# Management of a potentially aggressive patient on PCP.



## NYMedic828 (Jan 2, 2012)

Hey All, somewhat new here thought id start my first thread.

I'm a new medic in NY, and had a question regarding a call that occurred at my volunteer department. I was not at the call, but a brief story was told to me from a few people. 

Basically, it came in as a seizure at a local restaurant. When the crew got there, they had an agitated patient who was supposedly trying to smash the urinals in the bathroom off the walls with his bare hands. (and succeeding)

Now, in my volunteer area, the police department paid ambulance usually handle any EDP/Drunk/Drug calls unless a direct call to the fire department is made. In my paid area in the city, I am far more likely to run into this again. The only reason it occurred on a volunteer level here, is because it was reported as a seizure.

So, someone I guess at some point came to the conclusion that this man is either an EDP, or on some form of drug such as PCP.

I have no idea as to how cooperative the patient was, but apparently the paramedic on scene was able to successfully administer IN Narcan.

This is where my question arises. For a patient who is extremely agitated, no respiratory depression, and is a potential danger to himself and others, was narcan really the right move? I asked the medic who did it, (who is by no means experienced) and he figured it won't hurt him, so why not try it. 

From what I know, PCP causes the psychosis at lower doses, and at high enough doses can cause sedation/analgesia and ultimately seizure activity.

That being said, my argument was that the medic should have gotten on the phone with the medical director, given a convincing story and attempted to get approval for a discretionary of 10mg of versed IM or IN. (I do not know if IM would have been safe)

I figured that whether the patient be an EDP or on psychosis inducing drugs, midazolam would not only sedate the patient, making further assessment and transport easier but also ultimately preventing any further harm to the patient or providers.

Could anyone explain what the right move is?

Little side note, in my volunteer region, Controlled Substances are very rare. We are one of maybe 5 departments out of 72 that carry them. We carry Valium, Versed and Morphine. There are absolutely no standing orders in the region for the use of them, and the likelyhood of the medical director approving such a rare occurrence without a dynamite presentation is very minimal. In the city where I work, use of controlled substances is pretty routine and more leniency is given to the providers.


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## bigbaldguy (Jan 2, 2012)

If the narcan helped it probably wasn't pcp.


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## NYMedic828 (Jan 2, 2012)

bigbaldguy said:


> If the narcan helped it probably wasn't pcp.



Sorry forgot to point out that the narcan had 0 effect.


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## rmabrey (Jan 2, 2012)

Not saying its right or wrong, but in my system he probably would have gotten Ativan IM. It's not really supposed to be used for violent patients but since the call came out as a seizure it could be justified. 

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## usalsfyre (Jan 3, 2012)

Narcan was absolutely pointless, and did have the potential to harm the patient to boot.

See all the benzodiazepines in your narc box? Get ready, because your about to use them...

Failure to properly sedate this guy is how these presentations end up dead.


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## Handsome Robb (Jan 3, 2012)

rmabrey said:


> Not saying its right or wrong, but in my system he probably would have gotten Ativan IM. It's not really supposed to be used for violent patients but since the call came out as a seizure it could be justified.
> 
> Sent from my Desire HD using Tapatalk



Why would you have to justify it?

He's extremely agitated and a danger to himself and the crew. We'd get reviewed for not chemically restraining this guy. 

OP - There are 0 indications for narcan in this situation. We can't just run around trialing drugs on patients because "it can't hurt"


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## Cawolf86 (Jan 3, 2012)

Contacting PD and applying the liberal use of the benzodiazepines you carry. Here we would stage for PD and then chemically sedate with IN or IM Versed.

Edit - I would say that Narcan was borderline negligent. What was he hoping to accomplish? Say he had been using opiates with his PCP/Coke/meth. You take out the sedating effects of the opiates and your overdose is made worse. More combative and higher sympathetic stimulation.


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## usalsfyre (Jan 3, 2012)

NVRob said:


> Why would you have to justify it?
> 
> He's extremely agitated and a danger to himself and the crew. We'd get reviewed for not chemically restraining this guy.
> 
> OP - There are 0 indications for narcan in this situation. We can't just run around trialing drugs on patients because "it can't hurt"



There are systems out there that are EXTREMELY scared of narcotics and benzodiazepines as a culture, despite the fact they're some of the safer drugs we carry.


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## Handsome Robb (Jan 3, 2012)

usalsfyre said:


> There are systems out there that are EXTREMELY scared of narcotics and benzodiazepines as a culture, despite the fact they're some of the safer drugs we carry.



Geeze...That's not fair to the crew or the patients. Scary to hear that.


