Recognizing and Defusing Aggressive Patients

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

Objectives

1) Identify statistics highlighting violence against EMS providers

2) Explain violence prevention strategies

3) Discuss the stages of aggression

4) Highlight de-escalation techniques

Steve and his partner John, both EMTs, never saw it coming. The two were evaluating Henry, an elderly man whose daughter was worried because he hadn’t been taking care of himself since his wife died three months earlier. The frail man appeared malnourished and his house had not been cleaned in weeks. Henry made it clear that he didn’t want EMS care even though he obviously needed help. Finally, in frustration, Steve said to Henry, “Sir, you have two choices: you can come with us now, or we can get the police here. Either way you need to go to the hospital!” As soon as the words came out of Steve’s mouth, Henry screamed threats at the crew and ordered them to leave at once.

Introduction

I never saw my first experience with violence against EMS coming. I was working overnight in a large urban system and was preparing to transport a child between hospitals. It was late at night and I can only imagine how tired the mother was. As the nurse gave us a report, we assessed the patient and began setting up the equipment needed. At one point I asked the nurse if she would be OK if I changed the IV fluid and its rate. This set the mother off on a series of verbal attacks which began with, “Why don’t you just do your job and stop asking all those damn questions.” In retrospect, I handled things poorly. After several minutes of confrontation, the mother grabbed and hit both me and a security officer. In the end I had a startling realization about how easily our actions and statements can trigger violence against us. —Kevin Collopy

Violence Awareness

Classroom instruction doesn’t do it justice; every year there is an increasing number of violent acts against prehospital providers. Check the news feed on EMSWorld.com in any given week and there is likely to be at least one report of an attack against a provider. Current reporting systems truly underreport the violence that occurs, because there is no national reporting system for EMS providers to report verbal harassment or violent acts. One study found that violence occurs in one form or another on 8.5% of all EMS responses, and this on-scene violence is directed toward an EMS provider in over half of the cases.¹ Patients are responsible for violence against EMS 89.7% of the time; however, that does leave a large number of cases (such as that described in the opening) where a bystander is responsible. Violence can be verbal, physical or a combination of the two. In this study, physical violence was defined as any unwanted physical contact directed toward the EMS provider including slapping, hitting, pushing, kicking or spitting; verbal violence was defined as any unwanted abusive language, threats of violence or injury, or gestures towards the EMS provider.

There is potential for violence on many responses, so it is important to always be looking for early warning signs of escalating aggression or violence, such as increased nervousness or an individual beginning to pace or make fists. There is an increased risk for violence whenever there is police presence, a gang member involved, known/perceived psychiatric disorders, or the presence of alcohol/drug use.¹ Consider the violent scenes EMS responds to: stabbings, shootings, domestic violence, abuse, unarmed assaults, rape, motor vehicle crashes—the list goes on.

The risk of violence is increasing. The Occupational Safety and Health Administration (OSHA) recognizes increased violence risk coming from: an increased prevalence of handguns in the patient population; an increasing number of chronically ill mental patients; increasing gang activity; increased numbers of drug abusers; low staffing numbers (only two crew members on a scene); isolated work environments (a private home); limited back-up capabilities; and limited communication equipment (only one hand-held radio on a scene).²

Training to Recognize Dangers

OSHA standard 3148 contains guidelines for “Preventing Workplace Violence for Healthcare and Social Service Workers,” and includes prehospital providers. It is divided into five sections: management commitment and employee involvement; worksite analysis/risk assessment; development of hazard prevention controls; training; and record keeping.²

Management commitment and employee involvement

Management should actively provide necessary tools, such as risk assessment and priorities programs, to decrease the risk of injury. Management should create a violence prevention strategy that includes detailed violence prevention programs, a process for employee comments and complaints, a reporting system, and a safety committee that regularly discusses violence risks.

