combative patient

[CBEMT]

Combative person + no chemical restraint protocol = person going with PD.

"This is a medical problem, not a police problem. We don't take people to the hospital, that's your job."

Back to square one. Not saying it happens everywhere, but some people do in fact have cops like that.

Edited January 7, 2010 by CBEMT

[TysonB209]

That was my question, why not chemically restrain but I guess there's the answer. Still, if he's still posing a threat during transport why not get the po-po's back? Another question which I think was already asked, was he of relatively sound mind? GCS 15 and posing no immediate danger to himself? If so, why was he transported? Did the family make up the story of him cutting himself with glass to get you there faster?

If you have no spit hoods and the NRB wasn't staying on his face, try a pillow case (sans pillow). Your patient can still breathe just fine, but cannot spit on you

our system can be a little screwy at times and it seems like we get people dumped on us that have no medical need, however somehow they end up on our gurney and off we go..

Ok, I haven't posted in a while but this is a good one.

One way to change the toon of the dumbass doctors who won't give you orders for chemical restraints.

Let the patient be completely combative when you arrive at the ER, Let the patient go bat crap crazy in the ER, have him hit the doctor and knock him out. Then call the cops and have them shoot the bastard.

Let the doctor know that this would have been avoided had he have had the balls to give you sedation orders.

Or better yet, get your medical director to write you a protocol that precludes you having to call the hospital. If the hospital isn't going to look out for you then your medical director should.

One other thing, the first time one of you guys get's hurt from the doctor not giving you sedation orders, take the doctor and hospital to court citing that your injuries were a direct cause of them not giving you orders for sedation.

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.

And finally - when in doubt, stop the ambulance, get out and wait for the police. No sense in getting yourself hurt. The ambulance and it's equipment can be replaced, YOU CAN'T Be. Most times when the police hear that the patient assaulted you they are not so nice.

If your service isn't going to help you keep safe then you need to find a new service or you need to work to make the changes happen. Your safety is 100% your responsibility. Protocols and medications only go so far.

i REALLY REALLY like your style

Combative person + no chemical restraint protocol = person going with PD.

It's 2010, time for your local EMS to catch up on the times and offer interventions appropriate to the patient population.

Personally, I would have offered this kind individual a nice cocktail of Ativan or Haldol and Benadryl. Should he politely decline and continue his demonstration of low level Darwinism, he gets a consolation gift consisting of Anectine and an endotracheal tube. I am a firm believer in prophylactic RSI.

i wish our protocols were as liberal as yours sound. but our local pd refuses to take these folks because they have a medical complaint. whether its total bs or not. in the off chance that something were to happen. bye bye paramedic license..

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

dwayne your response is greatly appreciated. i was bigger than the patient, probably very easily could have beaten the living crap out of him. However that poses a serious threat to my employment. there was an issue like this in the past where 2 employees were canned for brawling with a patient. im just trying to find a "happy median" here where i can protect myself, my partner, and my patient, while staying out of trouble. the general agreement seems to be to get, call the 5-O and have them deal with the patient.

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

PRECISELY!

[fireflymedic]

i wish our protocols were as liberal as yours sound. but our local pd refuses to take these folks because they have a medical complaint. whether its total bs or not. in the off chance that something were to happen. bye bye paramedic license..

Protocols like that are more liberal for a reason in flight. This guy comes up and causes too much of an issue or starts affecting the pilot - down we go and it's not a pleasant parking job. Also, not like you can just say "Pull this thing over" - little different ya know? That's why I say - it's just as much for their safety as the crew's. There have been incidents of patients doing some truly insane behavior while in flight and when you're that far up, the safest thing for all involved is a tube and a vent.

[TysonB209]

Protocols like that are more liberal for a reason in flight. This guy comes up and causes too much of an issue or starts affecting the pilot - down we go and it's not a pleasant parking job. Also, not like you can just say "Pull this thing over" - little different ya know? That's why I say - it's just as much for their safety as the crew's. There have been incidents of patients doing some truly insane behavior while in flight and when you're that far up, the safest thing for all involved is a tube and a vent.

good point.. makes sense

[fireflymedic]

good point.. makes sense

Just another side of the fence...

[flight-lp]

"This is a medical problem, not a police problem. We don't take people to the hospital, that's your job."

Back to square one. Not saying it happens everywhere, but some people do in fact have cops like that.

Fortunately, our local PD agencies do psych transports in the case where a non-medical psych person has issues with safety.

An uninjured person with no complaints who is competent is not a patient, regardless of the opinions of others. If someone is impeding on my personal safety and for some reason I was not able to manage that person, then they will not be in or remain if already in my ambulance. PERIOD.

But again, chemical restraint and RSI are wonderful options to have........................

Tyson - Your local PD may refuse, but see what happens when you or one of your co-workers gets their ass whooped. You need to address this issue man.

[newenglandeve]

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 didnt 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..

For the spitting, consider asking your agency to purchase "spit hoods". Safariland produces one know as the "Tranzport Hood". These are specifically designed to allow a patient to breath, while not allowing them to spit at you.

[newenglandeve]

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.

This is huge!! The reason it is so difficult to establish protocols for Uncooperative patients is a lack of paper trail! The issue of being assaulted on the job in EMS is just finally getting the attention it needs. For the longest time being "hit" was considered "just part of the job." Keep filing paperwork with both your own agency and law enforcement!

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.

Consider checking out DT4EMS' website. I have recently taken this class and I was floored. The program was designed by a Paramedic/Police Officer, that is also a Defensive Tactics instructor. He has simplified defending yourself down to just a few simple principles to remember to help you not get into a bad situation or how to escape a bad situation if you find yourself suddenly in one. Well worth checking it out!

Stay Safe out there!