Violent patient policy.
- Thread starter JeffDHMC
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firecoins
IFT Puppet
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Talk to Kip.
If a violent patient is on scene, I stay in the rig. If a violent patient is in the rig, I get out.
If a violent patient is on scene, I stay in the rig. If a violent patient is in the rig, I get out.
daedalus
Forum Deputy Chief
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I subscribe to this philosophy as well.
Fragger
Forum Probie
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Call the cops !!!!!!!!!!:wacko:
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Eject! Eject! Eject!
DT4EMS
Kip Teitsort, Founder
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Yes he has. I would really like to encourage my friends from here to help with this "fact finding" mission. Jeff is doing some research and was asking specifically about policy/guidelines etc.
Truthfully answering about your agencies policies regarding incidents of violence/assaults toward EMS will help many. I have helped him as far as I am capable. I don't have the answers to specific policies at the various agencies you guys/gals work for.
Thanks a bunch!!
Kip
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First, welcome to the community!
While it will definitely be useful to evaluate other protocols and procedures, and I know you don't want to hear it, I really think that Kip is the person you need to talk to if you're serious about creating progressive protocols for your system.
I recommend Kip as an EMS professional and full time educator. Kip and the folks at DT4EMS are really on the cutting edge of proven tactics and techniques that work when dealing with combative and hostile patients. It's funny to hear folks talk about Kip's strategies and techniques in person, when I've known Kip as a member of our forum for the past few years. There is no better person to work with when developing strategies, and I've always found him to be a great communicator.
I too look forward to seeing what others post as far as protocols and guidelines, but I think you'll find that Kip is a bit ahead of his time when it comes to protection of the medic. We always preach scene safety first, but coming out of EMT school we have almost no actual techniques for dealing with challenging situations, and I think Kip's programs really fill that gap quite nicely. This is one of those situations where ten years from now we'll all be shaking our heads and wondering why he didn't implement defensive EMS sooner, but for now Kip is doing what he can through in-person training and online education.
Good luck!
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artman17847
Forum Crew Member
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these are Pa. protocols for AGITATED BEHAVIOR/PSYCHIATRIC DISORDERS
Pennsylvania Department of Health Behavioral & Poisoning 801 – BLS – Adult/Peds
Effective 09/01/04 801-1 of 2
AGITATED BEHAVIOR / PSYCHIATRIC DISORDERS
STATEWIDE BLS PROTOCOL
Criteria:
A. Patient with a psychiatric or behavioral disorder who is at imminent risk of self-injury or is a threat to others.
OR
B. Patient with a medical condition causing agitation and possibly violent behavior. Examples of these conditions are:
1. Alcohol or drug (e.g. PCP, methamphetamine, cocaine) intoxications
2. Hypoglycemia
3. Stroke
4. Drug overdose
5. Post-ictal after seizure
6. Head trauma
Exclusion Criteria:
A. None
Treatment:
A. All patients:
1. If violence or weapons are anticipated, consider waiting for law enforcement to secure the scene. Do not block patient’s exit – See Scene Safety Protocol # 102.
2. Initial Patient Contact – see Protocol # 201.
a. Call for law enforcement, if available, if patient is violent
b. Call for ALS, if available, if patient has altered LOC or is agitated. See Indications for ALS Use protocol #210
3. Assess for possible underlying medical conditions such as hypoglycemia, drug overdose, trauma, hypoxia, or post-ictal from seizure.
a. If present, use the applicable protocol.
4. Attempt to establish a rapport with the patient.1
5. If patient is a potential threat to him/herself or others and restraint can be accomplished safely by personnel on scene, the patient may be restrained (see procedure below) and transported against his/her will
a. Restrain the patient in the following situations:
1) Law enforcement personnel order restraint and transport
2) Mental health delegate on scene has initiated involuntary commitment papers (i.e. 302)
3) Medical command physician orders restraint and transport
4) The patient is a direct threat to EMS personnel and must be restrained to avoid injury.
5) The patient exhibits suicidal thoughts or actions.
b. If adequate personnel are not immediately available to restrain the patient, EMS personnel shall remain in a safe proximity to the scene and shall notify law enforcement or local mental health agency of the patient’s location and actions.
6. If the patient struggles violently against the restraints,
a. Call for ALS if available2
b. Administer high concentration oxygen via NRB mask.
7. Contact medical command for an order to restrain and transport the patient against his/her will, if not done previously.
8. Transport
a. Restraints during transport should restrict the patient enough to reasonably prevent escape from the vehicle or harm to EMS personnel.
b. EMS personnel must be with a patient at all times if the individual was restrained using this protocol.
9. Monitor vital signs and reassess
a. Reassess and document neurovascular function of restrained extremities.
Pennsylvania Department of Health Behavioral & Poisoning 801 – BLS – Adult/Peds
Effective 09/01/04 801-2 of 2
Procedure for patients that require physical restraint:
A. All Patients:
1. Use the minimum amount of restraint necessary to safely accomplish patient care and transportation with regard to the patient’s dignity.
2. Assure that adequate personnel are present and that police assistance has arrived, if available, before attempts to restrain patient.
