Coping with Violent People: A Multi-Part Series

Original Contribution

Coping with Violent People: A Multi-Part Series

January 2007

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Next to operating an emergency vehicle, nothing is as dangerous for an EMT as restraining violent people. Yet even our most widely respected texts portray techniques that are certain to produce injuries to crews. Many instructors freely admit their own discomfort with this topic. Many providers are ill-equipped, armed only with soft ties or Kerlix and tape. At least two states that we know of forbid field use of leather restraints as "hard restraints."

As of this writing, we can find no studies that illustrate how many patients or their families are likely to become violent in the field. In-hospital studies cite numbers between about 1% and 5%.¹ Providers with good interpersonal skills might mitigate those numbers, but even one patient in 100 would make behavioral emergencies more frequent than calls to which we devote much more training, involving obstetrics, hazmat, burns and, of course, weapons of mass destruction.

These are trying times for even the best of ordinary people, some of whom are overwhelmed, overstressed and generally frightened by the world that surrounds them. In addition, we are about to be faced with thousands of military veterans returning from war. When that happened after Vietnam, EMS providers encountered a significant increase in psychiatric emergencies, related in part to drugs they had never heard of. Our training for current and coming realities needs to be a lot better, and right now.

The procedures discussed in this series resulted from the work of more than a dozen Colorado EMS providers between 2001 and 2006 (see acknowledgements on page 50), based on hundreds of years of their own collective field experience in numerous parts of the United States. To develop them, we consulted more than 20 EMS texts in search of an existing procedure that was both humane for the public and safe for all concerned. None of those books provided more than some partial procedures and a few tips, some of which we all instantly recognized as hazardous. We also examined some 40 pieces of restraint equipment in the process of choosing our tools.

Our resulting strategy is comprised of the following steps:

Identifying people and circumstances in advance that are most likely to produce violent behaviors
Verbal de-escalation
Mitigating the effects of fight-or-flight syndrome (in patients and caregivers)
Take-downs (which we leave to police)
Application of two levels of physical restraint, both manual and with the use of appropriate equipment
Use of chemical restraint
Self-defense techniques that have proven their worth when situations escalate unpredictably
Useful documentation skills.

Overview
The procedures described in this series are based on some key beliefs: that caregivers should not blindly rush into any situation at their own peril, that patients' rights to care do not outweigh their caregivers' rights to safety, and that violence arises from medical disorders much more often than it does from criminal intent or psychiatric anomalies. Our goals were and are safety for caregivers and humaneness for the public.

Threat Assessment: Will this person explode?
People instinctively handle crisis in different ways. Some confront it straight on and simply deal with its implications. Others disguise it, dodge it or deny it altogether. A few eventually suffer physiologic sequelae when they can't cope with it. But regardless of whatever else they may do, many people lose control of their emotions in the face of crisis. That occurs most predictably when people ingest certain chemicals, especially stimulants.

People have a right not to be restrained. You can justly usurp that right only when 1) you are awarded the legal authority to do so, 2) you have a very good reason for doing so, 3) you have exhausted every other option, and 4) you are held accountable by someone else for everything you say and do in the process (by your colleagues, reinforced with a focused audit of all restraint calls).

EMTs usually derive their authority to restrain people from local statutes that apply in fairly specific situations. Their legal authority comes from the direct order of a police officer or a written order from a physician. An EMT would have a good reason to restrain someone if the patient poses a threat to himself or to the public. You never restrain people lightly; you absolutely never do it emotionally; and, if you don't have the necessary resources (including the right equipment), you'd better not do it at all.

To decide if you have the necessary resources, assess the patient and ask yourself: Is he just angry, or is he going to explode? That's part of the threat assessment you already do preceding and throughout every call. If you think he is the latter, call for PD immediately, as well as five strong people who are competent in your restraint procedures. How do you decide if a patient poses a risk of becoming violent? Good question.

We are currently studying the feasibility of predicting violence in the field and restraining high-risk patients preemptively. Using a tool called the Potentially Violent Person Profile Index, based on a 1996 ED study at the University of Michigan,² we have so far collected some 170 field reports of calls involving the use of restraints in an urban/suburban setting. The Michigan study identified five predictors of violent behavior in the ED: sex (73% male), age (between 19 and 49 years), history of violence, history of chemical ingestion and history of mental disease.

