I recently performed a physical exam on a man who had assaulted police officers, despite receiving instructions to refrain from doing so. They subsequently used a taser on him—twice—and then took him to the hospital for psychiatric evaluation. While conversing with him from the doorway of his room, I thought about this piece I originally wrote in April of 2006.

1. If possible, learn why the assault occurred. Did the patient feel cornered? Did s/he perceive the police as engaging in offensive maneuvers and thus reacted defensively? Did s/he believe that other people were trying to trying to steal his/her identity by staring into his/her eyes for exactly ten seconds? Inquire into the specifics of the assault prior to speaking with the patient. This information will help guide your interactions with him/her.

2. Introduce yourself to the patient and inform him/her that you shall be performing a physical exam. You may need to explain, in detail, what a “physical exam” is, as some patients may believe that this entails invasive maneuvers, while others do not realize that this means you will be touching the patient. Something succinct, such as “I will listen to your heart and lungs, push your belly, tap you with this hammer”, usually suffices. (NB: Some people may take offense to the word “belly”, as that may insinuate that their torsos are of larger mass than you deem appropriate. Choose your words wisely.)

3. Observe the patient’s reaction to your announcement. Should s/he immediately threaten to hit, bite, spit at, or kill you in a loud voice while giving you The Stare of Death, it would be wise to defer the exam. Your personal safety is important. If, on the other hand, the patient accepts your announcement—even with some suspicion or trepidation—you may proceed carefully.

4. Transparency will work in your favor. The following suggestions apply to any type of patient, assaultive or not: Tell him/her exactly what you are going to do before you do it. Inform him/her that you will be placing your left hand on top of his/her head while you shine a light into his/her eyes to look at his/her pupils before you actually do it. Tell him/her that your hands are cold before you palpate his/her neck for lymph nodes. Tell her that you will be placing your stethoscope near/around her left breast. Patients are people and all people like to be informed.

If, at any point during the exam, you begin to feel unsafe for whatever reason, abort your exam and step away from the patient. (Realize that you are indeed vulnerable at certain points during the exam. For example, your patient could feasibly bludgeon you with the bell/diaphragm of your stethoscope. Those things hurt when they smack against your head. (Another story for another time.) Alternatively, your patient could wrap the tubing of your stethoscope around your neck and suffocate you while you are slipping the earbuds into your ears. I’m just sayin’.) Your personal safety is important.

5. If you are unsure if your patient is becoming angry or agitated, ask. You will be modeling effective communication skills and developing rapport with the patient. For example, should the patient loudly balk when you shine your penlight into his/her eyes, remarking, “That f@#$ing bothers me—why do you gotta do that?,” it is appropriate to say, “I understand that this may be uncomfortable for you, but I am looking at the size of your pupils. Are you getting angry with me?” Should the patient state that s/he is not angry with you, it is helpful to say, “Okay; thanks for letting me know. Please tell me if you are getting angry or if I am pissing you off (and “pissing you off” is an acceptable phrase to use); that’s the last thing I want to do right now.” Such a statement not only communicates your true intention (because, really, the last thing you want to do is piss off someone who had assaulted someone earlier), but also lets the patient know that you care about their mental and physical welfare. People generally like that.

If, however, the patient says that s/he is getting angry with you, it is helpful to say, “What can I do to make this more comfortable for you?” Again, a physical exam ought to be a collaborative effort—you cannot effectively gather useful information if you and your patient are fighting each other. Should the patient remark that if you got the f@#$ away from him/her, that would make it more comfortable, then get the f@#$ away from him/her. Repetition is good: Your personal safety is important.

6. Either during or at the conclusion of your exam, inform the patient of your findings and offer a succinct summary of your assessment. If the exam was normal, tell him/her that it was normal. If you heard a three out of six, crescendo-decrescendo systolic murmur that was loudest at the left upper sternal border, tell him/her that you heard a heart murmur that may warrant further investigation. Should you say nothing to the patient, s/he will wonder what pathologies are brewing within his/her body.

7. Ask the patient is s/he has any questions. This again suggests to the patient that you care about his/her concerns, thus building rapport (and reduces the chance that s/he will pluck the tomahawk reflex hammer from your hands and smack you repeatedly with it).

8. Thank the patient for his/her cooperation. Because s/he did. This is also how you treat a fellow human being with dignity. Often, these patients who have assaulted other people are not treated with dignity (because of their assault history); this can cause feelings of shame and worthlessness (even if you only sense a veneer of grandiosity). Your humility and civility may confer a more positive impact on the patient than you realize—and will again greatly reduce the likelihood that you shall be hit.