any doubt and I don't know what the causes are. We've certainly had an increase in mental health interventions. I don't know that we're doing enough yet to help people and I do think we need to strike a balance. I think Dr. Smith's correct there. We don't need to stigmatize people any further than we need to. But at the same time, we need to make sure that people are protected, especially in the healthcare instances. You know, we're talking about emergency departments, but there are other areas in the hospital which are even grayer area. I know that, for example, on our medicine floors at my hospital, we have a number of patients with dementia who when they get very confused and scared and agitated, they will hit nurses. It's hard to hold them responsible because they truly are demented and often they don't really understand or know what they're doing. So that's a difficult situation. The other difficult situation I think is in psychiatric wards and I know we have a large one at Rutland and Central Vermont has the facility in Berlin there where people have been committed or are there for psychiatric disorders and often that's a very dangerous place to work for staff and it's hard to piece out how much people actually can be held responsible under those situations. Dr. Smith, what are your thoughts on that? You know, just some of these other areas in the hospital where it's even a grayer area perhaps than an emergency department, whether it be demented patients or psychiatric patients upstairs on the psych ward who strike out and injure people. Yeah, so a lot of thoughts on this although I don't practice in those settings myself, you know, we have a small community hospital like you do in Rutland and so we all know each other. So I'm intimately familiar with these kinds of stories. I think one thing that we just have to talk about with the geriatric dementia challenge is that there are very few resources in our state for these folks to go and be cared for outside of an inpatient hospital floor and many nursing homes who are as we know are very strapped for resources will refuse to take dementia patients who have behavioral problems. And so many of our hospitals are frankly overwhelmed with patients of this sort who have absolutely nowhere to go and it is on the verge of breaking our inpatient capacity. And so that is a critical need for our state to get ahead of because we have, you know, we have what we're like the fourth oldest state in the country or something and if you take Chittenden County. Second oldest, I think. Okay, yeah. So and that's not going away anytime soon. So we have a tidal wave of elderly patients that are going to be coming our way over the next decade and we do not have the resources to meet that that need in any way. So that's that's one separate issue. I think your question about about holding people in that circumstance responsible. I mean, none of us, you know, we, we reckon we deal with folks who have dementia or in the throes of a terrifying psychosis all the time it is a terrible thing to struggle with. And we take our role in that extraordinarily seriously. I don't think any of us would believe that someone in those circumstances should be punished in any kind of contemporary way. But what we do need is the resources and the ability to keep ourselves safe while we're caring for those patients. And we are still limited in that. And I think, you know, one thing I worry that, you know, as a public, we're a little bit still stuck in this notion of, you know, one flew over the cuckoo's nest, you know, 50 years ago of the sort of barbarity of mental health treatment, you know, 50, 40, 50, 60 years ago. And we still have this mental picture that that's the way things are in inpatient units. But it's just not the case. I mean, there are very professional, diligent, compassionate people doing this work. It is highly regulated as it should be. And anytime behavioral restraints are used, it is scrutinized with a fine tooth comb. Every single incident is reviewed in our hospital. And it's scrutinized by the Centers for Medicaid Services and the Department of Mental Health. And like this is incredibly visible and regulated area. But so we're a long way from all those terrible things that happened so many years ago. But we've drifted to a point where we often just don't have, particularly in the state of Vermont, the regulatory tools to safely manage these patients. So I don't think with those patients that are in the throes of a terrible mental illness, critical mental illness, I guess I'd say, or dementia, none of us want to see those. I mean, that would be crazy, right? None of us want to see those patients put in jail, God forbid, or anything like that. But we need the care resources to manage those patients ethically. And we're a long way from that in this state. Well, I want to thank both of you for being here. And this is an interesting, perhaps Senator Collamore is able to hear this. And maybe that'll be a next thing we'll look at, establishing some increased resources, particularly for our geriatric population who is struggling. But both of you have really contributed to moving this issue forward. I'm glad that there'll be some data collection as we go forward in the next year or two to see if the act, the law is actually working in the way it was meant to. But I think it's an important step forward, and I think we can all be appreciative of that. Thank you both. Senator Brian Collamore from Rutland, Senator Dr. Ben Smith from Central Vermont Medical Center. Thank you. And please join us on our next episode of Health Care Today.