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## rmabrey (Jan 3, 2012)

NVRob said:


> Why would you have to justify it?
> 
> He's extremely agitated and a danger to himself and the crew. We'd get reviewed for not chemically restraining this guy.
> 
> OP - There are 0 indications for narcan in this situation. We can't just run around trialing drugs on patients because "it can't hurt"



We are steered far away from chemical sedation........yet we are free to pretty much tube anyone we want 


Although we can call and get orders for pretty much anything. Docs here don't question much. 
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## usalsfyre (Jan 3, 2012)

rmabrey said:


> We are steered far away from chemical sedation........yet we are free to pretty much tube anyone we want
> 
> Sent from my Desire HD using Tapatalk



Because the Versed demon will come take your airway away!!!
/sarcasm


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## Handsome Robb (Jan 3, 2012)

rmabrey said:


> Although we can call and get orders for pretty much anything. Docs here don't question much.



I feel like you could call OLMD and hold the phone up so they could hear and you'd get orders in this situation :rofl:

Also, Cawolf brings up a very good point about the possibility of polypharm and what problems you could cause by reversing any opiates that may be onboard along with the stimulants.


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## rmabrey (Jan 3, 2012)

usalsfyre said:


> Because the Versed demon will come take your airway away!!!
> /sarcasm



This does make me realize something I never thought of, our protocols are so liberal with Intubation, yet chemical sedation is a no no. So we can give versed to tube them when a BVM is probably sufficient enough, but we can't knock them down for being a jerk :thumbdown:

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## Handsome Robb (Jan 3, 2012)

usalsfyre said:


> Because the Versed demon will come take your airway away!!!
> /sarcasm



You and I exchanged some pms about versed because I was afraid of the very same thing.

Then I watched my partner give a guy 10 mgs and the hospital give 5 mgs of Ativan and 10 mgs of valium to the same pt and he was still kicking *** and taking names. 


It's not so intimidating anymore. Although he did have some sort of drugs on board.


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## usalsfyre (Jan 3, 2012)

I gave an 8 year old close to 20mgs of it one day (granted he was intubated). His seizure never broke for more than 5 minutes. 

I fear hypotension way more than airway loss.

Remember, in the absence of other compounds that activate GABA receptors the effects of benzos are self-limiting by your endogenous GABA.


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## Shishkabob (Jan 3, 2012)

I've had one patient high on PCP.  It took 11 of us 15 minutes to finally gain control.  That's 11 fully grown adults.  TASERs, pepper spray, and other options at PD disposal will not work.  It will be a hard fight.  You WILL have to go hands on.  You will probably get hurt in some fashion, be it scratches, bruises, etc.    


They don't exaggerate when they say they have super human strength.  Add on top of that they are hallucinating and potentially think you're trying to kill them.  They'll probably be naked or close to it, covered in body fluids and potentially blood.




What do you do?  Prepare for the fight of your life, overwhelm them with a crap load of people, give Benzos (going to take most, if not all, that you have if they even have any effect),  control each appendage with ATLEAST 2 people, fight fight fight till you get all limbs restrained, and prepare for sudden cardiac arrest.

Oh, and enjoy moving them from the cot to the hospital bed... and if a nurse goes to remove the restraints, give one warning to try to stop them, then back out of the room quickly, unless you're looking forward to round 2.


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## Handsome Robb (Jan 3, 2012)

Linuss said:


> I've had one patient high on PCP.  It took 11 of us 15 minutes to finally gain control.  That's 11 fully grown adults.  TASERs, pepper spray, and other options at PD disposal will not work.  It will be a hard fight.  You WILL have to go hands on.  You will probably get hurt in some fashion, be it scratches, bruises, etc.
> 
> 
> They don't exaggerate when they say they have super human strength.  Add on top of that they are hallucinating and potentially think you're trying to kill them.  They'll probably be naked or close to it, covered in body fluids and potentially blood.
> ...


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## MedicPatriot (Jan 3, 2012)

I have had plenty of emotionally ill angry people, but have yet to experience anyone on PCP or similar drugs being combative.

Our protocols for chemical restraint are 5mg Versed & 5mg Haldol combo, both of which you must consult for if used as chemical restraint (hopefully will change). Now the funny part is that in my county only the supervisor ALS chase cars carry Haldol. Whatever the reason is, which just may be to save money for all I know, we would have to call for one and wait 7-10 minutes to get it. Now our protocols do allow for you to "do what ya gotta do" if youfind it extremely necessary to save life, so I COULD get away without medical consult but then you have to fill out a bunch of "WHY" forms.

Now on to my real question. Is 5mg IM versed typically enough for a grown man that is combative? I'm thinking maybe...but for a combative person on PCP or other drugs I have a feeling the answer is heck no. Therefore, my question is should I just consult right for the 10mg IM? I also would be asking for 50mg Benadryl as well.


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## usalsfyre (Jan 3, 2012)

Consult for "as much as it takes". 10mgs may not touch this guy, I've heard of 30 and up being used.


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## MedicPatriot (Jan 3, 2012)

usalsfyre said:


> Consult for "as much as it takes". 10mgs may not touch this guy, I've heard of 30 and up being used.



That sucks that we only carry two vials of 5mg each, but I guess there are always chase cars and more medic units if needed.


