Management of a potentially aggressive patient on PCP.

[DrParasite]

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.

 

[NomadicMedic]

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.

 

[CANMAN]

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.

 

[usalsfyre]

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.

 

[NomadicMedic]

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.

 

[CANMAN]

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......

 

[NomadicMedic]

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.

 

[DrParasite]

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.

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.

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

 

[DrParasite]

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....

 

[Shishkabob]

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.

 

[mycrofft]

"Sedagive?! SEDAGIVE??!!!"

 

[DrParasite]

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.

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.

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.

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?

 

[Maine iac]

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.

 

[NYMedic828]

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.

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.

 

[NomadicMedic]

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.

 

[NYMedic828]

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.

 

[CANMAN]

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.

 

[NomadicMedic]

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.

 

[NYMedic828]

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.

 

[NomadicMedic]

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.