Worksite analysis/risk assessment

The completion of a risk assessment is an important step in identifying locations where there is an increased risk of provider violence. For prehospital providers this can be as simple as using run reports to monitor locations where police presence is regularly needed, names of patients who have previously exhibited aggressive behavior, and even times of day where there is an increased volume of violent events. Some organizations may use a violence assessment checklist to determine the likelihood of on-scene violence.

Development of hazard prevention controls

Creating hazard controls is an essential step in reducing the risk of violence against crews. An example of this is in ambulance design. Placing heavy equipment in cabinets near the patient can provide them with access to objects than can be potentially used as weapons.  Consider placing equipment and supplies in cabinets that minimize patient access to dangerous equipment. Another example is in crew member and patient positioning. Allowing a psychiatric patient to sit in a seat or on the bench in the back of an ambulance during transport increases their access to crewmembers. It may be better to require all patients to be in five-point seatbelt harnesses on the cot and require crew members to sit behind the head of the patient during transport of psychiatric patients; this would keep the crew member at a safer distance from the patient. Other prevention controls are regular training on (proper) patient restraint devices, access to portable radios for all crew members, and radio access throughout the response region (management of dead zones).

Training

Every organization needs to have regular training on potential and changing risks within its region. Both the provider and the management have a responsibility to be aware of potential risks. Training needs to continue past risk assessment, and also discuss recognition and response to progressively aggressive patient behaviors, anger management, safety device location and personal protection systems. Some organizations even training on escape holds and techniques, as well as basic take-down and restraint methods, a discussion of which is beyond the scope of this article.

Record keeping

In addition to patient care reports, any workplace violence must be reported to OSHA using the OSHA 200 log whenever violence results in treatment beyond standard first aid; work time is lost; injury results in restrictive or light-duty; there is a loss of consciousness; or death. It is important to note some government agencies are exempt from utilizing this form. Organizational safety committees need to regularly review any incident reports, which are meant to be used anytime there was actual, or the potential for, aggression toward a provider. Remember, if an unexpected incident occurs and it isn’t documented for review, nobody else has the opportunity to learn how to prevent similar incidents in the future.

One prevention strategy that is particularly important to discuss is the provider’s tone of voice and body behavior toward patients. Many providers, particularly when stressed, have unintentionally used body language or a tone of voice that a patient may perceive as patronizing. This can be particularly true with difficult patient groups, such as drunk drivers; think about how you, or perhaps a partner, have acted. Could those actions have been perceived in a manner that could make the patient more aggressive or angry? Think about how we all want to be treated when we’re patients—no patient deserves to be treated differently. Always maintain calm, professional body language, and speak to all patients the way you’d want to be spoken to, regardless of whether the patient is your grandmother or a felon in a maximum security prison. Coming off in a negative light toward a patient is never beneficial.

The Aggression Continuum

Identifying the signs of an aggressive patient is an essential step in protecting yourself from harm; in addition to identifying the signs, it is also important to determine where on an aggression continuum the patient is. While there are many aggression continuums in the literature, below is a description of the aggression continuum described by Steven S. Wilder and Chris Sorensen from the book Essentials of Aggression Management in Health Care.³

There are six different phases people experience as they progress through aggressive behavior. Each phase builds on responses to the prior stage and escalates the seriousness of the situation. These six phases are: 

1. Calm and non-threatening
2. Verbally agitated
3. Verbally hostile
4. Verbally threatening
5. Physically threatening
6. Physically violent

Phase 1: Calm and non-threatening

Most people go through everyday life in a calm and non-threatening manner; they think logically, respond appropriately to situations and interact with society in a socially-acceptable way. As a prehospital provider, it is our goal to keep and/or return patients to this phase whenever possible. It is also essential to remain here as a provider, too.

Phase 2:  Verbally agitated

Many people experience phase 2. It is a fairly regular response to express anger toward an unpleasant situation or circumstance. Individuals in phase 2 use words and phrases to express their displeasure, have a strong tone of voice and speak more loudly. It is important to note, however, that in phase 2 anger is not directed toward any individual or group of individuals, but only the situation itself. Consider a situation where a teenager has been in a motor vehicle crash and they are visibly upset and worried that, “My dad is going to be so mad when he sees the car.” This can be an example of phase 2, and often these individuals will return to phase 1 with little or no help from anyone else.