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## NYMedic828 (Jan 3, 2012)

Thanks for the great answers.

Unfortunately I missed the call, but from what u heard benzos really sounded more justified.

Unfortunately we are one of those scared systems. It is a system of mostly inexperienced people and to get something like sedation, which is almost never done, is unfortunately a long shot.


In the city they would give it to me no problem.


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## DrParasite (Jan 3, 2012)

NYMedic828 said:


> Basically, it came in as a seizure at a local restaurant. When the crew got there, they had an agitated patient who was supposedly trying to smash the urinals in the bathroom off the walls with his bare hands. (and succeeding)


First thing, get everyone away from the bathroom.  Second thing, no one goes near the guy until PD gets there with enough resources to contain and restrain the individual.  Let him destroy the urinals, the mirrors, and the walls.  Either way, it's a violent unsafe scene, and EMS should NOT be getting involved until PD has restrained the guy.  EMS should NOT be getting hurt, should not be taking punches or kicks from this guy.

Let the cops do there thing.  if they need more people, let them call more cops.  

I've dealt with quite a few PCP users, usually they are 250 lbs, naked or nearly naked, and very violent.  I've seen 6 city cops restraining a guy who was in handcuffs, and he was still tossing them around like they were rag dolls.  These guys are not to be messed with.

Once the cops have him secured, and the scene is made safe, than maybe chemical sedation is an alternative to look for.  and make sure security/PD at the receiving hospital is ready to receive him.


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## Melclin (Jan 3, 2012)

NVRob said:


> You and I exchanged some pms about versed because I was afraid of the very same thing.
> 
> Then I watched my partner give a guy 10 mgs and the hospital give 5 mgs of Ativan and 10 mgs of valium to the same pt and he was still kicking *** and taking names.
> 
> ...



Not that I disagree but midaz can be a fraction unpredictable. And comorbities matter. In my short time I've seen 20mg render a 40kg cranky teenager ready for a light nap and 1mg render a 110kg bloke almost tubeable. 

I can see why clinical oversight types might wanna scare the lowest common denominator into a little respect for the drug.


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## Melclin (Jan 3, 2012)

DrParasite said:


> First thing, get everyone away from the bathroom.  Second thing, no one goes near the guy until PD gets there with enough resources to contain and restrain the individual.  Let him destroy the urinals, the mirrors, and the walls.  Either way, it's a violent unsafe scene, and EMS should NOT be getting involved until PD has restrained the guy.  EMS should NOT be getting hurt, should not be taking punches or kicks from this guy.
> 
> Let the cops do there thing.  if they need more people, let them call more cops.
> 
> ...



This ^^^

You'd be flat out trying to get me outa the ambulance.


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## Cawolf86 (Jan 3, 2012)

As an aside to the thread topic - say your first line drug was versed. What would your preferred initial route be? IM vs IN? Assuming IV access unobtainable due to the patient's condition. I know in theory IN should have a faster onset but in my personal, non-scientific experience IN versed has not been as effective as IM. Thoughts? Sorry if too OT for thread.


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## the_negro_puppy (Jan 3, 2012)

We carry these to tranquilize any dangerous animals (crocodiles etc) that we come across. We recently had protocols changed to allows us to use them on psychotic/overdose patients.


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## Akulahawk (Jan 3, 2012)

usalsfyre said:


> I gave an 8 year old close to 20mgs of it one day (granted he was intubated). His seizure never broke for more than 5 minutes.
> 
> I fear hypotension way more than airway loss.
> 
> Remember, in the absence of other compounds that activate GABA receptors the effects of benzos are self-limiting by your endogenous GABA.


A few years ago, I ended up giving something like 10 mg (IIRC, it was 2 mg doses) Lorazepam to a seizing patient. It would stop his physical seizure for about 10 min (usually less) and then he'd start right back up again. About the only benzo that worked on him was diazepam - and that was good for about an hour or so. This was about 10 years ago, so the exact doses and amounts I gave are a bit hazy... but what was impressed upon me was the need to have more than one option available, in the event what you're giving isn't working. And yes, the amount of lorazepam we gave him was quite a bit... and surprised all of us that he was still going...


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## NYMedic828 (Jan 3, 2012)

Cawolf86 said:


> As an aside to the thread topic - say your first line drug was versed. What would your preferred initial route be? IM vs IN? Assuming IV access unobtainable due to the patient's condition. I know in theory IN should have a faster onset but in my personal, non-scientific experience IN versed has not been as effective as IM. Thoughts? Sorry if too OT for thread.



I figure that less needles with a combative patient, is a safer approach.

If the guy is that aggressive, and an arm breaks free that needle might end up in you awfully fast.


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## flanaganj (Jan 3, 2012)

I would have PD restrain the patient, then 5mg haldol and 2mg ativan in the same syringe im. Then 50mg benadryl im. If after ten minutes he is still a danger to ME and himself, another 5 and 2. All standing order. If that doesn't work call medcon and get orders for versed on top of that. 