So far, we think we have validated most of that study's findings in the field. We're not sure about their specific age range, and we don't know how to reliably determine a patient's history of mental disease in the field, but we have added two more predictors: day of week (Friday and Saturday) and time of day (hours of darkness). Our intent is to collect a total of 250 patient care reports involving the use of restraints and publish our findings in a peer-reviewed journal.

Why Would an Assessment Tool Like That Be Valuable?
A lone EMT in the back of an ambulance is extremely vulnerable to a patient whose behavior suddenly changes. But on scene, it's the EMTs who possess tactical superiority. There, it can be common practice for a two-person ambulance crew to be backed up by a two- or three-person engine company and one or two police officers, in addition to family members. At no other time can a crew employ so much negotiating strength. Couple that with the fact that it takes the coordinated efforts of five trained people to restrain even a mildly violent patient, and the value of preemptive restraints makes sense.

Our current practice is to use these predictors of violent behavior to identify patients who pose a high risk. We advocate persuading them to willingly accept physical restraints, while EMS crews still have a tactical edge. We use the techniques of Verbal Judo³ to negotiate those situations, and we use Verbal Judo as our most basic tool for verbal de-escalation (it's described later in this article). In addition, we are absolutely committed to preserving the patient's dignity and managing our own emotions, no matter how unpleasant a patient might become. To reinforce that notion, we employ a focused audit of all of our restraint calls.

Restraining patients preemptively and cooperatively is not always possible, even for great caregivers. But when successful, it eliminates the risk of injury to patients and crews alike by negating the need for a forcible take-down.

We incorporate some key background reading into our training process, namely The Gift of Fear- by Gavin DeBecker.⁴ This book should be mandatory reading for every new EMT. It's a primer on the use of one's intuitive sense to assess threat, and its principles are essential to the understanding of situational awareness. We all possess an intuitive sense, but very few of us have ever learned how to use it. Intuitive sense is a most basic tool in assessing the risk of violence in someone, whether you know them or not.

We have also found it essential to conduct interagency training for every person who might participate in the restraint process. That includes local police officers, who are essential partners in any restraint process. They have much to share, and they deserve to understand how their EMS agencies are trained and equipped to restrain the public. (As you will see, this strategy will not work without the support of law enforcement.) EMS agencies also need to involve their legal counsel in any decision that affects how they restrain people. And finally, this is medicine. It mandates the detailed understanding and active involvement of an agency's physician medical director.

All of that will require some local planning on your part, but it's necessary. Every act of restraining someone necessitates smooth interaction and teamwork.

Before they restrain anybody, caregivers need to understand and believe this one thing above all others: They are caregivers-not judges, enforcers of the law or administrators of punishment. By stepping outside of that role, even for a moment, they instantly forfeit any legal protection that normally accompanies their profession. Restraining people is no job for an amateur.

Verbal De-escalation
Following assessment, the restraint process always proceeds to earnest, measured, deliberate efforts to negotiate for the patient's cooperation. Patients who can comprehend situations and communicate and who do not pose an immediate threat to caregivers warrant caregivers' efforts to negotiate. That's not a waste of time. Physical restraints are not only dangerous to apply, but they may be unnecessary-especially in cases when the patient's behavior is primarily grounded in fear. And they may provoke patients to struggle persistently, which can be fatal to them.⁵ People can become emotionally unstable for numerous reasons, the vast majority of which are medical.⁶ Some of those reasons can be mitigated by a calm, logical facilitator. The ones that are produced by chemicals (especially stimulants) usually don't yield to reason (or anything else, except possibly other chemicals), and those patients can be exceedingly dangerous both to themselves and others.

Fight-or-Flight Syndrome
Imagine you awaken from a deep sleep to the sounds of something banging around in your kitchen. When you investigate, you surprise a grizzly bear rummaging through your refrigerator. Within seconds, your body undergoes a number of physiologic changes, beginning with profound arousal. Some of those changes involve shunting of blood to your skeletal muscles, myocardium, pancreas, medulla and lungs, converting you into the best fighting, running machine you can be. If you can't whip a grizzly, you will surely be able to run your fastest. Not only that, chances are you will experience diminished sensitivity to pain or muscular tension, just in case the critter catches you.

