Responses to patients experiencing a psychiatric or behavioral emergency are relatively infrequent. At least that was my intuition after reading a news article from Minneapolis about the administration of ketamine to restrained patients.

In a one-year period, from June 1, 2017 to May 31, 2018, EMS providers from more than 1,000 agencies in the ESO EMS Index responded to more than 6.6 million incidents. About 360,000 (5.5 percent) of those calls were psychiatric or behavioral emergencies. My intuition about behavioral emergencies is wrong. Here is the data ESO shared with EMS1.

Behavioral emergencies are frequent

Surprisingly to me, behavioral emergencies are more frequent than diabetic emergencies (about 2 percent of responses) and five times more common than cardiac arrest responses - often reported as less than one percent of EMS responses.

Violent behavioral emergencies are rare

A majority of patients (93.8 percent) in the ESO EMS Index didn’t require physical restraint, chemical restraint, or a combination of physical and chemical restraint. The vast majority of patients exhibit no threatening behaviors, comply with EMS instructions and are assessed and treated without any type of restraint.

Follow the EMS use of force continuum

Treat the small number of patients showing signs of impending violence, making violent threats, or acting violently with an escalating use of force. Kelly Grayson described a four-level use of force continuum for EMS as:

1. Law enforcement presence
2. Verbal communication
3. Control holds and physical restraints
4. Chemical agents

When to use physical restraint and chemical restraint

Extreme agitation is dangerous for the patient, EMS and law enforcement. The patient is under extreme physiological challenge from tachycardia, tachypnea, hyperthermia and hypertension, as well as risk of self-inflicted traumatic injury. Physical restraint is a step in reducing the risk of harm and beginning to treat the underlying cause of agitation. Chemical restraint with ketamine stops the patient from violently fighting against restraint.

Physical restraints were applied in 8,069 (2.2 percent) of the behavioral emergency calls in the ESO EMS Index. Ketamine was administered to 1,106 (0.3 percent) patients. More than 13,000 patients (3.7 percent) received a combination of physical and chemical restraint, including one or more of these medications - ketamine, lorazepam, diazepam, midazolam or diphenhydramine.

What you should do now

1. Review, update protocols. In collaboration with your medical director review protocols for behavioral emergencies, application of physical restraint and administration of sedative and anti-psychotic medications.

2. Train the EMS, police response. Schedule training with law enforcement to clarify responsibilities for the restraint, sedation, assessment and monitoring of violent subjects.

3. Designate a restraint team leader. Many departments use a “Code Commander” to lead cardiac arrest resuscitations and completion of critical actions. Adapt that position description and checklist for violent patient incidents. “Captain K.” or “Ketamine Kommander” won’t go over well with the public so select a position title you want to hear on the evening news.

4. Preplan for media, policymaker scrutiny. The public, media and elected officials are increasingly skeptical and questioning the application of force to subdue suspected criminals and patients with acute mental illness. Be ready to describe the components and indications of your department’s behavioral emergency protocol, how frequently it is needed and the types of treatments used by your personnel.

Physical restraint is not a contraindication to ketamine sedation:

• Excited delirium: Medical emergency – not willful resistance
• Ketamine is a safer option for agitated patients and providers
• EMS1 Roundtable: Media report should drive EMS agencies to review ketamine protocols

Every emergency response by firefighters and EMS personnel is a venture into an unknown that is becoming increasingly violent, particularly for law enforcement officers who have become the victims of ambushes while responding to a call for service or while sitting in their patrol vehicles. Firefighters and EMS personnel are not immune to this threat of ambush. Chief Robert Avsec (ret.) responds to the fatal shooting death of Capt. Dave Rosa, Long Beach (Calif.) Fire Department, at a high-rise fire on June 25, 2018

What happened: A Long Beach (Calif.) Fire Department captain was killed, and a firefighter was wounded when an unknown assailant shot them as they searched for the source of an explosion at a local retirement community. The fire captain, a veteran of the department with 17 years on the job, was transported to a local hospital, where he later succumbed to his wounds.

The second wounded firefighter was also transported to the hospital where he was listed in stable condition. A third victim, a civilian, was also being treated at the hospital and was expected to survive

Key takeaways: There's not a great deal that we can do to prevent someone from taking a shot at us or targeting us with an IED. But what we can do is continually improve our abilities at sizing up situations and become better at non-linear thinking. Here are two key takeaways.

1. Include potential threat of violence against responders in exterior size-up.
Initial reports indicated the presence of blown-out windows, on what appeared to be a limited scale. Does this indicate an isolated explosion? What kinds of explosions could happen in the occupancy they were confronted with?

The building occupants also reported the smell of gasoline. Why would there be gasoline in a residential high-rise for senior living?

These two elements can mean one thing when evaluated separately, but perhaps something entirely different when evaluated together. Size-up has always meant gathering as much information as possible, as quickly as possible, and processing it as quickly as possible. This tragic incident serves to highlight the vital importance of exterior size-up for all situations.

2. Consider tactical fire training for law enforcement.
The incident also brings forth another question; do we need to provide tactical training for law enforcement officers to enable them to work with firefighters in an IDLH environment?

Fire departments and EMS agencies are increasingly doing the opposite of this by training rescue task force medics to move into an active shooter incident right behind law enforcement.

Perhaps we need to look at having law enforcement officers who can suit up and provide cover for firefighters while those firefighters extinguish or investigate a suspicious fire.

What's next: We'd be letting our fallen brother down if we didn’t take some of the elements from this tragedy and learn from them. The investigation into this tragedy is on-going, and hopefully more pertinent details will become available for analysis. In the meantime, fire and paramedic chiefs should:

• Review their policies for situations where violence is directed at fire and EMS personnel.
• Review their training policies for incident and risk assessment by its personnel.
• Work with their local law enforcement agencies to develop policies that proactively promote integration of their mutual resources on the emergency scene.

The scene is never totally safe:

• Apply best-available data to active shooter incident planning, training
• Why we need critical thinking for EMS scene assessments
• EMS in the warm zone: Tactical medicine inter-agency training

3. Awake during CPR: Are your field personnel, especially those using mechanical chest compression devices aware of CPR-induced consciousness? Are they prepared to sedate a patient who wakes up during chest compressions?

2. EMS ‘super-users’ are often non-violent offenders: Listen to Catherine Counts, PhD, discuss the integration of public health and public safety data on the Inside EMS podcast.

1. 2018 EMS Trend Report: Fitch & Associates and EMS1 will debut the 2018 EMS Trend Report next month at the Pinnacle EMS conference. Download the 2016 and 2017 EMS Trend Reports to read on your flight to Phoenix.

You are welcome to share the Paramedic Chief Leadership Briefing. Forward this email to your command staff or field personnel, print and post in the day room or training lab, or reprint in your organization or regional EMS association newsletter.

Got a leadership tip, management question, commercial use inquiry, or an article idea? Send me an email at greg.friese@praetoriandigital.com.