Dangerous patients in the exam room

Sitting alone in an exam room with a patient with a history of violence is one of the most difficult parts of my VA Medical Center practice. This was driven home for me not long ago when one of my patients, a man bigger than I am, lunged forward and curled his hands around my neck.

In my mind, I instantly ran over our academic protocol for handling this kind of situation, but dismissed it in a split second. The phone to dial the emergency code was out of reach. Worse, I was seated, and he was standing, looming over me. Cut off from the door, I had nothing that I could use for self-defense.

Five minutes earlier, I'd opened the patient's electronic health record and seen the same pop-up message that greeted me during his last several visits: "Behavior warning." I'd gotten used to the message by now and clicked past it. On this day, the patient had been five minutes late, and I was running 10 minutes behind for his 20-minute appointment.

Survival instinct trumps clinical judgment

My mind raced. Should I try to break his grip on my neck? Hit him in the gut? Aim lower, hitting him in the crotch out of desperate self-preservation? As a primary care physician, I had an arsenal of weapons to fight disease, but in the face of physical aggression, I was helpless.

Then, as suddenly as he'd grabbed me, his grip relaxed, and he straightened up.

"So now you understand the position I was in, and why I did what I did." The way he pointed his finger at me still seemed threatening, but the redness in his face was fading and the beginnings of a smile crossed his lips. "And why I need you to give me more Percocets, given the shape I'm in after what I've been through." He sat down, finally, although he was still between me and the door.

As he sat, I thought, "Did he just threaten me for drugs?"

Clinical reasoning gave way to survival instinct: At this point, whether or not he was due for his colon cancer screening seemed irrelevant. What I knew-and knew clearly-was that the fastest way to get him out of the room was to give him the prescription he'd wanted all along. Hastily, I wrote a script for a few Percocets, then folded the sheet in half. With luck, he wouldn't notice how few I'd prescribed until he left my exam room.

"Take this to our pharmacy," I said, my words trailing off. He took the script, stood up again, and backed out of the room, never breaking eye contact with me.