Shunting means borrowing. Where does that additional blood supply come from? Your cerebrum, for one thing. When you run from a grizzly bear, you don't need to be a profound thinker. It also comes from your digestive tract and your liver. No need to process food or toxins just now. Why is all that important, especially the part about the cerebrum?

In the world of Hollywood, people can produce glib, appropriate, even funny comments in the midst of life-or-death struggles. But Hollywood was built out of fantasy, not reality. Think about the worst, most emotional argument you ever had in your life. Was that an articulate moment for you? Did your words come easy and seem perfect for the occasion? Probably not. That's a natural consequence of borrowing blood from your cerebrum, especially when you only get one "take" and you're not reading from a script.

All of which is important as fight-or-flight syndrome. It explains why we have so much trouble communicating with people who are angry, chemically stimulated or scared, at least until (or if) we can calm them down enough to re-engage the thinking part of their brain. And it explains why they-and we-can become oblivious to muscular tension or pain. That makes us all as physically strong as we can personally be. And it's why, if we lose our temper, we can underestimate our strength and hurt people during the restraint process.

Some chemicals trigger the physical effects of fight-or-flight syndrome in patients (medically termed "excited delirium"). They're the stimulants, like adrenaline, PCP, LSD, Ecstasy, amphetamines, meth and, most commonly, cocaine. They can produce profound violence and induce patients to struggle furiously, even after they have been securely restrained. Uninterrupted, that kind of violence can be fatal in some people, especially those with advanced cardiovascular disease and those who are morbidly obese.⁷

Clearly, not all people can be returned to a rational state by even the best caregivers, and that's why we're discussing restraints. But some can. They tend to be those who are simply scared. We especially try to avoid restraining them, if we can.

Fight-or-flight syndrome can evolve in a matter of seconds. Fortunately, that evolution is generally recognizable as a pattern. It generally appears first as adrenergic signs (like tachypnea, tachycardia and diaphoresis), then unwarranted shouting, clumsy speech and, finally, cursing by people who normally do not characteristically use bad language. Our strategy employs a team member whose role requires the least physical exertion and who could therefore be the smallest person on the team. It's part of that caregiver's role to monitor the emotional status of other team members and warn them when they appear to be escalating. They have other responsibilities, as well, which will be described when we discuss physical restraints. Our prevailing hope is to keep all team members calm, regardless of what the patient says or does to them throughout the procedure.

Verbal Judo is a "soft" negotiating strategy, derived from the martial art form judo, whose name means "gentle way." One of the reasons Verbal Judo lends itself so well to the challenges of verbal de-escalation is that all of the police officers in our area have been trained in its use (in addition to all fire and EMS personnel). Once a practitioner has exhausted the options offered by Verbal Judo, it offers some specific wording that is recognizable to anyone schooled in its use, i.e., "Is there anything we can say or do to convince you to lie down on that cot and go with us to the hospital?" Police recognition of that language eases the transition between verbal de-escalation and the take-down process.

Take-Downs
You need statutory authority to touch someone or transport them against their will. In most jurisdictions, that means either a physician's order for a mental health hold or a police officer's determination that the person is a threat to himself or to others.

With that established, once we determine we will be unable to persuade a violent restraint candidate to accompany us to the hospital, we resort to a take-down. A take-down is a process of getting an uncooperative patient from his position of origin onto an ambulance cot, where the tie-down takes place. To us, those are two separate processes.

When we began developing this procedure, most members of our group had already conducted numerous take-downs as caregivers. Several of us had been physically injured by violent patients during that process as a result of inadequate training or resources. Consequently, we developed a new, simpler approach to take-downs: We leave them to the cops. Police are universally trained and equipped for take-downs; EMS crews are not. Police have the legal authority and an escalating infrastructure (including a series of forcible technologies) that support take-downs; EMS crews simply don't.

The development of and widespread access by police agencies to the Taser played an essential role in our decision about take-downs. The Taser is not a benign instrument, but we have seen its use produce a quantum enhancement in our own safety and that of our fire and police colleagues. More than just a noxious irritant like Mace or pepper spray (to which many delirious patients may be oblivious), the Taser instantly and consistently disables most people who cannot be controlled by any other nonlethal means. Generally, they go down like boxes of rocks.

