Every ED has patients who become part of the landscape. They come in once or twice a week, for all kinds of reasons. Sometimes they have chronic medical conditions they are unable to manage. Sometimes they are on the outskirts of society due to mental health or substance abuse disorders. The ER promises a few hours of sleep in a safe place and a meal. I formed an uneasy alliance with many of them—let them spend a shift stashed in a corner so long as they behaved.

Betty was something of a local legend. She was now in her mid-sixties, but back in the day she was “a fine-looking woman.” Beautiful, dangerous—someone you did not cross. She was frail now with failing kidneys and lungs ravaged by COPD. Her brown leathery skin had deep blue ink covering stringy muscles. She lay on the stretcher, tension wound deep in her sinews. She was curled up on her side in a protective position. Her hair was proudly long and black with a silver streak down the front that somehow made her look younger. Her hands were weathered and war ravaged. Each spindly limb was clutched into a narrow claw-like fist. She always seemed ready to pounce. Life had not allowed her to relax. Even in the dark, she was jumpy and excitable.

I usually gave her a wide berth.

That day, Betty had been brought in by ambulance after a fall. She was intoxicated but manageable. I was the charge nurse and it was a busy shift. I helped tuck her in from the ambulance, wrapping a child-sized blood pressure cuff around her skinny arm. She was dehydrated with a high heart rate—dangerous if your kidneys are failing.

She was more docile now than when we first met. A few years ago, she would roll into the unit yelling: “Who wants Indian tacos? Come on over and I will make you some.”

I bet they were really good.

Those first few years, she was brought in because she was drunk. Sometimes her blood sugars would be out of whack, but nothing a few turkey sandwiches and cartons of milk wouldn’t fix. Now she was drunk and sick. Diabetes, kidney disease, and emphysema were taking their toll. She wasn’t ready to give up her agency or her power.

Her workup often required invasive tests; merely mentioning them would get me thrown out of her room. Her veins were tiny, with few left that I could access. I dreaded when the orders would roll in. But invariably there was a paramedic who had sweet-talked his way in and collected the needed samples. She was laughing and flirting with him the entire time. She loved calling 911 because she could depend on half a dozen big strong men tramping through her little house.

This is a solid retirement plan—no shame in that game.

She was funny, spunky, and a survivor. She had three children—her oldest son had died violently and young. In her heyday, I would not have wanted to meet her in a dark alley. Now she was barely over 100 pounds and malnourished. It was busy so it would be a while before she would be seen. So I brought her the most magical gift the ER holds—warm blankets.

As I leaned in close to tuck those blankets around her, she pounced.

It was like slow motion. My stethoscope dangled dangerously between us. My hair hung long, falling like curtains around us. I had been trained to take precautions—the stethoscope could be used to strangle me. My hair could be pulled out by its roots. I had become lax since I didn’t do much patient care as a charge nurse.

A little voice warned me that I should not have let down my guard.

Her scrawny arms latched around me. She was sobbing hot tears into my neck. My shirt was wet with them. I did not sign up for this degree of intimacy at 2 p.m. on a Saturday.

“You remind me of my daughter. I haven’t seen her in so long.”

Dangit.

I locked eyes with her nurse, who was standing behind us filling out paperwork. She was in no hurry to trade positions with me.

I was looking for lice and thankful for the dark room.

I’m not sure how long I was supposed to stay like that. My back was stiff and sore. I usually observe the Disney Princess rule of hugs: Let the child break it first. But holy cow, she was not letting go. She probably needed this—we devalue human contact in society.

After an awkward beat, I patted her hair and broke away.

She was charismatic even now, in that way of old alcoholics. Everyone was her friend—all the cops, all the firemen, all the paramedics. We all had a Betty story. She was always drunk but mostly harmless.

I trusted Betty—she had never shown signs of violence. We were trained to watch for trouble: Never get backed into a corner, always have an exit, know where the panic buttons are. There are horror stories of nurses raped, stabbed, shot. Most of us ignore the threats. Those things happen to other people in other places.

The shift had picked up. I kept busy with the demands of a busy suburban ER—calling in Cath Lab for a STEMI, paging trauma alerts, assigning beds to incoming ambulances. Betty’s labs and imaging came back—she had a fractured hip and a blood alcohol level three times the legal limit. She would have to be admitted, dried out, and stabilized before her hip could be repaired. I was making phone calls. She would need a room close to the nurse’s station for direct observation.

Out of the corner of my eye, I saw a streak of canvas blankets and a blue hospital gown. It was headed for the main doors at a fair pace.

It was Betty.

“Stop her—she’s on a hold.”

Oh no.

Because of her blood alcohol and hip fracture, she couldn’t care for herself or make rational decisions. The physician had filed paperwork to have her involuntarily committed. They just hadn’t told us yet.

That made Betty my unexpected problem. We couldn’t lose a committed patient. Betty’s nurse and I made eye contact and sprinted for the doors. We ran through the full waiting room and out into the parking lot.

