How to Deal with Combative Patients

Have you ever had to deal with a combative patient?

Maybe the person is just verbally abusive or they try to push you out of the way out of frustration. Maybe they go so far as to take a swing at you in anger. Or maybe you're confronted with a 6'4" tall man, weighing 300 pounds and high on PCP and methamphetamines. Can you handle him?

Violent encounters, unfortunately, are commonplace for EMS providers. Yet few providers have formal training in self defense or appropriate patient restraint, says Steven "Kelly" Grayson, NREMT-P, CCEMT-P. And relatively few EMS agencies have formal restraint protocols for their providers to follow.

Grayson, a critical care paramedic for Acadian Ambulance in southwest Louisiana, spoke at the Wisconsin EMS Association's "Working Together: Emergency Services Midwest Conference and Exposition," held January 25–28. His presentation, "Show a Little Restraint: Dealing with the Combative Patient," offered common sense practices for EMS providers to keep in mind when dealing with combative patients.

The common causes of combativeness in patients are metabolic or chemical in nature. The main metabolic causes can be remembered with the acronym AEIOU TIPS:

• Acidosis or alcohol
• Epilepsy
• Infection
• Overdose
• Uremia
• Trauma or tumor
• Insulin
• Psychosis
• Stroke

The most frequent chemical causes are stimulants, such as cocaine, or hallucinogens like PCP, MDMA (ecstasy) or mushrooms.

Many combative patients are suffering from excited delirium, which is a severe disturbance in the level of consciousness and change in mental status over a relatively short period of time, says Grayson. It's manifested by mental and physiological arousal, agitation, hostility and heightened sympathetic stimulation.

Chances are good that if a patient presents with excited delirium the police have also been called to the scene, which can present its own set of challenges for EMS providers. As is typically the case, explains Grayson, because the patient is combative law enforcement officers will try to subdue and restrain the person. "And physical restraint results in only one thing (with patients exhibiting excited delirium)—more fighting," Grayson says.

EMS providers may be familiar with the Use of Force Continuum, which is used by law enforcement officers and is predicated on the assumption that a person is calm, rational and sensitive to pain—all things a patient with excited delirium isn't.

1. Level 1 is officer presence. Officer presence on its own may be enough to prevent or abort criminal activity; it can also exacerbate violence.
2. Level 2 is verbal communication. Officers will use verbal de-escalation techniques, giving the patient space, watching their body language, reducing stimulus and avoiding direct eye contact. The officer will remain calm, lower his or her voice and empathize with the patient.
3. Level 3 involves control holds and restraints. Whenever possible, leave restraint to the professionals. If you're forced to restrain a patient yourself, use the following guidance:

• Do NOT restrain the patient in a prone position. A supine or Semi-Fowler's position is best.
• Do NOT hogtie a patient or use a crossed arm restraint. If they've already been hogtied when you respond, have them untied. Either of these first two situations, if not followed properly, can cause the patient to asphyxiate, which is a major cause of in-custody deaths.
• Avoid metal handcuffs and handcuffing to a stretcher. Instead use flex cuffs whenever possible.
• Any handcuffed patient needs to be accompanied by a law enforcement officer in the ambulance.
• When you must restrain a patient make sure there is one provider per limb—arms, legs and head for a total of five. Do NOT dog pile the patient.
• If you control the patient's elbow (in a hold), you control the patient.
• Always follow local or system protocols.

4. Level 4 involves the use of chemical agents. This would be OC spray or mace for law enforcement and meds for EMS providers. The goal is to reduce combativeness, not to render the patient unconscious. Meds should be administered intramuscularly or intranasally, whichever is safest for the provider.
5. Level 5 is non-lethal force, such as a stun gun or taser.
6. Level 6 is deadly force.

Clearly, it's in everyone’s best interest not to have a situation with a combative patient escalate any higher than the earliest levels. This is why all EMS agencies, if they haven't done so already, should develop a restraint protocol specific to the needs of their system. "The adoption of a formal restraint protocol, utilizing physical and chemical restraint, will increase safety for you, your patients and other responders," Grayson says.

Signs & Symptoms of Excited Delirium

• Hypothermia, often accompanied by inappropriate nudity
• Imperviousness to pain
• Bizarre and violent behavior
• Hyperactivity and aggression
• Hallucinations
• Incoherent speech or shouting
• Incredible strength and pain endurance
• Physiologic hyper-sympathetic states

Jason Busch is an associate editor for EMS World.