Tactics for Combative Patients

By Michael W. Weaver

The call comes in as “Police on-scene request medic evaluation for bizarre behavior.” On fire department arrival, the patient becomes agitated, and his behavior deteriorates into open aggressiveness toward responders. Did police leave after fire department arrival? Was a path of egress left open? Is the patient intent on harm, or does he just want to run away? Oftentimes, this scenario involves a physical confrontation.

Emergency responders surround the patient, who is kicking, screaming, and trying to bite, while responders try to control him and gain his cooperation. After extreme effort, responders bring order to the chaos. They apply restraints, start IVs, give medications, and transport to the nearest Emergency Department (ED). Post call involves completing a patient report and putting the unit back in service.

On return to the station, personnel file injury/exposure reports, and work returns to normal. The crews, once again, survive their most recent “near miss.” Near miss? Yes, near miss! The brief series of events described above is the combative patient call. The combative patient represents a real hazard for emergency responders. He can cause debilitating injury, resulting in lost work and wages. He can be injured or die while in fire department care, potentially triggering a lawsuit and its attendant time demands. This does not take into consideration the negative impact such actions will have on co-workers or the respective employer, be it private or public.

SIGNS AND SYMPTOMS

The differential diagnosis for the combative patient can be, but is not limited to, the following: hypoglycemia, drug ingestion, head injury, carbon monoxide poisoning, psychosis/mental illness, and excited delirium. Excited delirium deserves special mention: It is believed that excited delirium is a true medical emergency with references going back as far as 1849 in insane asylums. Doctor Luther V. Bell described the condition as follows: acute onset of symptoms, delirium, extreme agitation, violence with no disposition to yield to overwhelming force, and the need to use physical restraint. Sudden, unexplained death was often associated with individuals presenting with these signs and symptoms. Today, very few cases occur in “managed care” settings. Unfortunately, not everyone in need of this care receives it.

Traditionally, police have been first to respond to individuals who possibly are in this condition because of violent behavior. With the proliferation of cell phones, emergency responders sometimes arrive prior to the point where the patient becomes violent. The patient may be in a state of delirium or agitation, with violence soon to follow. Police involve emergency responders sooner in the sequence of events to provide medical aid. This can result in emergency responders’ assisting in the restraint of the violent individual, thus putting them in the mix of witnesses involved in any inquest or other court proceedings that might follow an in-custody death.

The goal is to ensure responder safety in an unsafe environment by teaching early recognition, communication, scene command, body mechanics, and restraint techniques specific for the emergency responder.

MANAGING THE PATIENT

To provide meaningful management of the combative patient and maintain crew safety, specific criteria must be met.

Egress

Regardless of what we may be responding to, we must maintain our way out. This may sound overly dramatic, but think about it. Fatalities occur at fires because egress was compromised, either because of disorientation or obstacles. Without a clear path to the apparatus, you cannot transport patients. Sometimes you have to clear paths and remove doors. Everything is not OK until you have the means to leave. Keep that in mind as you respond to the next call.

Early Recognition

It is very easy to let tunnel vision focus all of your attention on the “medical emergency” and let the rest of the world disappear. You have a responsibility to your crew, your family, and yourself to not allow this to happen. Any call can produce a combative patient, whether it is the original patient you were dispatched to, an individual who wanders onto the scene, or the family member who hasn’t been taking his medication.

We spend our entire careers making observations and cataloging them into our brain for future use. We know what to look for to determine if our patient is emergent or stable. We do this automatically, either by observation alone or by a combination of questions and general impressions. We process the information, retaining what we need and discarding what we don’t. Early recognition begins with dispatch followed by scene size-up.

Not all combative patients are deranged and out of their heads—that would be too easy. Note the patient’s appearance: Is he calm or agitated, vocal or subdued? Does he have a defensive stance, with teeth and knuckles clinched? Does he seem to have a problem focusing on you? Is he communicating normally, or is he incomprehensible?

Remember, the patient’s disposition can change quickly, so be prepared. Possible signs to watch for include inappropriate clothing for environmental conditions, bizarre behavior, incomprehensible communication, animal noises, communicating with “imaginary” adversaries, and fear out of proportion to present events.