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## NYMedic828 (Jan 3, 2012)

flanaganj said:


> I would have PD restrain the patient, then 5mg haldol and 2mg ativan in the same syringe im. Then 50mg benadryl im. If after ten minutes he is still a danger to ME and himself, another 5 and 2. All standing order. If that doesn't work call medcon and get orders for versed on top of that.
> 
> Sent from my Nexus S 4G using Tapatalk




We don't carry Haldol or Lorazepam.

Some agencies carry Ativan instead of Versed, very rarely do they have both


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## abckidsmom (Jan 3, 2012)

usalsfyre said:


> Because the Versed demon will come take your airway away!!!
> /sarcasm



lol, I was talking to medical control not long ago and wanted to give Versed for a patient who had overdosed on something and was fighting and agitated.  (We have to get orders to use benzos for anything other than seizures.)  

The physician said, "I'm just worried about her airway if we end up oversedating her."  

I replied, "I am prepared to manage her airway, I stayed in a holiday inn express last night."

She said, "Oh, well, in that case...go ahead and give her the Versed."

The guys in the communications center met me at the back door of the ER with a high five.  They are sick of patients not getting the treatment they need because of worried doctors.


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## mycrofft (Jan 3, 2012)

PCP warriors will get drugs IM (backhanded into a thigh or buttock) or not at all, unless you can trap then in a closet and neb the entire volume.
Side issues with this sort of case:
1. Paradoxic effects to benzos: seen them. Ativan or Valium are like champagne to them.
2. Count MACE or pepper spray to list of chemicals likely on board. Now YOU can get a second-hand topical application as well, plus oily pper spray can make things like the floor get slick.
4. Valium is good. Less resp effects than some other drugs, works faster than some other benzos IM, does not have as short a half-life as some. However, I am not sure if it is doing anything but wallpapering the issue, it could make the pt simply more purposeful (a calm monster versus a panicked monster).
5. DOCUMENT! No matter what, you will be investigated for every booboo and death associated with this sort of pt and they are really subject to positional asphyxia, hyperthermia, and being trashed with batons.

Scene safety first and whatever you do, coordinate it.


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## usalsfyre (Jan 3, 2012)

NYMedic828 said:


> I figure that less needles with a combative patient, is a safer approach.
> 
> If the guy is that aggressive, and an arm breaks free that needle might end up in you awfully fast.



Yeah, but trapping a nostril in this patient can be pretty darn difficult.


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## mycrofft (Jan 3, 2012)

Just to be a wisearse, tell him it will get him high..?


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## NomadicMedic (Jan 3, 2012)

I had one of these the other night. I hate to fight, but there I was... me and two firefighters, rolling around on the floor with this whacked out dude. I'm a big guy, about 250, and the other two guys were also larger than the average bear and it took all three of us to get him to a position where I could atomize 5mg of Versed up his snout...

Then we jumped off and let him writhe around for a bit.

Shortly after that he became calm enough for us to wrap him up in a reeves and lug him out to the truck. 

I always vote for Versed in a MAD rather than IM. I would have wound up sticking one of the firefighters and that would have been no bueno.


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## Handsome Robb (Jan 3, 2012)

n7lxi said:


> I had one of these the other night. I hate to fight, but there I was... me and two firefighters, rolling around on the floor with this whacked out dude. *I'm a big guy, about 250*, and the other two guys were also larger than the average bear and it took all three of us to get him to a position where I could atomize 5mg of Versed up his snout....



This is what scares me a bit. I'm 155 and 5'8'' on a good day... I have no problem strength wise but in something like this leverage comes into play.


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## Cawolf86 (Jan 4, 2012)

So you would say the effect of 5mg Versed IN is similar to it's effects IM - with faster onset? Maybe it has just been the patient's I have used it on but I have found IN to not be as effective so far in my limited experience.


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## NomadicMedic (Jan 4, 2012)

Cawolf86 said:


> So you would say the effect of 5mg Versed IN is similar to it's effects IM - with faster onset? Maybe it has just been the patient's I have used it on but I have found IN to not be as effective so far in my limited experience.



I've only had limited experience with IN Versed. In the past I've been forced to use Droperidol or Haldol to manage this kind of stuff. However, I will say that the 5mg/1ml blasted up the nose of the guy who was fighting and trying to eat me worked pretty well in this case. I certainly didn't want to get anywhere near him with a needle.


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## usalsfyre (Jan 4, 2012)

Sometimes a quick "juke in, jab the thigh and head bob out" with the IM syringe and big (think 18ga through the clothes) can be safer and easier than the dog pile that ensues trying to get a nostril. The most effective way I found to get the node nose required at least one person per limb, one for the head, a "squirter" and possibly someone to lay on the torso. 

Either way once the meds in it's time to back off and let sleepy time kick in.


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## fast65 (Jan 4, 2012)

usalsfyre said:


> Consult for "as much as it takes". 10mgs may not touch this guy, I've heard of 30 and up being used.



