Combative patients: Don't be the "calm down guy"
Yelling "Calm down!" usually doesn't work
By Steve Whitehead
Occasionally, patients get out of control. It isn't our preference, but it's an unavoidable fact. We are frequently called upon to provide care to individuals who neither request nor want our help. In fact, we are often charged with protecting and caring for people who wish us harm.
Whether they are confused, combative or just plain mean, sooner or later we will meet the patient who aggressively tries to escape from us, or harm us. Whole classes and workshops are devoted to the complex task of safely restraining individuals who are fighting to get away or attempting to harm us.
This month, I'd like to address one critical mistake we often make when we are in the process of restraining a combative individual. This is a mistake that we all fall victim to occasionally, regardless of experience or training. It's the mistake of becoming what I call the calm down guy.
Who is "the calm down guy" you ask? He is anyone who gets the idea that it would be beneficial to address the patient's aggressive behavior by yelling, "Calm Down!" in their ear. The calm down guy (Yes, it's always a "guy") is the one who places themselves at the patient's head and repeatedly yells, "Calm Down!" as the patient kicks and struggles.
You've seen the calm down guy, haven't you? Perhaps you've been the calm down guy from time to time? If so, don't feel bad. I've done it myself, more times than I'd like to admit. It just seems like the right thing to do. The patient obviously needs to calm down more than anything right? If only we could just say it in a forceful enough way, surely they would understand what we need from them.
There are four good reasons to banish the calm down guy forever from your scenes.
1. It doesn't help the patient. Regardless of how good your intentions are, yelling, Calm Down!" in someone's ear never, ever helps them calm down. Try it sometime. When you are feeling frustrated and angry, ask a friend to get right up in your face. Maybe even have them grab a handful of your hair.
2. It doesn't help the calm down guy. Usually, it's the guy who needs to calm down the most who invariably ends up yelling, "calm down!" the loudest. The calm down guy often needs to take his own advice. Let the calm down guy take a step back, take a deep breath and rethink his approach.
3. It doesn't help the team. One provider yelling at the patient tends to wind everyone up. The next person who speaks will invariably speak louder, and so on, until everyone is yelling. The single provider who talks in a calm confident tone will do more to keep the team effective than a chorus of over-excited shouters.
4. It doesn't help the organization. We have to assume that we are always on film. When an Oklahoma State Trooper choked a paramedic on a remote suburban roadside, the act was caught by, not one, but two cameras. What you do on scene can be posted to the internet faster than you can put the rig in drive. In this, hyper-media environment, where everyone has the ability to instantly publish their cell phone video to a world-wide audience, the calm down guy makes everyone look bad.
So what should you say instead?
1. Let the calmest provider to talk to the patient. You probably know who that person is already. In any situation there is usually one person who is known for their calming demeanor and unflappable attitude. Let them do the talking. Position them at the head and have them simply talk to the patient.
2. Speak softer than you think you need is necessary. You want to be heard, but you can talk far softer than you want to and still communicate just fine. When we want to be heard, our instinct is to talk louder. However, when we drop our voice people tend to become quiet and focus on our words more intently. Speak softly and the volume of all communication on scene will like follow suit.
3. Use the patient's name. If you know the patient's name, use it. And explain what you are doing. Bob, we need to lay still. Help us take care of you Bob. The more personal you can make it the better. Using the patient's name sends an unspoken message to the patient that their identity is important to us. It also reminds everyone involved in the encounter that there is a real human being on the opposite end of all of this conflict.
4. Use the jury test. Now that we have a calm person speaking softly and using the patients name. What should they say? Imagine that your care for this patient was called into question and a jury was allowed to watch a video of you wrestling with your patient. Their job is to decide if your care was appropriate. Imagine that the volume on the video were turned down and you were allowed to explain to the jury what you were doing and why. What would you say?
Say those things to the patient. Say, "We don't want to hurt you Bob. Please stop fighting us. We need to care for you Bob. Please don't punch us. Bob, I need you to stop kicking. I know you don't want to hurt anyone. We're very concerned about you. We're trying to be gentle with you Bob, but you're making it very hard."
The things that you would want an untrained outsider to understand about why you did the things you did are the things you should tell the patient. If that worst case scenario ever happens, you won't have to worry about turning down the volume. Your testimony will already be on the video. And all of those statements in the above paragraph are far more likely to calm an angry patient than screaming, "Calm down!" in their ear.
I recall a saying that my EMS educator friend, David Fending, was often fond of quoting. He would say, "On a cardiac arrest, the first pulse you check should be your own." Dave's joke was a valid reminder. Sometimes, we need to check our own pulse. Often, when the calm down guy shows up on scene, it's time to step back and reevaluate our strategy.
Let the calm down guy be a reminder to the team. Instead of demanding calm from the patient, double check the team's pulse. It may be time for everyone to take a deep breath and move in a new direction.