by Karen A. Santucci, M.D., FAAP
You’re working in a busy emergency department
(ED) or pediatric office, and the tension in the air is
almost palpable. Your nurse approaches frantically signaling an escalating situation in exam room 5. The parents are irate and have become threatening toward staff.
You try to remain calm, get a semblance of the facts,
and with some degree of confidence and many sets of
staring eyes, steadfastly approach the exam room. You
take a deep breath, knock on the door and enter the
room. Immediately, you feel physically threatened by
two angry adults exhibiting limited self-control.
Having a step-by-step protocol to keep your employees, patients and others nearby safe will help you
think clearly and function effectively when faced with
these challenging situations. Such a protocol likely will
reduce anxiety and may save lives.
Following are strategies to use in potentially violent
situations in a pediatric office, health care clinic, ED
or hospital setting.
Before you enter the room
• Remove your stethoscope, necktie or scarf to keep
them from being a strangulation risk. Empty your
pockets of trauma shears and other sharp items that
could be used as a weapon.
• Notify an employee to stand by in case help must
be summoned per the protocol.
Use clear, calm, caring communication
• Upon entering the room, use a gentle and em-
pathetic voice to express concern and a desire to
help. Perhaps offer an apology in a calm voice.
The apology is not intended to be an admission of
guilt, but certain phrases can reduce tension. “I am
very sorry that things have been so difficult today.”
“I am so glad my nurse called me over.” “I would
really like to try to help.” Other messages to convey
are “You must be very concerned about your baby.”
“I can see that you love her very much.” “Let’s see
what we can do together to make things better.”
• Offering a seat, a box of tissues or glass of water can
be comforting and may diffuse the tension. Such
gestures show you as a caretaker, not an adversary.
• Use a qualified medical interpreter (in person or by
telephone) for families with limited English proficiency. Use a family member to translate only
if there are no other options and the situation is
urgent. Speak slowly and clearly and maintain eye
contact. Pause to allow the family an opportunity
to process the information and respond.
Include experts, if available
• If you’re in the ED, involving the child’s pedia-
trician who may have a longstanding relationship
with the child and family can calm the situation.
• Secure intervention from a clinical social worker
or chaplain, if one is onsite.
Implement protocols and panic buttons
Instituting a clear protocol on what to do and how to
do it is vital. Include key contact names and numbers
for resources. Have the action steps on laminated cards
and immediately available to employees.
Likewise strategically placed “panic buttons” to silently alert security, local police or protective services
can save lives. In extreme situations, it is advisable
to activate them before entering the patient’s room.
Having someone poised to use them should the situation deteriorate is another option. Most hospitals have
these devices. Since they are inexpensive, they can be
installed in pediatric offices and clinics. Place them
in several locations such as the front desk, physicians’
work room, laboratories and other central locations
easily accessible to staff, but not curious children.
Contacting help, documenting incidents
Don’t hesitate to contact local police if a threat is
made to you or another person or if any damage has
been done to hospital or office property. These actions
may be considered breach of peace, assault or destruction of property.
In some jurisdictions, a person is guilty of breach of
the peace in the second degree when, with intent to
cause inconvenience, annoyance or alarm, or recklessly
creating a risk thereof in a public place: 1) engages
in fighting or in violent, tumultuous or threatening
behavior; or 2) assaults or strikes someone else; or 3)
threatens to commit any crime against another person
or that person’s property; or 4) exhibits, distributes,
posts up or advertises offensive, indecent or abusive
matter concerning any person; or 5) uses abusive or
obscene language or makes an obscene gesture; or 6)
creates a hazardous or physically offensive condition by
any act that such person is not licensed or privileged
Depending on the jurisdiction, aggravated assault or
aggravated battery may be charged when a person has
the intention to cause physical injury with a weapon or
dangerous instrument. A person can be charged if recklessly engaging in conduct that shows extreme indifference to human life. Depending on the charges, he or
she may be incarcerated, fined, placed on probation or
mandated to provide community service, if convicted.
Notify child protective services. Family members
demonstrating aggression and violence may behave
similarly in the privacy of their home, placing the child
at increased risk of non-accidental trauma/child abuse.
Inform the proper person at your hospital. Many
institutions have a zero tolerance policy for threats and
may take legal action.
Create a narrative report about the incident. Follow
up with a certified letter to the party involved indi-
cating the facts of the situation, the outcome of the
confrontation and the risks of future acts. If there are
irreconcilable differences and you work in an ambula-
tory setting where there is the expectation of continuity
of care, you may consider severing the doctor-patient
relationship. Follow all relevant legal requirements for
Document the incident in the patient’s medical record. The best predictive marker of impending violence
is a history of violence. Flagging the record helps anticipate problems at future visits.
Dr. Santucci is a member of the AAP
Committee on Medical Liability and Risk
Be prepared to respond to potential violence in your workplace
• Guidelines for Preventing Workplace Violence for
Healthcare and Social Service Workers, https://www.
• Preventing Workplace Violence: A Road Map for Health-
care Facilities, https://www.osha.gov/Publications/
The following are published in the May issue of
Detention of Immigrant Children
— An AAP policy statement from the Council on
(See article at http://bit.ly/2ofkOIm.)
Disaster Preparedness in Neonatal Intensive
— An AAP clinical report from the Committee on
Fetus and Newborn and Disaster Preparedness Advi-
sory Council (See article on page 14.)
Nonemergency Acute Care: When It’s
Not the Medical Home
— An AAP policy statement from the Committee on
Practice and Ambulatory Medicine, Committee on
Pediatric Emergency Medicine, Section on Telehealth
Care, Section on Emergency Medicine Subcommittee
on Urgent Care, and Task Force on Pediatric Practice
Change (See article on page 22.)
The Breastfeeding-Friendly Pediatric
— An AAP policy statement from the Section on
Breastfeeding (See article on page 38.)
The Primary Care Pediatrician and the Care of
Children With Cleft Lip and/or Cleft Palate
— An AAP clinical report from the Section on Oral
Health (See article at http://bit.ly/2nDvUa2.)
Coming in June
• Fruit Juice in Infants, Children and Adolescents:
• Pain Assessment and Treatment in Children
With Significant Impairment of the Central
• Shared Decision-Making and Children With
Disabilities: Pathways to Consensus
• Delayed Umbilical Cord Clamping After Birth
This month in Pediatrics
Pediatricians and the Law