Phase 3: Verbally hostile

When individuals upset over a situation become so angry that allowing them to vent and normal calming efforts (discussed later) fail to have an impact, they have advanced into phase 3 and are considered verbally hostile. These individuals are so overcome by their anger that they lose the ability to converse about other items, such as their own health/injuries. While the anger is a distraction, it still isn’t being directed toward any single individual or group; however, the anger continues beyond what might be considered a normal period of time, such as a few minutes, or beyond the end of the situation itself. These individuals are unable to deal with the situation on their own and often need help from de-escalation techniques to help them return to a normal state (phase 1).

Phase 4: Verbally threatening

Anger directed toward a specific individual, group or object indicates that an individual has moved into phase 4. According to Wilder and Sorensen, look for one of two distinct red flags to suggest this phase is present. Red flag number one is the individual directs angry statements toward you, such as, “You need to go away,” or “They need to apologize to me now!” The second red flag is when the individual suggests consequences if situation doesn’t resolve to their liking. Absent from phase 4 are physical actions or movements, such as moving toward a weapon or making fists. This can be distinguished from phase 5 because the individual is making demands toward someone, or is hinting at or suggesting consequences for inaction, without specifying what the consequence might be or having the immediate items to carry out the consequence. This is also the final phase where prehospital providers are likely able to intervene to maintain control over a situation.

Phase 5: Physically threatening

By the time patients begin making physical threats, situational control is nearly lost and there is a very real potential for physical harm. Physically threatening individuals often stop voicing demands for action and instead exhibit body language that suggests their next moves. Look for a physical stance that anticipates violence, such as a fighting position, making a fist or looking for objects that can be used as a weapons. At this point, any object that is heavy and/or can be thrown may be used as a weapon against prehospital providers. How the prehospital provider responds to these individuals greatly determines the next step. If a provider responds with a tone of anger, aggression or threat, then the individual is more likely to attack.

A patient can give several other clues that they are physically threatening. Monitor for:

• Sudden movements toward the prehospital provider
• Muscle group tightening
• Twitching facial muscles
• Darting eye movement
• Fixed stare
• Shifting balance
• Increased voice volume
• Rapid breathing

Phase 6: Physically violent

Once individuals become physically violent de-escalation attempts stop, and personal protection and self-defense prevail. For prehospital providers it is essential to not only get out of and end the situation quickly and safely, but whenever practical there is also a duty to attempt to prevent injury to the aggressive individual as well. This is a difficult paradigm to accept at times, but personal safety is always first. However, what this paradigm suggests is that the least invasive restraint methods need to be used, especially when physical force is used. The remainder of this article focuses on defusing techniques to prevent individuals from entering phase 6.

Defusing Techniques

Whenever caring for an individual it is not only important to return patients to a calm and non-threatening state, it is also imperative not to do anything that may escalate the patients’ response. The best way to prevent escalation is to always ensure the patient is being given the very best medical care possible at that time; respect the patient’s dignity, including religious practices; listen to the concerns of the patient and their family; and always be compassionate and caring. While this seems simple on the surface, maintaining a non-judgmental position for different religious and personal beliefs, and different life-situations, can sometimes be a challenge.

Verbally agitated patients can often be calmed by following a few simple steps. One of the first and most important steps in diffusing any patient is to listen to them. There is a distinct difference between hearing and listening to a patient. Listening requires letting the patient finish their train of thought, acknowledging their feelings by not interjecting our own beliefs or thoughts, and reaffirming, “If I understand you correctly, this event makes you feel ___.” While listening, avoid phrases such as “Well I think,” or “If I were in your shoes,” as these have the potential to escalate the situation. Also make sure to respect the individual. Keep in mind how you would want to feel if you were in their shoes, after the event were over. Consider how the individual will feel once the event has passed. Remember that the individual is having difficulty dealing with the situation and that talking down to them is likely to deflate their self-esteem and may make the situation worse.