It's times like this that I enjoy having orders for Versed at 0.3 mg/kg...or "titrate to desired effect".


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## DrParasite (Jan 4, 2012)

n7lxi said:


> I had one of these the other night. I hate to fight, but there I was... me and two firefighters, rolling around on the floor with this whacked out dude. I'm a big guy, about 250, and the other two guys were also larger than the average bear and it took all three of us to get him to a position where I could atomize 5mg of Versed up his snout...
> 
> Then we jumped off and let him writhe around for a bit.
> 
> Shortly after that he became calm enough for us to wrap him up in a reeves and lug him out to the truck.


you pull up with yourself and 2 FFs?  on a PCP overdose?  and you decide to go wrestling? with all due respect, screw that (I'd say something stronger, but the Mods would spank me).  

I stand by my original statement: stay in a safe location until PD arrive.  Let them handcuff him behind his back, leg shackles if needed.  than sit of the guy and stick something up his nose.

The only time I would even think about getting involved is if the PCPer was if he was actively harming another person.  not damaging property, not threatening, only if they are actively harming someone else.  let him smash everything to pieces, tell anyone he is threatening to both stay away and seek safety, and tell the FF's to stay where they are, and wait for law enforcement to arrive with enough resources to restrain him.

I'm 6'3", about 250, and have no problems tackling someone or going hands-on if needed.  but the FD have a saying: risk a little to save a little, risk a lot of save a lot, risk nothing to save nothing.  I'll risk my life to save a life (and fighting with a PCP guy can do that), but that's the extend of it.  Don't risk your life for simple property.

I am not going to risk my life to help a violent OD who did it to himself.  I'm going to wait for LEO to arrive to do their jobs, and once they have made it a safe scene, then I will do my EMS job.


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## NomadicMedic (Jan 4, 2012)

Well, it was bath salts, not PCP... But excited delirium is excited delirium. 

And I felt that all three of us could handle the situation. Between my experience in self defense and the size of the two other guys vs the size of the patient, I was relatively sure I could get him restrained enough to sedate him and then step back, which is what I did.


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## CANMAN (Jan 4, 2012)

It's all fun and games until the fella with excited delirum pulls out a knife while three people are trying to tackle him and stabs someone in the chest. Then your screw 

I agree with Dr. Parasite. Not my emergency therefore I am not getting injured trying to help until the threat is handled be people with firearms and kevlar.


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## usalsfyre (Jan 4, 2012)

If they're like the majority of excited delirium patients I've dealt with they'll be nude on your arrival, so a knife will be pretty obvious .

The issue with "letting PD handle it" is that approach all to often leads to sudden cardiac death. They need early sedation.


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## NomadicMedic (Jan 4, 2012)

Agreed. These PTs need to be sedated early to decease whatever is causing the erratic behavior, whether its chemical or phsycological or a mix of the two. 

Also, The guy was naked except for a pair of boxers and was about 150 lbs ... and I wear a Kevlar vest on the job.  FWIW, I don't feel I need to justify my actions to anyone here. I simply related an experience that I had recently, using nasal versed to sedate a PT with excited delirium. If you chose to wait for PD, that is your decision. I have waited for PD in the past, and I'm sure I will again when confronted with a situation that I am not comfortable with. 

But, I do appreciate your concern.


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## CANMAN (Jan 4, 2012)

N7lxi I wasn't trying to bust ur balls. I wish my service had vests because we certainly operate in some crappy areas.    With that being said and I am sure I am going to get flamed on for this so I have my suit on, if said jackass arrest because we didn't sedate him early enough and let leos have their way first that's not really my problem nor will I feel bad. I am in the business of helping people but certainly didn't tell numbnuts to poison his body with chemicals to make him act like an *** and get naked. I am not willing to get injured for some drug user, if i wanted to wrestle super human strength with weapons i would have been a bull rider or clown. I have worked a few arrest in my days......


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## NomadicMedic (Jan 4, 2012)

CANMAN13 said:


> N7lxi I wasn't trying to bust ur balls. I wish my service had vests because we certainly operate in some crappy areas.    With that being said and I am sure I am going to get flamed on for this so I have my suit on, if said jackass arrest because we didn't sedate him early enough and let leos have their way first that's not really my problem nor will I feel bad. I am in the business of helping people but certainly didn't tell numbnuts to poison his body with chemicals to make him act like an *** and get naked. I am not willing to get injured for some drug user, if i wanted to wrestle super human strength with weapons i would have been a bull rider or clown. I have worked a few arrest in my days......



Can...That's cool. You have your way of defining appropriate patient care, and I have mine. That’s just one of the great things about a forum like this. Different opinions. Your reply is certainly not worth flaming you over. If you chose not to help patients, nor do you feel any remorse about letting an LEO tune him up and then watching him arrest ...  well then, you go boy! 

And yeah, having a vest certainly doesn't make you superman, but it is nice extra protection.