There, about 10 yards away, was Betty. Her yellow grippy socks were worse for wear and the hospital gown hung off her bony shoulders. Her rear was proudly displayed, and an elderly couple averted their eyes and scurried inside.

“BETTY GET BACK HERE! YOU AREN’T ALLOWED TO LEAVE.”

“NO! I’M LEAVING.”

Betty. Be serious right now because we BOTH know you are not going anywhere.

“Betty.”

I ply her with promises of turkey sandwiches and chocolate milk. Please come back inside so I don’t get in trouble. You are sick. You need surgery. How are you even walking with a broken hip. They put you on a hold.

Oh no. I should not have told her that.

She had been at arm’s length. I didn’t want to grab an old lady, but I legally could not let her leave.

It would be hard to explain losing a woman in her 60s with a broken hip and no pants.

I forgot how much Betty HATED being on a 72-hour hold.

She took it out on me.

She lunged with shocking speed. Her hands and ragged fingernails became claws. I deflected most of her blind attack with a forearm block, protecting my face and neck. She scrabbled for purchase in my flesh, and I wondered if her rabies shots were up to date.

The other nurse had moved behind Betty. Her arms clamped around Betty’s upper body, and I took a step back. Adrenaline pumping, we managed to talk her back into the waiting room. Security was meandering towards us.

“Thanks for your prompt response, guys. We got it under control.”

Betty was screaming at both of us—we were racist, we were discriminating, we were torturing a poor old woman.

There were around 50 people in the waiting room—an audience for her performance.

Every old drunk loves an audience.

“Betty—no one is torturing you.”

The two security guards began herding her back inside the emergency department. For security purposes, the ED is a locked unit. The doors must be triggered open by someone inside. The triage nurse had been giggling behind his hands and triggered the door.

I swear we didn’t plan this.

Sometimes, God laughs.

Betty had her back to the double doors, screaming profanities. Her rear was still hanging out in the breeze. Then she turned around.

The double doors open outward, and they hit her directly in the face.

I laughed. I am not responsible for my reaction. It was objectively hilarious.

“DID YOU SEE WHAT THEY DID? YOU ALL SAW IT.”

Yes, they all did. They were all laughing.

Including the triage nurse. This was technically his fault.

“YOU DID THIS ON PURPOSE.”

“Betty, we did not do that on purpose.”

Not gonna lie—I did not complete that sentence with a straight face.

The absurdity of the situation, the fact that it had happened in a room full of cameras and witnesses. It was serendipitous. I caught the eye of the triage nurse, and I knew he felt it too. So random—none of us could claim responsibility, so we were free to laugh without guilt.

No one was going to complain about the wait times today.

We escorted Betty back to her room and posted security at her door.

I went to the staff bathroom. I sat on the toilet seat to let my breathing settle. Now that the smoke cleared, I rolled back my sleeves.

My right arm had deep scrapes of various depths. There were parallel sets on my arm. I felt a line of deep welts across my left cheek and neck. My throat was dry and scratchy.

I stared at myself in the dirty mirror.

Across the hall, inside the trauma bay, was a cart for suturing. In the bottom drawer lay bottles of iodine and hydrogen peroxide. I grabbed a brown bottle and marched back into the bathroom. I scrubbed my arm with soap and water, then poured hydrogen peroxide over the deeper cuts, wincing as the solution bubbled into the gashes.

I cleaned the gashes on my face with iodine.

Betty had her call light on.

I poked my head in.

She had tears in her eyes.

“I’m sorry. I didn’t mean to do that to you.”

My cheek throbbed. My arm throbbed.

I noticed the scrape on her forehead and remembered neither of us had emerged unscathed.

“You should see the other guy!”

Betty cackled with laughter.

We were even.

She went off to surgery. Hip fractures are straightforward to repair. But they represent a lifestyle-changing convalescence—weeks of physical therapy. Depending on other people for months. She would be at the mercy of her caregiver and the reality of her age would be in her face daily.

Can’t raise hell like you used to. Maybe never would again.

Is that something worth fighting for? I could understand her urge to go down fighting. Rage, rage against the dawning of the light.

Raise hell while you still can.

Kristen Cline is a professional development practitioner for the Emergency Service Line at Stanford Tri-Valley Medical Center and holds an academic affiliation with Stanford University.

With over 15 years of experience in emergency departments, intensive care units, and critical care transport, she brings clinical depth and a commitment to education and advocacy.

Kristen is board-certified in multiple specialties and speaks nationally for organizations such as Paragon Education and Solheim Enterprises, focusing on certification review and emergency nursing practice.

She has authored and co-authored several publications and textbooks, including contributions to the Emergency Nursing Scope and Standards of Practice, 3rd edition.

Her peer-reviewed work includes articles in Annals of Emergency Medicine, on “Optimizing Pediatric Patient Safety in the Emergency Care Setting,” and in Pediatrics, on “Access to Optimal Emergency Care for Children.”

Recognized among ENA Connection’s “20 under 40,” she advocates for nurse wellness and trauma-informed care through speaking engagements, her Medium blog, and social media platforms like Instagram and Facebook.