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What would you do if a patient attacked you?

Last week in Pulse a GP described his experiences of being set upon by a disturbed patient ­ here Dr Fred MacSorley offers advice on self-defence

Never fight with patients ­ they are better at it than you will ever be~

recall the wise words above from my senior partner many years ago, and I've tried to abide by them.

I also learned the value of keeping an open mind in a confrontation; I try to view life from the patient's side of the fence. The offer of an early apology, even when a perceived rather than an actual mistake has occurred, often defuses a difficult situation.

But even the best medicine will not work on everyone. So how do you manage someone who is beyond reason and intent on causing you or your staff harm, as happened to Dr Charles Gould (see his article in Pulse last week)?

Early recognition of the seriousness of the situation is the first thing. Advanced drivers are taught to scan the road as far ahead as possible to identify any hazard at the earliest possible stage so they have time to react. The same ethos applies in self-protection. Recognise the signs of impending violence early, and get out or call for help.

So what are the signs? An increasing display of agitation, disinhibition, raised voice and shouting are all symptoms of adrenaline running in your patient, and if you feel your own adrenaline running, avoid the temptation to confront, argue your point or stare them out. It's better to speak calmly, quietly and slowly while planning your way out of there.

An angry patient who is pointing and, in particular, jabbing a finger at you while invading your personal space (they are literally 'in your face') is displaying clear warning signs of potential violence.

One sign never to ignore is when a clearly disturbed patient who is threatening you starts to dance or chant. Recognise the situation early and put the safety of yourself and your staff first.

If actually attacked

If you are attacked, you are entitled to defend yourself. In an invasion of your personal space, the adoption of a simple fend-off stance (arms held up to chest level, palms towards assailant) will provide a measure of protection. What if things get worse? What if you are actually attacked? It's difficult to describe the practical aspects of self-protection techniques without demonstrating them, but here are some verbal descriptions of what to do.

 · Assailant grabs your wrist tightly and won't let go. Exploit the weakest link in the grip by aiming to pull or twist your wrist through the gap between the assailant's thumb and forefinger, often achieved by supination and lateral deviation of your wrist.

 · Assailant grabs you by the throat and pins you to the wall. You are having difficulty breathing and you can't cry out. Turn your head to the side (the sternomastoids are harder to compress than your trachea), force your chin down to the medial end of your clavicle and with your next breath you can shout for help.

 · Assailant has a knife and is advancing towards you. Grab hold of a chair, your bag, a coat, anything to place between you and that blade. You are buying time while shouting for help.

 · Assailant grabs you from behind. Don't fall to your knees. Your assailant wants you on the floor. Stay upright and repeatedly stamp a heel as hard as you can on to the dorsum of your assailant's foot (right on the laces). Twist round and shout for help.

At the RSM's annual forum for GPs in September, Lawrence Lavery and I will be running a workshop on self-protection for doctors. In a workshop setting it is a lot easier to teach inexperienced people ­ like doctors ­ simple but useful techniques for protecting themselves. We believe prevention is the best cure, so take a little time to consider some of the many courses in self-defence available locally and go along to learn a single simple technique to cope with each type of scenario mentioned above. Once mastered, go home and teach your kids. It makes sense.

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