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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


EMS response to a known or suspected behavioral emergency requires a high level of situational awareness, cautious yet deliberate assessment and treatment actions, and coordinate 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

Read and share these tips to better assess, treat and transport patients with behavioral emergencies. (Photo/Pixabay)
Read and share these tips to better assess, treat and transport patients with behavioral emergencies. (Photo/Pixabay)

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 view on how to approach people with excited delirium and listen to a discussion of excited delirium treatment on the Inside EMS Podcast.

Synthetic drugs, which are cheap and potent, can cause violent behavior. The unpredictable ingredients in Flakka can cause wild, bizarre, violent and extreme behavior. K2 is another synthetic drug that can cause violent behavior. An Atlanta man attacked and bit his girlfriend before he went into cardiac arrest. Learn about this growing problem and how K2 has also caused mass casualty incidents in Tulsa, Oklahoma, Austin, Texas, San Diego, and Mobile, Alabama.

Behavioral emergency PPE

Medics are routinely punched, kicked and spat at. A recent study found medics are assaulted more often than firefighters. 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. An Alabama woman started shooting inside an ambulance. EMS personnel in Detroit and San Diego were stabbed by a bystander while tending to a patient. A volunteer firefighter, responding to a medical emergency, was shot and killed by the patient who was allegedly having a seizure. Incidents like these are accelerating the conversation and decision about whether every medic should be wearing body armor on every call.

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. Ketamine has shown promise in rapid and safe sedation of patients with excited delirium syndrome. Ketamine is also being used to subdue flakka users.

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 health care 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 yourself

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. 

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