combative patient

[azemtjunkie79]

hi first to introduce myself, my name is Tyson and i work in central california for american medical response. i have been employed with AMR for 4 years, 2.5 of them as an EMT and 1.5 as a paramedic. My partner and i were recently called out for a male cutting himself with broken glass. After staging for our local police department, we arrived on scene to find a young man lying on his bedroom floor with no injuries. Per family patient has not been acting himself lately and they wanted him transported for psychiatric evaluation. The patient was "less that cooperative" to say the least. We got the patient into the back of the ambulance and restrained his arms since he was already showing signs of being combative. While on our way to the hospital the patient became extremely combative, biting, spitting, kicking, screaming, etc. etc. etc. How do you deal with the patient? please no lectures on scene safety. if the patient was acting this way on scene law enforcement would have ridden in..

I have worked as a psych tech for 10yrs now as well as a EMT, i worked for a behavioral ambulance company for awhile and that what we specialized in was those types of calls, really all u can do is restrain all limbs, spit mask if u have one or just a regular Tb mask works just fine. As a medic u have the option of giving them a IM considering patient wouldn't allow u to give them a IV. Sedate and restrain. That's all you really can do.

[stcommodore]

I work in a very "not" progressive urban service but we at the least have versed and a chemmical sedation protocal. If the patient is struggling against restraints and you can't explIn away the issue medically then put them to sleep. I work part time at a service that doesn't have restraints and each time I am on an incident where they were needed and I did't have them I write an incident report so there is a paper trail.

[DwayneEMTP]

Thank you for the replies!!!! unfortunately we have no protocols for medicinal restraints or "sedation." numerous other paramedics have called out base facility and asked for it and it was denied. looking back i should have taken a rider.. however he didn't seem like he was going to give me as many issues as he did while we were on scene. i guess i just didnt expect things to head south so quickly.. the obvious answer to this question seems to be "kick his ass!!" HOWEVER! i enjoy working as a paramedic and want to continue to do so. we did try the NRBM, but he was thrashing around so much it stayed on his face for all of 3 seconds..

Hey Tyson, welcome to the City.

I'm going to take the less politically correct road here, as I have a feeling that's what you're really asking.

How big is this guy? How big are you?

This is what this situation says to me, that he started out being just sort of an ass, yet during transport this turned into an 'Oh Shit!' moment and you asking how to deal with it on your own? I get that...

First off, for me, once he began to spit, all bets are off. Now he's gone from being an asshole to creating a significant bio hazard for me, and that just simply is not going to continue. Where I work it's pretty rural and PD is rarely on scene, often will not respond in a reasonable time if called, and when responding there are only a few officers that will be of any real help when they get there, so we tend to always think of resolving these types of problems without outside help.

We have pretty progressive protocols so I'm allowed options for sedation, though if this isn't in my opinion a true psych, meaning that this is some spoiled kid acting like a weenie because it gets him attention, I may choose not to use them. I'm happy to use them to ease the situation for the truly mentally damaged, but not so quick for the spoiled idiot. Moot here I know as you don't have a chemical option.

This just happened a few nights ago. I dropped the head of the cot, pt didn't have a shirt on or I would have pulled it up over his head, pushed his head to the side with my knee and put my full weight on that knee, mashing his head down into the cot. At this point I had complete control over him, not to mention eliminated the possibility for spitting and biting. I had my partner pull over, come to the back. While I kept his head mashed, all the while he's screaming about abuse and law suites, my partner pulled all of the straps as tight as they would go, tied each hand with Curlex to the Pt's thighs, pulled the chest and shoulder straps as tight as possible, to the point of restricting breathing even. This ended his options for any significant struggle. I put a surgical mask over his face, (this pt was a muscly 250 or so) and taped it in place with medical tape wrapped all the way around this head.

None of this was done in anger, which I believe is a significant point. This guys was not happy, but he also understood that his dangerous behavior was not a game to me and was going to be neutralized. I'm not his mother or father, to be held hostage by such behavior, but I am a husband and a father who is going home without spreading disease to my family.

Once he calmed a bit I loosened the chest strap so he could breath freely, chose a vein on the outside of his bicep and got an IV in case something else was going on here that I hadn't discovered yet, and we rode into the hospital. By the time we arrived he was calm and assisting me with his assessment like an honest to God human being.

Now, you're probably going to see me get a beating for this answer, and my rating is likely to drop significantly, but that's OK, I'm wearing my big boy pants. And I do certainly see the need for this type of pt handling as a failure on my part. as there are many here that may be able to talk this pt into behaving without needing to resort to the above tactics as I most often can, but in my experience sometimes EMS simply becomes a contact sport.