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## DrParasite (Jan 5, 2012)

usalsfyre said:


> The issue with "letting PD handle it" is that approach all to often leads to sudden cardiac death. They need early sedation.


yeah and?  if their heart stops, they (should) pass out, no longer be violent, and you can do your job of saving their life.  They need early sedation, yes, but when the 150lb PCP guy throws your 200 lb body 10 feet in the air and get your hurt, than what?  That's why it's a scene safety and LEO matter until he is brought under control.





n7lxi said:


> Also, The guy was naked except for a pair of boxers and was about 150 lbs ... and I wear a Kevlar vest on the job.  FWIW, I don't feel I need to justify my actions to anyone here. I simply related an experience that I had recently, using nasal versed to sedate a PT with excited delirium.


most PCP guys tend to end up naked.  I remember being dispatched for the naked man running down the street... 6 cops later, he was in cuffs and on my stretcher.  I wasn't worried about weapons, I was worried how hard he was going to hit me if he got the chance. and your right, you don't have to justify your actions, but I don't want someone to say "well, if n7lxi did it so can I" and end up getting himself hurt on the job because he was thrown around like a rag doll by a PCPer.





n7lxi said:


> Can...That's cool. You have your way of defining appropriate patient care, and I have mine. That’s just one of the great things about a forum like this. Different opinions. Your reply is certainly not worth flaming you over. If you chose not to help patients, nor do you feel any remorse about letting an LEO tune him up and then watching him arrest ...  well then, you go boy!


To each his or her own I guess.

and PD shouldn't be tuning the guy up or arresting the patient.  They should be restraining the violent patient using the appropriate level of force, and placing him or her in protective custody.  and yes, I will feel no remorse about  letting PD do that before I even attempt to do anything.  they are training, PPEand it's not my job to get hurt wresting with a self induced PCP overdose patient


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## DrParasite (Jan 5, 2012)

CANMAN13 said:


> I am in the business of helping people but certainly didn't tell numbnuts to poison his body with chemicals to make him act like an *** and get naked.


hey now, lets not talk about alcohol like that....


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## Shishkabob (Jan 5, 2012)

Everyone has their views.  DrParasite won't help PD, that's fine, that's his decision.  Me?  I'm getting in there, for 2 reasons.  

First, I know if I was fighting a patient, they'd help me.  I'm not going to sit idly by as PD are wrestling, especially since this is the kind of person you need to overwhelm with people, not tools.

Second, it's my patient.  This person is being transported by me, guaranteed.  A PCP overdose or the like will ALWAYS be transported by EMS, never by PD.  Whatever happens to them is up to me, and will be left on me.  


This patient needs sedation, which can only be done by me, and will probably go in to cardiac arrest, which only I can run effectively.  If me getting in, getting some early sedation, is what prevents cardiac arrest, so be it.


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## mycrofft (Jan 5, 2012)

"Sedagive?! SEDAGIVE??!!!"


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## DrParasite (Jan 5, 2012)

Linuss said:


> Everyone has their views.  DrParasite won't help PD, that's fine, that's his decision.  Me?  I'm getting in there, for 2 reasons.


I think you misunderstood me.  I didn't say I won't help PD.  I said it's a PD matter, and PD should use their resources to mitigate the situation.  I HAVE helped PD when they needed extra hands/light wrestling with a patient, and would do so again.  

But no one should think that 2 PD officers and 2 EMTs and 2 Paramedics is the same as 4-6 PD officers, especially when dealing with a PCP overdose.  Otherwise all you will get are 2 officers, as they will assume the EMTs and Medics will be the extra muscle, instead of the 4 to 6 that you need.  PD should have the appropriate manpower to mitigate the threat.


Linuss said:


> First, I know if I was fighting a patient, they'd help me.  I'm not going to sit idly by as PD are wrestling, especially since this is the kind of person you need to overwhelm with people, not tools.


with all due respect, it is their job to enter the unsafe scenes and make them safe. that's in their job description.  That's why if you have two idiots beating the crap out of each other, it's the job of PD to separate them, not EMS, and once they are separated, EMS can treat the injuries.

the patient needs to be restrained using tools (generally handcuffs), to the point where you can treat him and not having the injured party injure you.


Linuss said:


> Second, it's my patient.  This person is being transported by me, guaranteed.  A PCP overdose or the like will ALWAYS be transported by EMS, never by PD.  Whatever happens to them is up to me, and will be left on me.


not disagreeing with you, but just because handcuffs are applied by PD doesn't mean they are under arrest or being transported in a patrol car.  You are still going to be treating and transporting the patient.





Linuss said:


> This patient needs sedation, which can only be done by me, and will probably go in to cardiac arrest, which only I can run effectively.  If me getting in, getting some early sedation, is what prevents cardiac arrest, so be it.


I agree, and I agree.  but if you get  hurt while attempting to sedate the guy, and are no longer able to treat the cardiac arrest, than what good do you become to the patient?


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## Maine iac (Jan 20, 2012)

Go big or go home.

