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Show a little restraint: Dealing with the combative patient

Application of a four-level force continuum for patients with combative or violent behavior towards EMS providers

Updated February 22, 2018

Violence against medics is on the rise. But according to Kelly Grayson’s presentation at EMS World Expo 2012, most responders are ill-equipped to deal with violent patients.

Grayson, an EMS1 columnist and co-host of the Inside EMS Podcast, outlined how in a survey of Albuquerque EMS providers, 90 percent of 331 respondents reported an assault or violent act by patient, but 71 percent reported no clear protocols on handling these types of patients.

In Loma Linda, Calif., 61 percent of 522 respondents reported an assault on job, 25 percent of those also reporting an injury from that assault. And 95 percent reported restraining patients — although most had not been trained on how to do so.

The first step in dealing with dangerous patients is deciphering dispatch’s language.

“‘Scene safe, law enforcement present’ really means ‘scene NOT safe, law enforcement MIGHT be present,’” Grayson said.

Then one must consider patient history, including potential organic and toxicological causes for the combative behavior. Remember to stay out of the kitchen and the bedroom (knives and guns), and watch the patient’s body language for clues the situation’s about to go south.

If things take a turn for the violent, Grayson outlined how four levels on the use of force continuum are suitable for EMS providers:

Level 1: Law enforcement officer presence

While it can result in the prevention or cessation of crime, it sometimes adds an adversarial and intimidating presence to patient encounters. It’s important to balance the need for provider security with patient comfort. Use your position as a caregiver to your advantage to convince the patient that you are only there to help.

Level 2: Verbal communication

Practice verbal deescalation techniques, and give the patient space. Keep your hands open, and it might be helpful to reduce stimulus – that means sending other people on scene away. Avoid prolonged direct eye contact, and don’t argue with the patient. It’s easy to start shouting back at a combative patient, but keep your voice low, remain calm, and explain what you’re doing or going to do.

Level 3: Control holds and restraints

Whenever possible, leave restraint to the pros, Grayson said. But when forced to restrain a patient yourself, the most important restraint tip is to keep the patient out of prone position because this can make it more difficult for the patient to breath and to monitor the patient’s breathing and airway patency.

Supine or semi-Fowler’s position is best. So don’t hogtie the patient, and if that’s the case when you arrive, request that the hogties be removed.

Any handcuffed patient needs to be accompanied by a law enforcement officer in the rig, unless you can get flex cuffs or hobble restraints on the patient instead. Follow local and system protocols, of course. The ratio of one provider per limb, Grayson said, can usually control a violent patient, but controlling the patient’s elbow is also effective.

Level 4: Chemical agents

While the police usually use noxious stimuli (decontaminate with lots of water), EMS chemical agents involve sedatives and antipsychotics. “The goal is to reduce combativeness, not to render the patient unconscious,” Grayson said. When you provide a benzodiazepine or an antipsychotic, be sure to monitor cardiac and respiratory after administration.

Patients may turn violent for a number of reasons, but most are suffering excited delirium due to substances like alcohol or “upper” drugs such as meth, flakka or crack, Grayson said.

Violence against EMS providers will continue to be a problem until all agencies can put together a protocol that involves these levels of restraint, the session was told.