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Hi, a few comments regarding the excited delirium "medic minute". First, I noticed that it was slightly longer than a minute! * The physician talks a lot. The expression "a picture is worth a thousand words" may apply here. Would it be possible to find some video footage of a patient suffering from excited delirium to add to the presentation? For example, some excellent video is available here: www.youtube.com/watch?v=RGXC5h3eSIA * Have you considered having a paramedic introduce topics regarding appropriate restraint tactics? There are few areas where we have more relevant direct exposure and clinical experience than a BCEM physician, but this is one of them. As a paramedic, it sometimes grates when a physician is lecturing about field triage (if they don't have prior military or EMS experience), or field restraint. This may result in more buy-in from your staff. * The direction to restrain the patient on an LSB so that they can be rolled if they vomit seems to contradict the general admonition not to place any restraints that interfere with respiration. While this may seem obvious, it may be wise to emphasise that the chest restraints should be placed more loosely than with conventional spinal immobilisation. * I am surprised that there is no mention of chemical restraint, or treatment of the excited delirium here. I realise local medical protocols vary, but I think a case can be made that there is great danger to both the patient and first responders here if you don't attempt to address the agitation. In my region, the immediate priority would be to get 10 mg haloperidol / 10 mg midazolam in I.M. as rapidly as possible. Are you willing to allow your paramedics to fluid bolus or give sodium bicarbonate if there's QRS widening, or ongoing severe agitation? Are they being given direction as to how to proceed if the patient's temperature is 41 C? Is ketamine an option in your service? There is obviously a cost/benefit analysis here, and there has to be a level of comfort in the paramedic's ability to continually re-assess the airway and manage it appropriately. But sometimes something done poorly, or with a lower level of skill than present in the ER, is still better than doing nothing. * This is a matter of personal taste, but the music is a little irritating. Also, on some visceral level, the images of a bunch of guys in bunker gear sitting in a pump truck annoyed me. It seemed that the consistent message of this video, was not restrain the patient prone, to avoid placing knees on the torso, and not to restrict the airway or respiration. However, there was not a lot of concrete information on how to do this. If this was something I was developing, I would look to emphasise the following things: (1) An understanding that this is a medical emergency, and a brief discussion of some of the potential complications, e.g. restraint asphyxia, arrhythmia, MH, rhabdo, etc. Make your paramedics buy in to the idea that this is potentially a critical ill patient, not simply someone with a mental health or substance abuse issue. These patients are often blamed for their pathology, which results in suboptimal care. (2) Recognising that this is a team sport. The smartest thing anyone can do in this situation, is to: * Avoid engaging, if at all possible, until a plan is drawn up amongst responding agencies. * Have EMS and law enforcement discuss how best to proceed, e.g. prepare restraints, draw up chemical restraint, briefly verbalise the risks of prone restraint (law enforcement should already be aware, but depending on your locals, they may not). * Calm any family or bystanders, and warn them that any restraint procedure is going to look violent, but your intention is to help this individual. This act more than anything else will mitigate potential legal issues later on. You want sympathetic bystanders, if at all possible. * Not rush. Sometimes your (or law enforcement's) hand is forced. But an under ideal circumstances, a brief scuffle for some IM chemical restraint, if you can, disengage, and let it have some effect. Then, a restraint procedure, likely followed by further chemical restraint, hopefully IV access for better titration, and then an assessment of life threats, e.g. 12-lead, acid-base status, hyperthermia, etc. Largely this is about having law enforcement and EMS work together. And it rarely works perfectly. Often your EMS providers will arrive to six cops sitting on a prone subject, cuffed behind their back. They need to know that their most important task here is to advocate for this patient, and make sure they're appropriately restrained. In my area, not chemically restraining someone like this would be negligent.