3. Call for ALS, if available, if patient continues to struggle against restraint.2
4. Restrain all 4 extremities with patient supine on stretcher.3,4,5,6
5. Use soft restraints to prevent the patient from injuring him or herself or others.7
a. If the handcuffs or law enforcement devices are used to restrain the patient, a law enforcement officer should accompany the patient in the ambulance
b. It is preferable that a law enforcement officer follows the ambulance in a patrol car to the receiving facility if physical restraint is necessary.
6. Do not place restraints in a manner that may interfere with evaluation and treatment of the patient or in any way that may compromise patient’s respiratory effort.8
7. If the patient is spitting, may cover his/her face with a surgical mask or with a NRB mask with high flow oxygen.9
8. Evaluate circulation to the extremities frequently.
9. Thoroughly document reasons for restraining the patient, the restraint method used, and results of frequent reassessment.
Possible Medical Command Orders:
A. Medical command may order restraint and transport of a patient against his/her will.
Notes:
1. Verbal techniques include:
a. Direct empathetic and calm voice.
b. Present clear limits and options.
c. Respect personal space.
d. Avoid direct eye contact.
e. Non-confrontational posture.
2. There is a risk of serious complications or death if patient continues to struggle violently against restraints. Sedation by ALS personnel may be indicated in some circumstances as directed by ALS protocols or by order from medical command physician.
3. Initial “take down” may be done in a prone position to decrease the patient’s visual field and ability to bite, punch, and kick. After the individual is controlled, he/she should be restrained to the stretcher or other transport device in the supine position.
4. DO NOT restrain patient in a hog-tied or prone position.
5. DO NOT sandwich patient between devices, such as long boards or Reeve’s stretchers, for transport. Avoid restraint to unpadded devices like backboards.
6. A stretcher strap that fits snuggly just above the knees is effective in decreasing the patient’s ability to kick.
7. Padded or leather wrist or ankle straps are appropriate. Handcuffs and plastic ties are not considered soft restraints.
8. Never apply restraints near the patient’s neck or apply restraints or pressure in a fashion that restricts the patient’s respiratory effort.
9. Never cover a patient’s mouth of nose except with a surgical mask or a NRB mask with high flow oxygen. A NRB mask with high flow oxygen may be used to prevent spitting in a patient that also may have hypoxia or another medical condition causing his/her agitation, but a NRB mask should never be used to prevent spitting without also administering high flow oxygen through the mask.
Performance Parameters:
A. Review for documentation of reason for restraint and restraint method used. Consider reviewing every call when physical restraint is used.
B. Hospital-operated services may have additional JCAHO requirements for documentation.
C. Review for documentation of frequent reassessment of vital signs, cardiopulmonary status, and neurovascular status of restrained extremities. Consider benchmark of documenting these items at least every 15 minutes.
Pennsylvania Department of Health Behavioral & Poisoning 801 – BLS – Adult/Peds
Effective 09/01/04 801-1 of 2
AGITATED BEHAVIOR / PSYCHIATRIC DISORDERS
STATEWIDE BLS PROTOCOL
Criteria:
A. Patient with a psychiatric or behavioral disorder who is at imminent risk of self-injury or is a threat to others.
OR
B. Patient with a medical condition causing agitation and possibly violent behavior. Examples of these conditions are:
1. Alcohol or drug (e.g. PCP, methamphetamine, cocaine) intoxications
2. Hypoglycemia
3. Stroke
4. Drug overdose
5. Post-ictal after seizure
6. Head trauma
Exclusion Criteria:
A. None
Treatment:
A. All patients:
1. If violence or weapons are anticipated, consider waiting for law enforcement to secure the scene. Do not block patient’s exit – See Scene Safety Protocol # 102.
2. Initial Patient Contact – see Protocol # 201.
a. Call for law enforcement, if available, if patient is violent
b. Call for ALS, if available, if patient has altered LOC or is agitated. See Indications for ALS Use protocol #210
3. Assess for possible underlying medical conditions such as hypoglycemia, drug overdose, trauma, hypoxia, or post-ictal from seizure.
a. If present, use the applicable protocol.
4. Attempt to establish a rapport with the patient.1
5. If patient is a potential threat to him/herself or others and restraint can be accomplished safely by personnel on scene, the patient may be restrained (see procedure below) and transported against his/her will
a. Restrain the patient in the following situations:
1) Law enforcement personnel order restraint and transport
2) Mental health delegate on scene has initiated involuntary commitment papers (i.e. 302)
3) Medical command physician orders restraint and transport
4) The patient is a direct threat to EMS personnel and must be restrained to avoid injury.
5) The patient exhibits suicidal thoughts or actions.
b. If adequate personnel are not immediately available to restrain the patient, EMS personnel shall remain in a safe proximity to the scene and shall notify law enforcement or local mental health agency of the patient’s location and actions.
6. If the patient struggles violently against the restraints,
a. Call for ALS if available2
b. Administer high concentration oxygen via NRB mask.
7. Contact medical command for an order to restrain and transport the patient against his/her will, if not done previously.
