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Expert tips for EMS handling of behavioral emergencies

Prepare for behavioral emergencies by understanding pathophysiology, personal protection, patient handling and restraint techniques, and the importance of documentation


Read and share these tips to better assess, treat and transport patients with behavioral emergencies.


This article was originally posted Feb. 4, 2016. It has been updated with new information.

EMS response to a known or suspected behavioral emergency requires a high level of situational awareness, cautious yet deliberate assessment and treatment actions, and coordinated response among EMS providers and law enforcement. We have compiled this directory of our top articles and videos on behavioral emergencies. Use these for your own self-directed learning, planning and delivering company or squad training, and to revise and update protocols.

Behavioral emergency pathophysiology

Many violent patient outbursts are due to an underlying medical problem. Metabolic derangement, like hypoglycemia or hyperglycemia, can lead a patient to strike out at or resist EMS treatment. EMS providers are regularly challenged to differentiate alcohol intoxication from a diabetic emergency. Learn how to distinguish diabetes from drunk.

EMS providers are regularly called upon to assess alcohol-intoxicated patients, some of whom are or can become violent. Careful assessment is required to determine if a drunk patient can be left in the care of friends, family or law enforcement. Or if a patient, no longer able to maintain their own airway, needs EMS airway monitoring and management.

Excited delirium is a condition characterized by extreme agitation, hyperactivity and escalating body temperature. EMS providers need to think and act quickly when encountering a patient in an excited delirium. Learn why this is a medical emergency and not willful resistance. Watch a video on how to approach people with excited delirium and listen to a discussion of excited delirium treatment on the Inside EMS Podcast.

Behavioral emergency PPE

Medics are routinely punched, kicked and spat at. A 2016 study found medics are assaulted more often than firefighters. A 2019 City of Austin EMS Department Assault Survey found 63% of field medics said they were assaulted in the past two years, and more than 69% of field personnel agreed with a statement that said assaults are an unavoidable risk of an EMS career. Learn how to prepare your defensible response to avoid letting spitters conquer you in this article by Lt. Dan Marcou.

A patient that attacks an EMS provider is no longer a patient. They have become an assailant and there is no obligation to stay with and attempt to treat an attacker. The Escaping Violent Encounter video series teaches medics how to recognize, avoid and escape from attacks. Watch, discuss and practice the techniques presented.

EMS providers are also threatened with guns, stabbed and shot. Two Arkansas paramedics were shot on duty while aiding a woman with knee pain when the patient’s boyfriend approached them and began arguing with them.

Incidents like these are accelerating the conversation and decision about whether every medic should be wearing body armor on every call.


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Protecting EMS providers from violence

Strategies for recognizing and defusing dangerous encounters, as well as how to equip first responders with protective gear and technology to keep them safe on the streets.

Behavioral emergency patient handling and transport

Violent patients, regardless of the cause, are a danger to themselves, bystanders and emergency responders. Art Hsieh’s three golden rules for handling drunk patients are broadly applicable to any type of behavioral emergency. Next read these six ways from Kevin Grange to facilitate a safe and successful contact with a behavioral emergency patient. Patrick Lickiss concludes a patient self-harm scenario with adolescent psychiatric patient assessment tips. One of his top tips is about the importance of establishing patient rapport.

Physical or chemical restraint is needed for some behavioral emergency patients. Watch this Remember 2 Things video on how to safely restrain patients and this video on when to give patients control versus you taking charge.

Read these seven tips to remember when restraining a patient, the importance of restraint that is humane and respectful, and Kelly Grayson’s four-level use of force continuum for EMS providers.

Chemical restraint is a treatment option that should be available to every paramedic who may encounter a violent behavioral emergency. The use of ketamine to sedate patients with excited delirium syndrome has been widely discussed as legislation limiting its use has been enacted in Colorodo. Listen to an episode of Inside EMS on the use of ketamine in EMS as well as the broader implications of legislators weighing in on EMS practices.

Just important as what to do is what not to do when during an encounter with a violent patient. Read about the three patient restraint errors to avoid from Steve Whitehead.

EMS leaders and mental healthcare providers need to discuss and explore if an ambulance is the best vehicle for transporting psych patients. This is an especially important discussion for transporting patients that don’t require medical monitoring or care during transport from the emergency department to a mental health facility.

If an ambulance is used for psych patient transport follow these five tips to make it safe for providers and patients.

Look out for your own safety

Your emotional and physical behavior towards a patient experiencing a violent outburst during the call is just one aspect of looking out for yourself. Potentially just as important is documentation that patient restraint was performed within protocol guidelines. Assume that during any violent patient encounter you are being recorded. Follow your department’s policies and protocols throughout the call and thoroughly document what you did and didn’t do during the incident.

Finally, prepare yourself for a violent encounter with a behavioral emergency patient with these four tips from Kip Teitsort. And if you are assaulted on the job as an EMS provider you must absolutely press charges to make EMS better and safer for yourself and other EMS providers.

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.