Two people were charged last week for either attacking or threatening county medical professionals, a trend that those in the field recognize as regular occurrences.

In the two separate and unrelated scenarios, two Butler Memorial Hospital nurses were allegedly beaten and one emergency medical technician was allegedly threatened, all of which happened while they were on the job.

"I’ve been punched. I've been kicked. I've been hit. I've been doing this for a long time,“ said Tammy May, a nurse at Butler Memorial Hospital. "You never know what's coming through those doors."

May also serves as Butler’s president of the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP). She said she has seen or heard many violent tales told by her colleagues.

"We've had nurses headbutted to the point that they lose consciousness. We've had people with arms broken,“ May said. ”The most frequent thing is that they get their thumbs broken. That's something patients can grab and break."

U.S. Department of Labor data showed the incident rates for violence against healthcare workers steadily rose between 2011 and 2018, according to a report in April 2020.

In 2011, the incident rate of violence-caused injuries to healthcare workers was 6.4 per 100 full-time employees. In 2018, that rate rose to 10.4 per 100 full-time employees.

These injuries are also a cumulative total from across the spectrum of health care, including doctors, nurses and EMTs. It also includes nurses and aides from long-term care facilities.

“It’s a rising problem. It’s growing nationally, and it’s well recognized,” said Dr. David Rottinghaus, an emergency medical physician who also serves as chief medical officer for Butler Health System.

EMTs rush from one emergency to the next, sometimes not knowing what they will encounter.

“It’s a necessary risk of the business,” said Nathan Bacher, a supervisor for Butler Ambulance Service.

In 2019, 4,200 of the 21,500 injured EMTs nationwide said their injuries were caused by violence on the job, according to data reported by the U.S. Centers for Disease Control.

“Every employee has experienced it once, and some have seen it multiple times,” Bacher said.

Bacher said often when called to a known threat or combative patient, paramedics stage one to two blocks away until police give the all-clear. He said his staff has access to Kevlar vests. He said they also have a good support group for those who have been through violent situations.

“It’s a peer support group led by experienced employees,” Bacher said.

As the patients leave the scene and head to the hospital, EMTs give the staff as much information as possible, according to Rottinghaus.

"We have kinships with our pre-hospital health providers and law enforcement, as well," he said.

Across these incidents, there are varying motives behind the violence.

Bacher said in his field, EMTs often encounter people who are confused, sick or mentally unwell.

“Unfortunately, most combative patients aren’t doing it because they want to hurt somebody,” Bacher said.

Rottinghaus said the hospital’s Behavioral Health Unit has been struggling with violent patients for many years, but as mental health issues have become more prominent, violent situations began growing across all areas of healthcare.

“We know a lot of this starts outside the hospital and is a public health issue," Rottinghaus said. "The need for behavioral health and psychological counseling has increased."

May said attacks can happen anywhere. She said she has also seen family members and patients’ visitors become violent or threatening. She said it is more often the patients, and some have less excuses than others.

“Sometimes it's out of the patients’ hands, but sometimes there's patients who are belligerent and who do it intentionally," May said.

Rottinghaus said in cases of violence, health care workers have to rely on training to handle a tough situation that requires them to still keep the patient’s health and well-being in mind.

"Our first focus remains the safety of all, including the patient," he said.

According to May, health care workers are restricted to more defensive tactics when encountering violence.

“We’re not allowed to lay hands on a patient in any way, shape or form that could be harmful to them,” May said.

May said the goal of any maneuver is to evade or free themselves only. She said nurses are often trained how to get out of chokeholds or how to free themselves from being bitten. She said they are told to not fight back.

“That’s very difficult to do when you’re being assaulted,” May said. “It’s a hard line not to cross because that’s an instinct, part of a defense mechanism.”

Bacher said paramedics also have to take defensive approaches when tackling tough scenes. He said police officers, by law, have many more rights to protect themselves, and so it’s best to allow them to do their work first.

However, he said sometimes it’s not an option because police or dispatchers might not be aware of a patient’s mental or emotional status before EMTs arrive.

“We don’t carry weapons or anything,” Bacher said. “The EMS direction is to get away from the danger.”

According to May, in the hospital the protocol calls for the debriefing of staff members involved in a violent encounter. She said these debriefings are meant to examine a situation, how it came to be and possible improvements for the future. She also said they are not practical.

May said in her 30 years as a nurse, she hasn’t been debriefed once, but she understands why.

When a patient gets violent, a “Code Yellow” is called, and other nearby staff and security personnel are called to assist. May said when the situation is over, staff needs to return to their jobs and make up for work they didn’t accomplish during the time of the incident.

May said scheduling a debriefing later can be hard due to conflicting schedules.

Rottinghaus said debriefings are difficult to perform for those reasons, but in some situations they can, and will, be used; however, he said every situation, regardless of whether there was a debriefing, is examined and reviewed.

Rottinghaus said they use a combination of footage from security cameras and conversations with employees to look at scenarios for any loopholes or pitfalls in the procedures.

“Procedural improvement is a constant process in Butler Health System,” Rottinghaus said. "The safety of our staff and patients is paramount.“

Some nurses, unions and legislators are fighting for improved conditions to deal with the growing aggression against health care workers.

As a union, PASNAP backs state House Bill 348, which would require every facility in the state to create a violence prevention committee. The committee would conduct annual risk assessments, identify safety and security threats, and develop prevention programs. The law would also hold the institution accountable through fines and penalties.

Two U.S. Senate committees announced earlier this month that they plan to focus on mental health.

The U.S. Finance Committee is looking to create a mental health package by this summer, including closing pay gaps between behavioral and physical health providers, as well as bolstering telehealth services.

Meanwhile, the U.S. HELP Committee is looking at legislation that could improve addiction and mental health programs.

Rottinghaus said specifically in regard to the mental health legislation, it would be tackling a root problem that eventually leads to volatile situations with patients.

"Step one is recognizing the problem,“ Rottinghaus said. ”It’s a big-scale operation. It’ll take a lot of resources to really help people.“

Rottinghaus said despite any advancements, it would be impossible to prevent every volatile situation.

“We are naturally exposed to more risk than the average person due to the situations we handle,” Rottinghaus said. “We do know, as health care workers, that the potential and threat is there.”

Bacher also said he sees inevitable chance encounters with violence, and it’s one he and his staff have to be prepared for every day when they enter the field.

“It’s a necessary evil of the business,” he said.

May said she recognizes there are circumstances that are not in anyone’s control, but there are always improvements that can be made. She said she wants to see a day come where a nurse isn’t expected to see violence at some point in her career.

“It's become a part of the culture, where it's just part of our job, and it really shouldn't be part of our job," May said.