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:
- Law enforcement presence
- Verbal communication
- Control holds and physical restraints
- 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
- 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.
- Train the EMS, police response. Schedule training with law enforcement to clarify responsibilities for the restraint, sedation, assessment and monitoring of violent subjects.
- 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.
- 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: