Restraint of an Agitated Patient

The elderly man took a big swing at the social service worker. Fortunately he missed, but that was the last event that would be tolerated for the evening, so the worker and accompanying police officer called for EMS to transport the man to the hospital.

Attack One is dispatched on a report of a violent male, with police officers already on scene and the scene secure to approach. The response is to be without lights and siren, so the crew has time to prepare to immobilize an uncooperative patient.

On arrival they find an elderly man sitting in his front room with two police officers and the social worker. One of the officers asks the Attack One paramedic to meet with him in the kitchen for an explanation of the situation. The two EMTs remain with the patient, and the female EMT takes the lead in talking to him. The patient does not want anyone to touch him, so there is initially no attempt to take vital signs or perform a physical assessment.

The EMT pulls up a chair and sits down about six feet away from the patient, introduces herself and asks if the man needs anything to make him more comfortable, like maybe a drink of water. She has the male EMT step back to the front door and take all the medical equipment out onto the front porch. She speaks nonthreateningly, in simple, short sentences the patient can easily understand.

After a short time the patient asks, “Do you know why they took my wife away?”

Without looking to the social worker, the EMT replies, “No—why don’t you tell me what you know about it?”

He looks down, and the EMT takes the opportunity to exchange a glance with the social worker. The EMT is going to be in the position of being a friend and rescuer to the patient, because it is obvious the social worker was somehow involved in an activity the patient is unhappy about. The paramedic in the other room is receiving the details of how earlier in the day, an adult protective services worker completed a monthlong evaluation and found the man’s elderly wife in conditions that were dangerous to her. They had a younger relative come into the home to transfer her to a skilled nursing facility. A family member had stayed with the elderly husband until 1800 hours, but when he left and the sun set, the man became angry and hostile. A police officer arrived and called the social worker to assist. Neither was able to calm the man.

The female EMT works to befriend the man, who appears to be in good physical condition, has no smell or appearance of intoxication and sits with his fists clenched on his couch. He will not make eye contact.

“I really would like to hear about your wife,” she asks. “Would you please tell me?”

The man begins to speak and talks about his wife being ill but still able to take care of herself and him. He explains he can’t see well, and his wife did all the functions in the house that required reading, and could do so from her wheelchair as he moved her around. He did not believe she should be removed from the house, “but these bad people came and had a nephew take her away.”

The social worker gives a quick motion with his hand that indicates to the EMT that some of the details of the story are correct, but some probably are not.

The short story from the man gives the EMT enough opportunities to build some trust. She begins by confirming how important it is that couples work together to get important jobs done, just like the crew members here to help him today. She asks for some details on what his wife would read, and he starts into stories of their life together. The female EMT motions for the other EMT to go get a cup of water for the patient. “He sounds a little dry,” she says, “and might want a drink.”

The atmosphere in the room is becoming friendlier, and even the social worker is able to enter the conversation and laugh when the man asks about adding some gin to the water.

However, things grow tense again when the paramedic and police officers reenter the room, and it is clear to the man that the police are insisting he be taken to the hospital for evaluation, since he physically threatened the officer and social worker.

At this point the man reaches behind him and, out of the back of his pants, pulls out a knife about eight inches long. “I want you people to bring my wife back, or I’m going to leave and get her myself,” he warns, brandishing the knife. “Nobody try to stop me!”

The female EMT is still closest to the patient, and she remains seated and calm. “That won’t help your wife or you,” she tells him, “so please just hand it to me, and let’s talk about how we can help her.”

She manages to open a conversation with him, almost one on one, and he hands the knife to her.

Over a few minutes of dialogue, the patient is convinced that his best option is to ride in the ambulance to the hospital, talk to the patient assistance team there, have a warm meal and let the doctors there check his eyes to see if they can be improved. The hospital will also be able to get the best information on his wife. The paramedic defers to the EMT for all interaction with the patient, including getting vital signs and making sure the patient has no further weapons on him.

The paramedic moves away to the front yard to contact medical control by phone and receives agreement to transport the patient to the hospital for evaluation of his overall health and his eyes. This gives the crew an opportunity to relate a positive choice to the patient.

The patient remains calm en route to the hospital. The EMT is the primary caregiver and communicator in the patient care area.

Hospital Course

The patient is peaceful as he enters the emergency department, and the nursing staff evaluates him. At that point the patient again gets very agitated and threatens the nurses and staff. Staff members try again to deescalate things, but the noise, bright lights and smell of the facility cause him to call for his wife and disregard requests from the staff. The staff then consider both physical and chemical restraints.

Instead the female EMT comes back into the room where the patient is being treated and succeeds in talking with him until the hospital-based counselor arrives and assumes responsibility. The patient is admitted, and his eyesight is improved by cataract removal and a new set of glasses. He is found to have a degree of dementia but is counseled to his best level, then discharged to his family.

Case Discussion

There are many reasons why a person may become agitated. Some are medical causes that include illnesses, hypoxia, head injury, drug/alcohol ingestion, or a combination of the above. Other causes are an aging brain and underlying mental health problems.

Persons who are agitated and have performed criminal actions are primarily the responsibility of law enforcement, although in some jurisdictions EMS may assist in transporting them for medical evaluation or treatment. Those patients will have their method of restraint selected by the officer. EMS personnel cannot remove civil liberties and restrain persons unless there is a medical reason to do so.

For persons with agitation caused by medical reasons, there are three methods of providing treatment and transportation that’s safe for the patient and the EMS staff. A great reference for EMS providers is the NAEMSP position paper published in 2002.¹

Options for EMS restraint of agitated patients include:

• Verbal restraint—Any verbal communication from a prehospital provider to a patient utilized for the sole purpose of limiting or inhibiting the patient’s behavior.
• Physical restraint—Any method in which a technique or piece of equipment is applied to the patient’s body in a manner that reduces the subject’s ability to move his arms, legs, head or body.
• Chemical restraint—Any pharmaceutical administered by healthcare providers specifically for the purpose of limiting or controlling a person’s behavior or movement.

There are certain situations, like patients with uncontrolled behavior related to substance abuse and excited delirium, that must proceed quickly to both physical and chemical restraint. These usually involve law enforcement personnel and some use of law enforcement materials.² Every EMS provider needs a physical restraint protocol that’s written in cooperation with local mental health and chemical dependency treatment organizations, approved by medical direction and understood by every EMT.

Many situations that result in agitated prehospital patients can be resolved by simple conversation and direction by EMTs. But patients with the potential for uncontrolled violence must be restrained to protect themselves, crews and bystanders. Treatment and transportation decisions must be based on what can be done safely. That may also involve chemical restraint protocols for medications administered by paramedics.

Verbal restraint is the first option for management of an agitated patient. Its objectives are to ensure the safety of the patient, staff and others in the area; help the patient manage his/her distress and regain control of his/her behavior; avoid the use of other restraints if possible; and avoid coercive interventions that may escalate agitation (like application of physical restraints).

“Talking someone down” is a process many EMTs may be comfortable with due to their underlying personality, the training they’ve received or experience seeing other emergency personnel display excellent methods of verbal deescalation. There are written educational programs that provide EMTs with deescalation training, and some in-person training programs will do the same. A 2012 article by Janet Richmond is particularly detailed on methods used for verbal restraint in the emergency setting.³

If verbal communication is not effective, physical restraints are typically employed, using a variety of devices applied to the extremities and torso or using law enforcement techniques and procedures. Once the patient is restrained, one EMT must maintain constant supervision en route to and at the hospital, until the patient is safely turned over.

Even in these difficult agitated-patient incidents, there is an opportunity for good customer service. The use of verbal deescalation is usually obvious to family and bystanders. The use of physical restraint may require an explanation if they are present. Done in a professional and nonjudgmental fashion, the action can be explained in such a way that the crew appears patient-focused and caring.

Learning Point

EMS personnel must be capable of using appropriate restraint when an agitated patient must be treated and/or transported. Verbal restraint is an option where the patient is unlikely to be uncooperative and violent.

References

1. Kupas DF, Wydro GC. Patient Restraint in Emergency Medical Services Systems. NAEMSP, https://www.naemsp.org/Documents/Position%20Papers/POSITION%20PatientRestraintinEMSSystems.pdf.

2. Augustine JJ. Arms and ‘The Man.’ EMS World, https://www.emsworld.com/article/12005057.

3. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BEAT De-escalation Workgroup. West J Emerg Med, 2012 Feb; 13(1): 17–25.