To Wrestle or Not?

     You are on scene at a private home, where a 34-year-old male patient is clearly in the midst of a behavioral emergency. While most of what you've heard sounds like chronic depression, the two angry outbursts you've already witnessed, brief though they were, indicate something else is going on and leave no doubt that this could get ugly in a heartbeat. A few minutes ago, your partner stepped out to request law enforcement, but you are still looking at a six- to eight-minute E.T.A. for the cavalry. A look at your patient, who is getting louder and increasingly animated, makes that eight-minute E.T.A. seem a long time away. The patient's wife and 2-year-old son are curled into a corner of the couch, both clearly frightened as they watch events unfold.

     This scenario and countless others like it are played out every day across America. When a seemingly smooth-running call suddenly takes a turn for the worse with an angry, possibly soon-to-be-violent patient, the EMS team has to make a decision about whether to try to physically subdue and restrain the patient. Should you find yourself in one of those unfortunate circumstances, here's a short list of things to consider before checking the box marked "wrestling 101."

How Good Are Your Self-Defense Skills?
     Grabbing someone who doesn't want to be grabbed and subduing him when he doesn't want to be subdued is no small task. If that person is under the influence of meth, crack or PCP, the difficulty factor is raised several-fold. If there is a physical encounter, I'd put the chance that one or more of the people involved will be injured close to 100%.

     Every now and then, I see one-day self-defense courses offered at a conference. While they may demonstrate useful techniques, what really matters is your ability to make any given technique work every time (or close to 100%), and that takes a lot of practice. One of the worst combinations is the One-Day Wonder wearing the Star of Life with his recently acquired knowledge tangling with some street-savvy gangbanger. I've seen middle school-age kids raised on the streets with almost a black belt level of self-defense skills.

Two-On-One Odds May Not Be As Good As They Seem
     Generally speaking, two-on-one odds are pretty favorable, but in the realm of a behavioral emergency where drug-fueled reactions come into play, things don't often turn out as well as one might hope. A well-orchestrated and physically supported takedown requires five people: one for each extremity and one to fasten the securing devices into place.

Beware A.D./E.D.!
     There has been an increase in articles published about people abusing cocaine, amphetamines, methamphetamine or PCP, who, as a result of multiple factors, get worked up into a blind rage. This is a particularly lethal aspect of the clinical syndrome known as agitated or excited delirium. If a patient whom you suspect is abusing any or all of the drugs listed above becomes increasingly loud and angry, try to avoid a physical confrontation at all costs. If indicated, retreat to the safety of the rig. If you feel you are still at risk, leave the scene immediately.

     I heard of one case where a cocaine abuser with excited delirium was Tased 14 times in five minutes, and it still took a total of six police officers and EMS providers to get the patient secured to a gurney for transport.

     Always be on the alert for patients who look like they might transition into agitated or excited delirium. If a physical confrontation is inevitable, do your best to get five people on your side; you are going to need them. If I were alone with my partner, I would always suggest that we run before choosing to tangle with one of these folks.

Sometimes It's Best To Leave
     In the opening scenario, retreating to the security of the rig would have been the best idea, if the wife and son had not been present. With their well-being to consider, the decision to leave became far more complicated, as it is likely that any attempt to take the wife and son with you would only have made the patient angrier and potentially violent. Under circumstances where you are clearly stuck, you need to try stalling tactics to buy time until law enforcement arrives.

     In a different scenario, where you and your partner are the only ones on scene with the patient, never hesitate to use the retreat-and-regroup process. Oftentimes, just getting out of the close physical proximity to an angry patient may calm him down faster than anything else.

Is Physical Restraint Your Last Option?
     If physical restraint isn't your last option, it should be. Taking down a patient on an emergency scene should always be your last choice, unless you are attacked by the patient and have to act in self-defense. In the case above, the scene becomes much more volatile and risky with the wife and child in the room. If this turns into a brawl, either or both of them could be injured, or the child could become a hostage.

     Always exercise restraint before choosing the "let's get physical" option. Try to defuse the situation using a calm, nonthreatening tone of voice in conjunction with other verbal techniques focused on turning the emotional tide in another direction.

Conclusion
     The next time you find yourself in one of those "could turn violent" or "is going to turn violent" moments, think through that short list as you ponder the question of whether to wrestle or not. As often as possible, select "or not."

Until next month...