Now understand, had this been someone truly in mental pain I would have mashed his head into the mattress as described above but would have kept it there only so long as it would have taken for my partner to get me a line and some Versed from the lock box and life would have been peachy just the same. I simply don't like to be bullied or threatened into giving drugs by chronic assholes as opposed to those seriously ill.

Bottom line is that you stay safe. If something like this works for you, go for it. If not, as mentioned above, get your ass out of the truck, call in PD, and get ready to eat some crow. :-)

Dwayne

[stcommodore]

See also "what happens in the back of the ambulance"

[flight-lp]

I have worked as a psych tech for 10yrs now as well as a EMT, i worked for a behavioral ambulance company for awhile and that what we specialized in was those types of calls, really all u can do is restrain all limbs, spit mask if u have one or just a regular Tb mask works just fine. As a medic u have the option of giving them a IM considering patient wouldn't allow u to give them a IV. Sedate and restrain. That's all you really can do.

Actually, no that is incorrect. As Dwayne pointed out, once they move onto becoming a threat to your personal safety, the bets are off. A combative individual can "decline" an IV all they want, if they are a danger to themselves and / or others, they are getting an IV providing it can be accomplished safely and efficiently. In many cases, asinine behavior can be predicted in the attention seeking population. Because of this and the very nature of psychological disease, I will usually establish an IV while on scene with adequate assistance available should the individual have a differing belief of the appropriate course of action.

One that really sticks in my mind was an addict high on PCP. Dude was carrying 4 cops on his back. 10mg of Versed

IM didn't phase him.....................But the 200mg of Anectine IM eventually did. Sometimes you just have to improvise to insure you go home safely at the end of your shift.

Again, the OP needs either appropriate sedation options or a better transport policy.

[HERBIE1]

Lots of good ideas here, and as always because of differences in training, protocols, sizes of patients/ providers, transport times, back up availability- there is no one solution to a problem such as this. Experience will tell you what you need to do, and as has been mentioned many times, self preservation is the best policy- whatever it takes to stay safe.

Also- listen to that little voice inside your head. He gets more and more brilliant, the longer you do this job. If you have a feeling someone may act up- BELIEVE IT, and be proactive.

I'm always hesitant to use restraints for several reasons. First, in order to safely apply them, you need tons of help. Trying to tie up a combative patient with just 2 people is a recipe for disaster- someone is going to get hurt. Couple that with the confined space in the back of a rig and even if you have tons of help, you quickly run out of room, especially if you only have access to one side of the patient. Another reason- I have seen PCP ingestions where the patient treated leather restraints as if they were toys and snap the buckles. ideally you would apply them in a more controlled setting with plenty of space and assistance, but patients don't always present that way for you.

Working in an ER, we would have at least 6-7 people to safely apply restraints. One for each limb, another to secure the torso, and 2 or more to actually apply and secure the restraints. Unless your rig is the size of an RV, that's too many people.

My favorite restraint in a pinch- wide rolls of Kerlex. Yes, old school I know, but there's a reason it's so widely used- it works. It's readily available, quick to apply-especially if there's only 2 of you- and you don't need to fumble with keys, straps, and buckles. All you need is a couple quick slip knots and the job is done. Couple that with your seat belts and that person is not going anywhere. Yes, most places frown on this now, but I have yet to hear a hospital complain that a person has been restrained in this manner. They would much rather have a person present to them under control and be able to calmly assume care of the patient then to have them flailing and flopping as you roll through the doors. You simply need to ensure the gauze is wide enough as to not impair circulation or cause injury. It's also easy to remove- simply cut it off when you turn the patient over to the ER.

A suggestion for new providers- talk to law enforcement people and/or a martial arts pro and get some tips for yourself or have an informal session for your people. I learned long ago from a partner who was a martial artist a couple simple techniques to control someone-- basic judo holds, pressure points, blocks, etc, and they have come in handy countless situations. They are also not for someone out of control- a novice use of martial arts moves will end up getting you hurt. These tips are very helpful for someone who is beginning to get squirrely- often times if the person feels you are in control of them- a simple arm lock, for example, gets their attention, shows that you will not tolerate them acting like a moron, and they tend to settle down. Unless someone is psychotic, even a drunk usually realizes when they are in a no win situation. The first time I saw the guy use a simple grasp of a person's thumb to render an idiot completely cooperative, I was a believer. No fighting, no wrestling, no injuries to anyone- problem solved.

Edited January 7, 2010 by HERBIE1

[Just Plain Ruff]

Once your personal safety is at risk then all bets are definately off. If it's me or the patient then you can be darned sure that before I'm taken out that patient is going to be dead first.