Pretty useful podcast here about this subject:  [edit: I guess since I am new I can't post a link... But google EMCrit's podcast on the Art of Human Bondage]

The service I did my training time at had Versed, Haldol, and ketamine, and most medics carried handcuffs (as well as vests). I've pushed 10mg of Haldol on a coked out fellow, and right after he calmed down for a second he was physically restrained to the cot. He was with it mentally and wanted to help us so he tried to stay calm, but we were fully ready to go versed if need be. 

I've also had the Ketamine ready to go but we got to the ED before we needed to push it. He was being a little too disruptive in the trauma room and he was RSIed before we even had the ambulance clean again.

With these patients you are doing a disservice to them if they are not being fully controlled. While it is case by case and I don't think every crazy person should be tubed, they NEED to be controlled.

There are some pretty good case studies about excited delerium out there and these guys just drop dead if it is bad enough. If my service did not allow me access to chemical restraints I would be talking to my med director pretty quickly.


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## NYMedic828 (Jan 20, 2012)

Maine iac said:


> Go big or go home.
> 
> Pretty useful podcast here about this subject:  [edit: I guess since I am new I can't post a link... But google EMCrit's podcast on the Art of Human Bondage]
> 
> ...



Thats interesting they carried versed and not valium. Usually valium seems to be the primary choice for agencies that don't carry a more diverse benzo supply.

and isnt Valium the primary choice for cocaine OD but I guess IV Versed would have nearly the same effects with a shorter duration of action.


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## NomadicMedic (Jan 20, 2012)

Maine iac said:


> The service I did my training time at had Versed, Haldol, and ketamine, and most medics carried handcuffs (as well as vests). I've pushed 10mg of Haldol on a coked out fellow, and right after he calmed down for a second he was physically restrained to the cot. He was with it mentally and wanted to help us so he tried to stay calm, but we were fully ready to go versed if need be.



That’s very interesting. I was taught that anytime you use Haldol to sedate an amphetamine overdose, you need to use a benzo along with it. For instance, at a previous service, for suspected Cocaine ODs, we used 2 to 4mg of Valium with 10mg of Haldol. I was under the impression that the seizure threshold was dramatically lowered with the Haldol, and I seem to recall that Haldol alone for Cocaine or Amphetamine OD was frowned upon. At my current service, we go straight to the Versed.


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## NYMedic828 (Jan 20, 2012)

n7lxi said:


> That’s very interesting. I was taught that anytime you use Haldol to sedate an amphetamine overdose, you need to use a benzo along with it. For instance, at a previous service, for suspected Cocaine ODs, we used 2 to 4mg of Valium with 10mg of Haldol. I was under the impression that the seizure threshold was dramatically lowered with the Haldol, and I seem to recall that Haldol alone for Cocaine or Amphetamine OD was frowned upon. At my current service, we go straight to the Versed.



Do you guys have standing orders for the benzo on ODs?

We don't carry haloperidol in NYC unfortunately and our only standing order benzo is for seizures. 

To my knowledge haldol also has a high occurrence of dystonic reactions and many doctors give it with 25-50mg of benadryl.


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## CANMAN (Jan 20, 2012)

IMO Haldol is kinda a crappy med for "chemical restraint" in the field unless coupled with other meds for long term effect. The onset of action for Haldol is typically about as long as a standard transport time, thus I alway hit with both a benzo and the Haldol. The hospitals dont care for it much because they have someone that will sleep for 24 hours in the ED but thats not my problem.


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## NomadicMedic (Jan 20, 2012)

NYMedic828 said:


> Do you guys have standing orders for the benzo on ODs?
> 
> We don't carry haloperidol in NYC unfortunately and our only standing order benzo is for seizures.
> 
> To my knowledge haldol also has a high occurrence of dystonic reactions and many doctors give it with 25-50mg of benadryl.



We have Haldol/Versed on standing orders for chemical restraint, but if it's a suspected OD, we need to make med control contact.


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## NYMedic828 (Jan 20, 2012)

n7lxi said:


> We have Haldol/Versed on standing orders for chemical restraint, but if it's a suspected OD, we need to make med control contact.



Thats a nice standing order to have.

We have medical control chemical restraint only here. Have to call make the convincing danger to self and others case.

I do know people who have had a dangerous enough patient that documented "he began seizing" But im not too keen on things that can get me jammed up.


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## NomadicMedic (Jan 20, 2012)

Smart move. If you always tell the truth, you'll never contradict yourself. 

Luckily, the docs here trust us... When we call for orders, they almost always grant them.


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## NYMedic828 (Jan 20, 2012)

n7lxi said:


> Smart move. If you always tell the truth, you'll never contradict yourself.
> 
> Luckily, the docs here trust us... When we call for orders, they almost always grant them.



Thats one of the problems I immediately realized as a new medic here in NYC.

we have like 20 medical directors, so for starters none of them know you, and we really have a diverse standard of competency amongst providers which leaves little to trust from the doctors.


