Careers often align with personality, interests, morals, and aspirations. This allows professionals to develop a sense of passion for, and fulfillment from, their chosen field. I chose emergency medicine, like so many others, to care for patients who are in their most vulnerable state. We must know a little about a lot or, more accurately, a lot about a lot. We must be flexible. We must adapt to nuances that might be encountered. We must be ready to intervene.

Think about the person who served you your morning coffee with genuine friendliness, considering every detail in that process—from brewing to presentation—and everything in between. Their enjoyment for what they do is clear. Did you ever think about their safety as they are passing that cup of coffee over to you? Do they think about their safety as they are steaming milk or pressing espresso beans?

As a member of the Air Force, deployed to Afghanistan in 2011, I have seen war where I should have seen it—in a designated war zone. Unfortunately, I have also witnessed violence in places where in all regards I should not have. As an emergency medicine resident, I have seen the toll that workplace violence is taking on our specialty, our patients, and our entire medical community. A recent incident in which a colleague took his own life with a firearm while on shift has brought these issues into sharp focus for me, with the need to understand that workplace violence is not simply “part of the job.”¹

The questions raised by this tragedy are many: How did a gun make its way into the emergency department in the first place? Data from the National Institutes of Health suggests that up to three percent of ED visits result in a weapon being confiscated, and there has been an increase of 20 percent of firearm deaths since 2019.² But this was not a patient, it was a colleague! Why were there no safety measures in place to prevent this from happening? More than just security and metal detectors, where were the mental health resources to support this health care professional? Was anyone close to him checking on him, asking questions? Working in the emergency department, we are subject to high rates of burnout, depression, and anxiety that have all been exacerbated by the COVID-19 pandemic.³ Perhaps most importantly, how was this individual able to function at a high level, caring for patients while in such psychological distress? These questions are impossible to answer, and uncomfortable to discuss, but they demand our attention. The medical profession cannot continue to ignore our own personal safety. The gaps in safety that exist in our workplaces need emergent attention. It is not just a matter of physical safety. It is also necessary to address the critical issue of mental health. Stigma surrounding mental health among those who provide health care must change. We must create an environment in which it is okay to ask for help when we need it, without fear of judgment or repercussions.

The incident in question also highlighted the impact that workplace violence and mental health can have on the victims who are present during such events. Those of us who were on shift at the time of the suicide attempted to resuscitate our colleague while still treating many other sick patients simultaneously.

The continuous hum of quiet voices, footsteps, alarms, the occasional shriek of a patient who just received a needle stick on a busy evening with a packed waiting room, was interrupted suddenly with a “BANG!” Did a patient just fall and smack their head? Did a stack of printer paper fall off the top shelf? Did a pile of crutches just go crashing to the ground? The gut-wrenching screams that followed solidified the reality of the situation.

The smell of gun powder hung in the air. Lying by my feet, someone was injured—or worse. Did he plan to do this today? Did something happen on shift to lead him to this? What was the last thing I said to him? Did I even say hello to him today? Was my calling in emergency medicine designed for this moment?

What happened next was a combination of the human spirit and fundamental training in its most raw state. A tornado of organized chaos managed to transport him to the resuscitation bay as the tasks of life-saving maneuvers began. In the end, I walked out of the resuscitation bay with a defeated look on my face and blood-soaked shoe prints that trailed behind me. A crowd formed outside the room of his colleagues and close friends. Hope turned into sadness and anger as reality became apparent. This traumatic experience left many of those who were there that night with moral injury and some with post-traumatic stress disorder. All were forever changed. The smells, the sights, the sounds, and the constant replay of every detail of what happened, persist as nagging psychological scars.

Reflecting on this, there were no obvious warning signs. Previously established mechanisms for staff and patient safety did not work and were not designed for this. Now I realize we need to be proactive and heed the opportunities that cross our paths every day. For example, the Journal of the American Medical Association recently reported that mental health related emergency room visits spiked between 2011 and 2020.⁴ Anyone complaining of mental health struggles, violent tendencies and warning signs must be taken as seriously as any high-risk chest pain patient stating that their chest pain feels just like their last heart attack!

We must do better, and it starts with identifying the opportunities that present themselves to us on a daily basis. We owe it to ourselves, our patients, and our colleagues to create a safe and supportive work environment first, so we can give our vulnerable patients our very best. A recent Association of American Medical Colleges article suggested that “physicians have a vital role in combating gun violence, which is a major public health issue in the United States.”⁵ It is time for us to address workplace violence in emergency medicine. We must work together to create a culture of safety and support, where everyone feels comfortable asking for help when they need it. This starts with a safe workplace. Just as the barista who served you your coffee this morning is entitled to a safe workplace, so are we.

Many thanks for additional contributions made in the formulation of this article by Gus M. Garmel, MD, FACEP, FAAEM, and Moises Gallegos, MD, MPH. 

Dr. Taylor is a proud father, USAF veteran and graduate of the University of Nevada School of Medicine. Currently, he is a PGY-3 Stanford Emergency Medicine Resident.

References

1. McGuire S, Finley J, Gazley B, et al. 18 Workplace violence reporting behaviors in emergency departments across a healthcare system. Ann Emerg Med, 2021;78(4):S8.
2. Richtel, M. Emergency room visits have risen sharply for young people in mental distress, study finds. New York Times website. Published May 1, 2023. Accessed December 11, 2023.
3. Rodriguez RM, Montoy JCCM, Hoth KF, et al. Symptoms of anxiety, burnout, and PTSD and the mitigation effect of serologic testing in emergency department personnel during the COVID-19 pandemic. Ann Emerg Med. 2021;78(1):35-43.
4. Kielman R, Mercer R. Stabbed. Kicked. Spit on. Violence in American hospitals is out of control. New York Times website. Published October 24, 2023. Accessed December 11, 2023.
5. Weiner S. Physicians can — and must — help prevent gun deaths, trauma surgeons insist. AAMC News website. Published November 4, 2023. Accessed December 11, 2023.