In rare cases, even the Taser does not disable people. We believe this is a strong argument for the involvement of police in the decision-making process. We also believe the eventual need for deadly force is a potential consequence that an EMS crew must weigh early in any restraint process. Obviously, we are all helpers. But we should value our own rights to safety (and the well-being of our families) before the rights of violent people who may not benefit from our most earnest efforts to help them.

We would like to thank the following people for their assistance with photos for this series: Johnny Blackston, Kristy Buckalew, Dave Christenson, Carl Craigle, Curtis Gall, Melissa Lunt, Steve Rollert, Elisabeth Simma, Keith Staples, and Ted and Crystal Thompson.

References

Brice J, et al. Management of the violent patient. Prehosp Emerg Care, p. 49, Jan-Mar 2003.
Gregg CM, Krause CJ. Violence in the health care environment. Archives of Otolaryngology-Head & Neck Surgery 122(1):11-16, 1996.
Thompson GJ, Jenkins JB. Verbal Judo: The Gentle Art of Persuasion, revised ed., 1994 & 2004, Quill/HarperCollins, NY.
DeBecker G. The Gift of Fear: Survival Signals That Protect Us From Violence. Little, Brown & Co.: NY, NY, 1997.
Kupas DF, Wydro GC. Position Paper: Patient Restraint in Emergency Medical Services Systems, Prehosp Emerg Care, p. 341, Oct-Dec 2002.
Cf #1, p. 48.
Ibid, p. 51.

Thom Dick has been involved in EMS for 35 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar414@aol.com.

Steve Rollert has worked as a full-time EMT-B since 1989 and is currently employed by Platte Valley Ambulance in Brighton, CO.

Protecting Yourself Legally
Forcibly restraining and transporting people is not just physically dangerous. As a class of calls, it produces more than its proportionate share of legal actions. That doesn't mean we should refrain from restraining people anymore than we should fail to intubate or cric them appropriately. But restraint calls do warrant some specific documentation strategies.

When you describe a restrained patient's behaviors, try to avoid the use of adjectives like "violent," "belligerent," "combative" and so on. Instead, use Twink Dalton's strategy of describing what the patient says and does. Twink has a lifetime of experience as a top-notch paramedic-nurse-EMS educator in Nebraska and Colorado, and she has probably taught more of us than anybody can count. Her experience is that when you try to describe behaviors (with adjectives) and a legal question comes up, you usually end up having to recall what you meant when you wrote your description.

That usually means a phone call from an attorney, as much as two or three years after you write your description. Not many of us can randomly recall a response after a couple of years' worth of additional responses, and God help us if we get caught pretending under oath. On the other hand, if you document what the patient says (in his own words, exactly) and what the patient does, any questions that may come up at a later date can be answered by the chart-even if you don't remember a thing about the call. Your narrative, written at the time of a call, has great credibility two years later, unless you do something else to discredit yourself during or after the call.

What if the patient uses bad language? Write it in the chart, just the way he uses it. You're not writing a speech for a garden party. Give your future readers a clear and unvarnished picture of what you saw and heard. What if the patient does things that are terribly uncivilized? Same deal. What gets you in trouble is altering the truth, not accurately recording it.

Acknowledgements
The author gratefully acknowledges the following, whose ideas and efforts were instrumental in the development of this article and/or the procedures it describes.

Bruce Amdahl, NREMT-P
Dennis Baker, NREMT-P
Kyle Buss, PA-C
Carl Craigle, NREMT-P
Twink Dalton, MSN, NREMT-P
Thom Dunn, PhD, NREMT-B
Lester Federoff, MICP
Jeff Forster, NREMT-P
Grant Gilliland
Art Kanowitz, MD, FACEP
JoAnn Kean
Pam Landis, EMT
Charly Miller, NREMT-P
Mark Mayo, MICP
Kevin Neu, NREMT-P
Chris Olson, MICP
Jim Page, JD
Doug Perry, NREMT-P
Robert Putfark, NREMT-P
Steve Rollert, NREMT-B
Sean Schwartzkopf, EMT
Mark Seidel, EMT
Officer Dave Snelling
Steve Whitehead, NREMT-P