Communication

Although there are several levels of communication specific to the emergency responder, we all need to be able to call for backup. Be sure to consider the proximity of fellow emergency responders. Can they arrive at your location in a timely manner if you need additional resources?

Do not leave your radio if you exit your rig. Mobile radios have become the emergency responder’s lifeline. Depending on locale, a dispatch center monitors all radio traffic and allocates the appropriate resources. Common terminology allows effective communication without confusion. Does dispatch know that “code red” means every available police officer report to the location stat, guns drawn in the ready position? Without the use of common terminology, you may get a single unit, in no special hurry, unprepared for the circumstances. This represents a huge disparity that is not uncommon when multiple disciplines are at the scene.

Equipment

There are a myriad of restraints on the market today. Few, if any, are specific to the needs of emergency responders. Most are designed for in-hospital care or facilities specializing in mental health crises. None are suitable to control the combative patient in the emergent setting without being augmented by personnel or additional straps. The few restraints that appear to be adequate for our use are accompanied by documents that prohibit their use with “combative individuals.” This, of course, is to limit liability from the misuse of their product.

I prefer to use padded limb restraints, with straps long enough to secure with overhand knots. You must immobilize the patient before beginning treatment. You can accomplish this by securing the patient to the backboard, first with restraints to the wrists and ankles, then with at least four backboard straps crisscrossing the patient (photo 1). Limb restraints should be extremely tough, provide adequate cushion for application directly to skin, and have extremely long straps. This helps secure the patient to the backboard and enables you to tie knots farther away from the patient’s hands. With the patient secured in this manner, you can transport face up. Consider all restraints you apply in the field to be for short-term use only—to facilitate treatment.


1. Photos by Honorary Everett Firefighter Jim Leo in memoriam
Click here to enlarge image

Using the backboard enables you to restrain and immobilize the patient only one time, negating the need to remove the restraints to move the patient to the hospital bed. In addition to being safer for the emergency responder, this facilitates safe treatment—i.e., clearing emesis via a “backboard roll”—and minimizes conflict. Additional pieces of equipment to consider are the C-collar and a “spit-sock.”

Training

Practice verbal and nonverbal nonaggressive communication—palms up, no sudden movements, and calm instructions as to what you want the patient to do. Depending on the circumstances at this dynamic scene, maintain this communication during the entire patient contact.

Body language plays a role in the communication process as well. Remember to keep the patient at ease and give him space so he does not feel trapped. It is natural for us to assume aggressive postures and project authority with our voice during a conflict. This can be overcome with proper training and practice. Study video to help visualize the correct procedures to take, and practice until you become proficient.

It is best to place the patient in a position where he cannot use his strength effectively. If the patient is supine, you can control his arms much more effectively if you keep his arms straight and at a slightly greater than 90° angle to his body (photo 2). Concentrate the weight of your torso over the patient’s arm and keep his palm to the floor; this way, the patient will not be able to lift you. The same applies if the patient is prone. Once you have secured him to the backboard, you can roll him safely onto his back and apply the backboard straps (photo 3).


2.
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3.
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There is much concern about the patient being face down. When done properly, this is a very brief event. It poses less risk to the patient and crew than trying to “flip” the individual over before restraint.

The restraint techniques law enforcement agencies and state correctional facilities use in Washington State, especially in the management of juvenile inmates, have helped minimize injury to staff/officers and inmates/suspects. These techniques, adapted to and made compatible with the equipment and training specific to emergency responders, can help make us more safe and efficient. Their purpose, when used in conjunction with body mechanics, is to facilitate control and minimize injury. The greater the struggle on the part of a combative individual, the more force you must apply to gain control. This may cause pain, but it is necessary.

Inappropriate or excessive force can result in injury to the patient. Professional instruction minimizes the chances of improper use and abuse of body mechanics and restraint techniques.

Adequate Number of Trained Personnel

An acceptable minimum of trained personnel would start at six—four to five for control, with an additional two to three for restraint. More often than not, you will have three on-scene with medics responding. If the patient becomes violent, egress is unsafe, and deescalation fails, attempt to control the patient with the resources at hand. With training, three personnel can acquire and maintain control long enough for incoming units to respond for aid.

