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A Touch of Delirium and a Silver Badge: Challenges of Integrating Security and Healing in Hospitals

“They’re killing me,” Mr. S. whispered to me in Spanish, fear flashing across his eyes. “I have to get out of here.” He yanked his legs upward, but the soft restraints tied around his ankles tugged him back, tethering him to his hospital bed.

I first met Mr. S. two nights ago, when I admitted him for a urinary tract infection. We had a pleasant chat about his loving son and his work as a carpenter before he retired. In the last 24 hours, however, he had become confused and delirious. At midnight, I received an urgent page: “Patient S agitated, pulling at lines, threatening staff. We’re calling security now.” I made a beeline to his bedside, crossing my fingers that I’d get there before the armed officers.

Enforcement and Health Care

I work at one of several hospitals in the country whose security force is staffed by law enforcement personnel. It’s also one of the 52 percent of hospitals nationwide whose security guards are armed with handguns. On a regular basis, I am faced with a peculiar tension that arises when health care priorities misalign with apparent security goals. On the one hand, there are the unpredictable needs of sick, vulnerable, and, at times, unstable patients. On the other hand, there are the day-to-day stressors experienced by staff and the occasional real threats to their safety.

Unfortunately, in trying to negotiate this tension and promote safety via security officers, all too often the patient ends up feeling more vulnerable, attacked or even unsafe. In some extreme instances, there have been cases of assaults, shootings, and Taser attacks on patients by hospital-based security personnel.

Control versus Cure

I was nervous that evening as I scurried up the stairwell to Mr. S’s room, wondering what would happen when he was confronted with the security guard. When I arrived, I saw four nurses crowded around his hospital bed, making the final adjustments to the restraints by fastening the soft cotton rings around his ankles and wrists and pulling the straps tightly to the metal frame of the bed. There was no sheriff in sight. I exhaled — relieved — and moved quickly to the head of the bed. Mr. S was mumbling, his eyes darting from me, to the vitals monitor, to the aide, to each of the nurses in the room, clearly delirious and tugging at the restraints. I crouched next to him, listening to his concerns and speaking to him in soft, calm Spanish, “We’re here to take care of you, Mr. S. You’re here in the hospital. Your son is coming to see you tomorrow. Everything is going to be okay.”

And just as it seemed like Mr. S was starting to relax his pull on the restraints, a new voice bellowed from behind the privacy curtain in his room. “Sir, you will have to calm down.” We turned to see a uniformed sheriff’s officer emerging at the foot of the patient’s bed, barking orders in English. The patient looked startled for a minute, his eyes clouded, then he quickly resumed his tugging and yelling. “The race is coming, I have to go in my car right now!” he shrieked. The officer didn’t blink, clearly not understanding the patient’s Spanish. “Calm down,” he shouted back English, his gun bouncing off his hip.

But Mr. S’s agitation was mounting. Suddenly, he had an arm free and the sheriff jumped on him along with the other nurses. Mr. S. fought back harder now, spitting and swearing and flailing his arms. The sheriff grabbed the patient’s left arm, held it down, and leaned his weight into it as his holster banged against the hospital bed.

Security for Whom?

As I think back to this moment with Mr. S, I am struck by how helpless I felt. While I had a clear idea of what the patient needed medically — reorientation, soothing, establishing familiarity — the sheriff seemed to have a completely different agenda. Indeed, our strategies as health care providers often come into conflict with those of security personnel due to a fundamental difference in training and perspective. Health professionals are trained to see the patient as a whole, to think about the root of a patient’s illness or behaviors, and to provide compassionate treatment. In contrast, law enforcement culture traditionally focuses on detecting threats and responding quickly and accurately to eliminate those threats. It can therefore be incredibly challenging to come up with a shared vision between care providers and security personnel to address safety concerns involving patients, especially during one-off or emergent encounters.

In addition, the story of Mr. S illustrates how power dynamics impact a patient’s experience of a security force. Traditionally, patients in the hospital are in a relatively disempowered role — feeling ill, awaiting diagnoses, getting poked and prodded, being asked to share deeply personal aspects of themselves with people they just met. Not to mention the possibility that patients may be in psychiatric distress, unable to control their bodily functions, or unable to communicate. The presence of new authority figures such as security guards who generally respond only in crisis moments can thus be particularly intimidating for a patient who may already feeling vulnerable.

This feeling of vulnerability can be further compounded by cultural and language differences. Despite regulations establishing language access services in hospitals across the United States, there are still instances in which patients are not provided with the culturally sensitive care and interpretation or translation services they require. When these oversights are carried out by security personnel, as in the case of Mr. S., situations can quickly escalate when they may have been more easily resolved with adequate communication.

The unequal power dynamics related to security personnel are particularly salient when the officers are armed or part of a law enforcement body. While potentially a reassuring presence to some, patients who have previously felt targeted or discriminated against by law enforcement officers may find the very presence of these uniformed guards intimidating or disconcerting. This is certainly relevant at our hospital, which serves large numbers of undocumented immigrants, formerly incarcerated people, and people of color from neighborhoods in the city that have been disproportionately over-policed. To these patients, the presence of uniformed officers may re-traumatize them, even within the walls of an institution that aims to heal.

To be sure, there are instances in which the specialized approach of law enforcement can be appropriate. From 2012 to 2014, violent crime within hospitals and other health care institutions increased by 40 percent. In my own workplace this past year, an active shooter incident required a fast, specialized response by our security force to ensure the safety of all patients and staff.

Nevertheless, it is not necessary to apply this degree of force to the vast majority of everyday incidents our security personnel encounter. To the contrary, it is likely that applying excessive force to these everyday security challenges may actually escalate conflicts unnecessarily.

A Path Forward

What are the alternatives? Some hospitals have hired private security guards that are armed with nothing more than pepper spray and trained extensively in de-escalation. Other hospitals have developed crisis-response teams that include an interdisciplinary team of mental health professionals, social workers, and, when indicated, security guards. Some other hospitals have deemed their security force “peace officers” and made sure they dress in clothing that is not intimidating to patients who have a history of negative experiences with law enforcement. Whatever form the solution takes, it is clear that hospitals will benefit from honestly addressing the inherent conflict between health care and law enforcement, and have clear strategies in place to mitigate the tensions that arise.

Thankfully, in the case of Mr. S, things ultimately did deescalate. The sheriff left, I kept up my calming advice, and his agitation improved. Nevertheless, I’m convinced that a more thoughtful response and more coordination between all of us involved would have likely led to a more rapid de-escalation, and may have ultimately resulted in Mr. S feeling more cared for and safer, even in the face of his medical challenges. For Mr. S. and so many other patients, a shift in how we think about security and safety within our health care institutions is needed in order to truly foster a culture of caring and healing for all.

Image credit: Gun Belt by torbakhopper licensed under CC BY-ND 2.0.

Juliana E. Morris, MD, EdM Juliana E. Morris, MD, EdM (2 Posts)

Resident Physician Contributing Writer

University of California San Francisco

Juliana is a PGY-2 resident in Family and Community Medicine at the University of California San Francisco (UCSF).