But if you have any way of getting out of the ambulance you better take it because you as a professional provider, you are responsible for keeping the scene safe.

If you lose control and the patient gets hurt but you can defend your actions then yeah, you're going to get sued but at least you are safe.

If a patient goes bat shit crazy on me and I can't get out of the ambulance then that patient is gonna get hurt.

It all bois down to this, if you go home safe at the end of your shift then your day was good.

[fireflymedic]

While I agree to some extent that yes, not all psych patients are aggressive - the potential to be is much higher. They are obviously not thinking clearly at that point, thus why you were called in the first place and are transporting. There have been numerous times that a patient wasn't expected to be a problem and became one enroute for a variety of reasons. If I don't have PD I AM going to have an extra set of hands, I'm not doing this by myself. It's mine and my partner's safety above everyone else's.

If you have been contacted for a psych patient (or even a suspected one) in this area, PD always goes first and evaluates the situation. My former partner was shot in the head and his partner killed because PD didn't go check it out first. Nobody thought it was going to be a problem. Now a good EMT is dead and a compassionate medic is out of EMS completely. Sad. Unfortunately, it took this to happen before this department chose to make corrections to their system (granted it wasn't for a psych call, but the man had an extensive psych history which now automatically flags in the system and PD is sent with).

However, the reason you are being called is they are not thinking properly. If they are at the point they are willing to hurt themselves (even if just for attention) are they really thinking clearly enough to not want to hurt you in the process? I'm not entirely convinced. I'm with flight-lp - especially in that environment - it's not safe. If I'm expecting a problem, or you start to give me one, I'm going to take measures to ensure everyone's safety - including yours. Another good thing to pursue is a defensive tactics for EMS class - there's some people connected with Dayton that do a pretty decent one and I'm sure they are across the country. It's not how to legally beat the crap out of a patient, but rather if all crap hits the fan, how you can at least keep yourself reasonably safe until you get help from the guys with the guns.

Bottom line - make sure you come home at the end of the shift 'cause you aren't effective if you are hurt or dead.

[ambodriver]

In our region we are able to give 10 mg of Versed IM to the combative patient. This works great if you have enough guys to hold him down, I don't attempt to get close to the pt. with a needle unless he is being held down. I've done thid quite a few times in our lock up. Usually for this type of patient we will have the police and our FF's assist us with 4 point restraints. A pair of panty hose is great to put over a patient's face to stop spitting. This way you can still monitor the airway quite well. Safer than pillow cases. A NRB mask also works to block spit. Spit can be very dangerous...we are talking about hepatitis. Don't joke around with it. Stop it at any cost it is a BIG risk.

Stay safe foks!!

Or you can do what some medics I've worked with, IV em, Versed em, Sux em and tube em. Tell the doc that you were concerned about their ability to protect their airway and you RSI'd em. Not saying it will cover your ass but someone has to.

??? really ???

Edited January 7, 2010 by ambodriver

[HERBIE1]

Once your personal safety is at risk then all bets are definately off. If it's me or the patient then you can be darned sure that before I'm taken out that patient is going to be dead first.

But if you have any way of getting out of the ambulance you better take it because you as a professional provider, you are responsible for keeping the scene safe.

If you lose control and the patient gets hurt but you can defend your actions then yeah, you're going to get sued but at least you are safe.

If a patient goes bat shit crazy on me and I can't get out of the ambulance then that patient is gonna get hurt.

It all bois down to this, if you go home safe at the end of your shift then your day was good.

Totally agree, but what about the 5 foot 1", 110lb provider? Their options are limited. Years ago I worked with a girl about that size, but had the mouth of a trash talking WWF member. After hearing her go off on someone in the middle of a crowd of hostiles, I went bananas on her. I said she has every right to speak her mind- except when it endangers me, and if she was instigating a fight, I would NOT be backing her up.

She was incredulous- "You can't leave me alone like that!"

I told her- "Try me." It's the old line- your mouth is writing checks your body can't cash.

She never called my bluff.

I told her that I have a family to worry about, and even most scumbags have ethics- they won't go after a girl. They would probably knock her out of the way to get to me and kick my arse, so she had better learn to keep her mouth shut.

Gawd knows I've been in my share of scuffles over the years, but I'm too old for that crap anymore, and it's not worth the hassle. Our society is far more concerned with protecting the rights of "victims' these days, and everyone has a camera/cellphone. We lost a medic a few years ago because he was caught on a security camera beating up a patient. The medic was way out of line and although the patient apparently initiated the fight, that is not what the cameras saw, nor how the incident was portrayed in the media. The medic was fired and the "victim" got a nice settlement.