Communicate the circumstances to hasten the response of incoming crews and to let them mentally prepare for the task. Dispatch can alert law enforcement, assign additional crews, and have equipment brought to the scene.

On arrival, the second crew should go directly to the patient. This saves time and provides much-needed aid to the first on-scene crew. As the scene commander maintains communication with the patient, the crew is controlling the limbs of the combative patient. The scene commander may control the head to prevent biting.

As additional emergency responders arrive, they can bring the soft restraints, backboard straps, and backboard to the scene. As one crew controls the patient, the extra personnel will apply the restraints. The arrival of law enforcement, depending on protocols, jurisdictions, and staffing, may allow emergency responders to disengage and observe from a safe distance. If there is a medical emergency and the patient is still combative, you must package the patient for transport to the ED.

A Plan

Individuals have died while in police custody and while receiving care from emergency responders following a combative state. Prior planning between law enforcement and emergency responders will help lessen the chances of this happening. Keep in mind that we are in the public eye and our actions on-scene could be the latest video entry on a popular Web site. If the circumstances permit, quickly restraining the patient and providing rapid transport will lessen exposure and expedite treatment. The standard O2, IV, ECG, and blood glucose with vitals should be the first order of business when placing the patient in the transport unit. Get medical control involved. A physician may be needed to authorize the restraint and further treatment of the patient.

Do not forget: The patient must be searched for weapons and sharps. This will likely be done after the patient is restrained and preferably by law enforcement.

Putting the patient on the backboard facilitates a quick head to toe and allows constant monitoring of his condition. If the patient continues to fight, consider sedation in accordance with local protocols. Remember the differential diagnosis of altered mental states, and treat as necessary. Monitor circulation to the extremities. With few exceptions (such as hypoglycemia), the restraints should stay in place until removed by hospital staff.

TRAIN FOR INFREQUENT INCIDENTS

With few exceptions, firefighters train for fighting fire much more often than they actually fight fire. This makes the firefighter more safe and effective at a task that he would have little experience with otherwise. The danger of fighting fires is out of proportion to the frequency at which they occur. The same logic should apply to the combative patient.

Before restraining the combative patient, ask the following questions: Is there a medical emergency that requires treatment? After initial contact, can we safely observe the patient from a distance until law enforcement officers arrive? Is the decision to restrain based on safety for the patient and crew or made out of anger? On whose authority are we acting? Could the techniques used to restrain be considered a type of lethal force? Can I justify my actions if someone is badly hurt?

Local laws and protocols can answer most, but not all, of these questions. Early recognition and maintaining paths of egress give us options. Restraint of the combative patient should be an option only when all other avenues have been exhausted or the emergency responders’ personal safety is compromised if the patient is not restrained. The crew’s safety comes first, followed by efforts to maintain patient dignity. Always show respect and professionalism. Law enforcement officers should be the first choice when dealing with physically aggressive individuals. Consider developing common terminology, protocols, and training with your local law enforcement agencies.

REFERENCES

1. Bell, LV, “On a form of disease resembling some advanced stages of mania and fever,” American Journal of Insanity, 1849: 6:97-127.

2. DiMaio TG, JM DiMaio. Excited Delirium Syndrome: Cause of Death and Prevention. Boca Raton, FL: CRC Press, 2005.

3. Kupas DF, GC Wydro. “Patient Restraint in Emergency Medical Services Systems - Position Paper of the National Association of EMS Physicians,” Prehospital Emergency Care. 2002; 6: 340-345.

4. McEvoy, M, “EMS Response to Behavioral Emergencies and Restraints,” Fire Engineering, December 2001.

Michael W. Weaver is a firefighter/paramedic for and a 12-year veteran of the Everett (WA) Fire Department. He is an instructor in safe handling of combative patients and a competency based training (CBT) instructor for the department. Weaver served for four years in the U.S. Army, assigned to the Second Ranger Battalion and a Long Range Reconnaissance Unit.

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