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## NomadicMedic (Jan 21, 2012)

NYMedic828 said:


> Thats one of the problems I immediately realized as a new medic here in NYC.
> 
> we have like 20 medical directors, so for starters none of them know you, and we really have a diverse standard of competency amongst providers which leaves little to trust from the doctors.



Yeah, that's a problem. Luckily, here in DE, it's small enough that our docs know all the medics by name. If you can paint a clear picture of why you need what you're asking for, you'll seldom get denied. 

I envy you working in NYC, but I'm sure the call volume must just wear you down. :/


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## NYMedic828 (Jan 21, 2012)

n7lxi said:


> Yeah, that's a problem. Luckily, here in DE, it's small enough that our docs know all the medics by name. If you can paint a clear picture of why you need what you're asking for, you'll seldom get denied.
> 
> I envy you working in NYC, but I'm sure the call volume must just wear you down. :/



Its actually not that stressful as ALS.

As BLS i would get hammered on a daily basis probably 4-8 jobs a day.

As ALS, I do 2-4, and i actually enjoy my job now that I can legitimately treat people's ailments.


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## Maine iac (Jan 21, 2012)

4-8 runs a day? How long are your shifts??

2-4 calls in a single shift?

Wow.

So NYMedic where you work BLS is called to the scene first, then if they determine ALS is required you get called in? If so, I have always wondered how your cardiac calls work.... Is ALS getting called out for all chest pains?


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## Youngin (Jan 21, 2012)

Possibly a dumb question: What's EDP stand for?


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## Ramis46 (Jan 21, 2012)

LOL.. in our Service, we RSI people like that.. We don't really like to take their High away... just make them mot so Combative!


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## SliceOfLife (Jan 21, 2012)

n7lxi said:


> Agreed. These PTs need to be sedated early to decease whatever is causing the erratic behavior, whether its chemical or phsycological or a mix of the two.
> 
> Also, The guy was naked except for a pair of boxers and was about 150 lbs ... and I wear a Kevlar vest on the job.  FWIW, I don't feel I need to justify my actions to anyone here. I simply related an experience that I had recently, using nasal versed to sedate a PT with excited delirium. If you chose to wait for PD, that is your decision. I have waited for PD in the past, and I'm sure I will again when confronted with a situation that I am not comfortable with.
> 
> But, I do appreciate your concern.



Vests don't protect you from knives unless it is a stab vest, which most aren't.  Unless you are in the UK.


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## Maine iac (Jan 21, 2012)

Andrew said:


> Possibly a dumb question: What's EDP stand for?



Emotionally Disturbed Person


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## Aidey (Jan 22, 2012)

SliceOfLife said:


> Vests don't protect you from knives unless it is a stab vest, which most aren't.  Unless you are in the UK.



There are combination vests.


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## SliceOfLife (Jan 22, 2012)

Aidey said:


> There are combination vests.



I have never seen one used.  Have you?  Adding stab protection to a vest is awesome but it requires rigid plates which are expensive and stiff.  Unlike a ballistic plate, these encompass the entire vest.

Some how I doubt that is what he had on.


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## Aidey (Jan 22, 2012)

Yup, at least several of the police around here have them.


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## SliceOfLife (Jan 22, 2012)

Who knows maybe it was Class IV armor and he had a ballistic shield in front of him.  We can only speculate.


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## NomadicMedic (Jan 22, 2012)

SliceOfLife said:


> Who knows maybe it was Class IV armor and he had a ballistic shield in front of him.  We can only speculate.



Or, you could just ask. 

Our vests are Kevlar and are not stab vests. However, as I mentioned, the guy was naked, except for some shorts and was not armed.

I don't want to beat this dead horse, but the fact remains, the patient I was treating needed to be sedated for his safety and the safety of the crew treating him. The two EMTs and I were able to accomplish this without much difficulty. If the situation was different, my plan of attack would have been different. Every situation is different and needs to be fluid.

What I did may not be recommended for you. My actions on scene are my own. Let's move on.


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## NYMedic828 (Jan 22, 2012)

Maine iac said:


> 4-8 runs a day? How long are your shifts??
> 
> 2-4 calls in a single shift?
> 
> ...



8 hour shifts.

Depends on the call type. Injuries, Trauma, CVA, abdominal pain, non-copd asthma, sick jobs all go direct to BLS.

Substantial medical calls like cardiacs, AMS, hypotensives, Diff Breathers, inbleeds all go to ALS directly.

Jobs like cardiac arrests get a BLS an ALS a CFR fire engine and an ems supervisor.

Jobs that the ALS are extended to, get a bls backup if they are closer for a high priority job.

Jobs that are high priority bls with no BLS available get an ALS bus but thats rare.

We have a priority 1-8 system. A 1 being an arrest or something, 3 being chest pain and whatnot. Anything 3 or under is considered high priority. Abd pains are a 5, edps are a 7. Standbys are 8. Anything 7 or higher is a non emergent response.


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