Avoid giving orders. Dictating what an individual must do, particularly in a condescending manner, is more likely to fuel the fire than it is to calm. Instead, offer the individual an opportunity to share what options they see in the situation and ask them what their desired outcome might be. Once they share options, it might be appropriate to share how you can offer support in each of the options (or none as the case may be).

As tempting as it may become, avoid developing a threatening body posture when an individual becomes verbally hostile. Stay calm and relaxed and remain at eye level with the individual. If they are sitting, sit so you can look directly at them, not down on them. When standing, maintain a non-threatening position by keeping your hands where they can be seen, shoulders relaxed and speaking softly. Further, keep a respectful distance. A safe buffer zone for aggressive patients is six feet (Wilder and Sorensen), however this distance may be decreased or increased as situations change. While talking to the patient, continue to listen and let them verbalize their concerns. At an appropriate time offer choices to the verbally hostile patient. Avoid directions and instructions, and base the options on the patient’s actual concerns. Do not include threats such as, “I will have to call the police,” in choices.

Should an individual exhibit verbally threatening behavior, remain steadfastly aware that the situation is rapidly changing and de-escalation will be more difficult. Acting carefully can help prevent the situation from worsening in the first place. Maintain eye contact without staring. Look at the patient in a manner that lets them know you are there for them, but is not threatening. Just keep a soft facial expression that doesn’t show displeasure, anger or hostility. One trick is to focus on the patient’s left eye rather than both eyes (Wilder and Sorensen). Also, watching the patient’s eyes prevents your back from being turned on the patient and allows you to monitor for signs the patient is beginning to look for weapons.

Avoid making the patient feeling trapped. When someone feels trapped, they feel like they’ve lost control or someone else is trying to control them. An individual may feel physically or psychologically trapped. Physical trapping occurs when an exit is blocked, they are backed into a corner or they believe they are being restrained. Restraint here can be perceived from a gesture as simple as placing a hand on a shoulder. To avoid this always gain permission before touching the patient, and tell them exactly what you plan to do. Psychological trapping can occur when a patient is left believing that they only have two options: fight or follow your command. To avoid psychological trapping maintain choices as positives and let the patient believe the decision is theirs to make.

Patients that are physically threatening are dangerous and it’s important to recognize when this critical point has been reached. A physical response may be needed but is beyond the scope of this article. However, while interacting with these patients remember to maintain a non-threatening posture and remain calm. Look for a safe withdrawal path and do not allow the patient to get between you and the exit. And if you have not been trained in defensive tactics, withdraw from the scene at this time.

Potentially Threatening Actions by EMS Providers

• Talking down to the patient
• Talking loudly
• Standing over them
• Staring down
• Limiting a patient’s options
• Trapping the patient
• Arguing
• Violating personal space
• Grabbing the patient

Non-traditional Weapons Against EMS Providers

• Ash trays
• Pens and pencils
• Lamps
• Extension cords
• Alcohol bottles
• EMS equipment
• Wall hangings (including pictures)
• Canes and walkers

References
1. Grange JT, Corbett SW. Violence against emergency medical services personnel. Pre Emerg Care 6(2): 186-90. 2002.

2. Occupational Health and Safety Administration. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. https://www.osha.gov/Publications/OSHA3148/osha3148.html

3. Wilder SS, Sorensen C. Essentials of Aggression Management in Health Care. Upper Saddle River, NJ: Prentice Hall, 2001.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Ministry Spirit Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.

Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California San Francisco and a former New York City paramedic for 10 years. Contact him at sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is the EMS education manager for the San Francisco Paramedic Association in San Francisco, CA, where he is responsible for the original and continuing education of EMTs and paramedics. Scott has worked on numerous publications as an editor, contributing author and author, and enjoys presenting on both clinical and EMS educator topics. Contact him at scottrsnyder@me.com.