pumped up kicks + a shotgun approach: violence in the ER


In September 2010, a little known American indie pop band released their debut single, which went on to become one of the most popular songs of 2011. The song spent eight consecutive weeks at the No. 3 spot on the Billboard Hot 100 and earned a Grammy award nomination for Best Pop Duo/Group Performance.

Despite the catchy upbeat tune, “Pumped Up Kicks” by Foster the People is a dark song about the homicidal thoughts of a troubled youth.

“All the other kids with the pumped up kicks you better run, you better run, better run, outrun my gun / All the other kids withe the pumped up kicks you better run, you better run, better run, faster than my bullet.”

Gun violence is a persistent and disquieting issue that continues to grow, despite increased awareness and efforts to limit firearm access. Schools and communities have shared the grief following tragedies such as Columbine and Sandy Hook. Hospital personnel not only care for the victims from these events, but have been the targets of violence as well. Just earlier this year, on January 20, 2015, a man of unremarkable height, weight, and appearance, walked into Brigham and Women’s Hospital in Boston, Massachusetts and asked to see Dr. Michael J. Davidson [1]. The man opened fire when the cardiovascular surgeon stepped into an exam room to speak with him. He shot both the doctor and himself. Ultimately, both men died.

Most hospitals do not have metal detectors placed on their entrances. Long wait times, high-stress situations, and short fuses compound the anxiety and frustration felt by both patients and visitors, making emergency departments particularly susceptible to workplace violence. Nurses suffer significantly more verbal and physical assault compared to physicians, sometimes more than twice as a frequently in some studies, although the rates for physicians are also high [2,3]. Gates et al. found that 51% of physicians reported at least one episode of physical violence against them within that past 12 months [3]. Given the known tendency for underreporting of events — individuals rationalizing that this is just “part of the job” of working in an emergency department — the actual incidence of workplace violence is likely even higher. Another study of six different emergency departments found that 20% of verbal threats to any staff member resulted in physical injury [4]. The graph below depicts the range and percentage of physical assault reported from their findings:


According to the study by Gates et al., not surprisingly, alcohol intoxication, drug use, and psychiatric illness have been cited as the most frequent risk factors for perpetrators of abuse against health care workers. Most assaults occur overnight and increase with increasing wait times. Concerningly, 25% of violent episodes were related to the ease of ability to bring weapons into the emergency department. [3]

Not only does workplace violence cause obvious physical distress to those involved, it can also create an environment in which health care workers feel unsafe. Of the different types of staff in the emergency department, patient representatives have the highest percentage of workers (60%) that report feeling unsafe [3]. In general, there is an inverse relationship between feelings of safety, all types of violence, and job satisfaction. Acute stress symptoms are most prevalent in staff that report the greatest frequency of verbal and physical threats and assaults [2].

Prevention strategies to address workplace violence include specific training of medical staff to recognize signs of violence, modification of the actual physical structure of the emergency department, and policy development [4]. Surveyed health care workers reported that they would like to see an increased police presence and more physical barriers, such as metal detectors [3].

The American College of Emergency Physicians recommends the following from their fact sheet on Emergency Department Violence:

Q: How should emergency staff deal with potentially violent individuals?

Emergency staff should trust their senses if they feel uncomfortable around a patient. They should be vigilant and not isolated. They should call security when they first become aware of a threat. In addition, emergency staff should maintain a safe distance, if possible, and keep an open path for exiting. They should present a calm, caring attitude and not match threats or give orders. It’s important to acknowledge the person’s feelings and avoid behaviors that may be interpreted as aggressive. Eye contact should be limited.

Q: What measures can be taken to anticipate and manage the incidence of emergency department violence?

Emergency departments should have a plan for managing potentially violent situations. This plan should include who responds, a team leader, each person’s responsibility (including the team leader), and the steps that should be taken to respond. In addition, each hospital and emergency department must base its responses to violence on physical location, types of patient populations and histories of prior violent incidents. Some measures that can be taken are:

  • Train personnel – Increase training of doctors, nurses and security personnel about de-escalation techniques, how to recognize potentially violent patients early and getting help before incidents occur.
  • Secure environments – Use 24-hour presence of trained security officers, place unobtrusive “panic” buttons in several locations, control access and egress into and out of the department, install metal detectors and physical barriers such as bullet proof glass

Q: What are the clues to potential violence?

  • Behavioral clues
    • Posture: tense, clenched
    • Speech: loud, threatening, insistent
    • Motor: restless, pacing, easily started
  • Historical and epidemiologic clues
    • History of violence (especially if frequent, serious or unprovoked)
    • Threats or plans of violence
    • Symbolic acts of violence
    • Young and male
  • Diagnosis. Certain diagnoses are associated with violent behavior:
    • Substance abuse: either acute intoxication or withdrawal
    • Acute psychoses (especially acute mania or acute schizophrenia)
    • Acute organic brain syndrome
    • Personality disorders
    • Partial complex seizures, temporal lobe epilepsy
  • Time of Day. Incidents are more likely to occur on a night shift


Related Resources

Preparing for the Unthinkable: Physician Safety Paramount Following Shooting of Boston Surgeon

Bitten, Shot, Spat On: Violence in Hospitals Common for Staff

Emergency Department Violence Fact Sheet: American College of Emergency Physicians



  1. Freyer F, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. Boston Globe. January 20, 2015. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html
  2. Kowalenko T, Cunningham R, Sachs CJ et al. Workplace violence in emergency medicine: Current knowledge and future directions. J Emerg Med. 2012; 43(3):523-531.
  3. Gates DM, Ross CS, McQueen L. Violence against emergency department workers. J Emerg Med. 2006; 31(3):331-337.
  4. Kowalenko T, Gates D, Gillespie GL et al. Prospective study of violence against ED workers. Am J Emerg Med. 2013; 31(1):197-205.

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