8. Transport
a. Restraints during transport should restrict the patient enough to reasonably prevent escape from the vehicle or harm to EMS personnel.
b. EMS personnel must be with a patient at all times if the individual was restrained using this protocol.
9. Monitor vital signs and reassess
a. Reassess and document neurovascular function of restrained extremities.
Pennsylvania Department of Health Behavioral & Poisoning 801 – BLS – Adult/Peds
Effective 09/01/04 801-2 of 2
Procedure for patients that require physical restraint:
A. All Patients:
1. Use the minimum amount of restraint necessary to safely accomplish patient care and transportation with regard to the patient’s dignity.
2. Assure that adequate personnel are present and that police assistance has arrived, if available, before attempts to restrain patient.
3. Call for ALS, if available, if patient continues to struggle against restraint.2
4. Restrain all 4 extremities with patient supine on stretcher.3,4,5,6
5. Use soft restraints to prevent the patient from injuring him or herself or others.7
a. If the handcuffs or law enforcement devices are used to restrain the patient, a law enforcement officer should accompany the patient in the ambulance
b. It is preferable that a law enforcement officer follows the ambulance in a patrol car to the receiving facility if physical restraint is necessary.
6. Do not place restraints in a manner that may interfere with evaluation and treatment of the patient or in any way that may compromise patient’s respiratory effort.8
7. If the patient is spitting, may cover his/her face with a surgical mask or with a NRB mask with high flow oxygen.9
8. Evaluate circulation to the extremities frequently.
9. Thoroughly document reasons for restraining the patient, the restraint method used, and results of frequent reassessment.
Possible Medical Command Orders:
A. Medical command may order restraint and transport of a patient against his/her will.
Notes:
1. Verbal techniques include:
a. Direct empathetic and calm voice.
b. Present clear limits and options.
c. Respect personal space.
d. Avoid direct eye contact.
e. Non-confrontational posture.
2. There is a risk of serious complications or death if patient continues to struggle violently against restraints. Sedation by ALS personnel may be indicated in some circumstances as directed by ALS protocols or by order from medical command physician.
3. Initial “take down” may be done in a prone position to decrease the patient’s visual field and ability to bite, punch, and kick. After the individual is controlled, he/she should be restrained to the stretcher or other transport device in the supine position.
4. DO NOT restrain patient in a hog-tied or prone position.
5. DO NOT sandwich patient between devices, such as long boards or Reeve’s stretchers, for transport. Avoid restraint to unpadded devices like backboards.
6. A stretcher strap that fits snuggly just above the knees is effective in decreasing the patient’s ability to kick.
7. Padded or leather wrist or ankle straps are appropriate. Handcuffs and plastic ties are not considered soft restraints.
8. Never apply restraints near the patient’s neck or apply restraints or pressure in a fashion that restricts the patient’s respiratory effort.
9. Never cover a patient’s mouth of nose except with a surgical mask or a NRB mask with high flow oxygen. A NRB mask with high flow oxygen may be used to prevent spitting in a patient that also may have hypoxia or another medical condition causing his/her agitation, but a NRB mask should never be used to prevent spitting without also administering high flow oxygen through the mask.
Performance Parameters:
A. Review for documentation of reason for restraint and restraint method used. Consider reviewing every call when physical restraint is used.
B. Hospital-operated services may have additional JCAHO requirements for documentation.
C. Review for documentation of frequent reassessment of vital signs, cardiopulmonary status, and neurovascular status of restrained extremities. Consider benchmark of documenting these items at least every 15 minutes.
DT4EMS
Kip Teitsort, Founder
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Wow! Thanks Matt!
Hockey
Quackers
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Three words
Call Chuck Norris
Call Chuck Norris
Sasha
Forum Chief
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Three words for you, Hockey.
Still. Not. Funny.
Still. Not. Funny.
Hockey
Quackers
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Knock it off, keep it on topic, and keep it civil...
Otherwise Chuck Norris will be the least of your worries.
Otherwise Chuck Norris will be the least of your worries.
AJ Hidell
Forum Deputy Chief
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I assume that you are looking for non-medical protocols and guidelines, correct?
There is an operational theory that such things are best not put into specific written policy. You simply cannot pre-dictate how people are to respond to threats under stress. It simply does not happen often enough for them to be expected to respond by a cookbook formula that they have never had the opportunity to practice. I am sure that Kip would be the first to agree with this. Being told what to do is not likely to translate in an actual ability to do so. You have to practice it to the point of it becoming second nature in order to have any expectation of retention.
If you go putting procedural policies into place that you are not actually giving your personnel relevant training on, it is going to fail. And when it fails, the organization is liable. Likewise, if you put policies that limit your personnel's ability and options to defend themselves into writing, you are liable when they get hurt. Consequently, to a limited extent, ignorance is bliss. That means you want to establish only policies that relate to intuitive, common sense reactions that any reasonable man is likely to take. That includes:
1. Maintaining awareness of your surroundings.
2. Maintaining a non-threatening and non-provocative demeanor.
3. Retreating when threatened.
4. Calling for law enforcement support.
Anything more would likely be found unreasonable by any court. Dictating that your personnel utilize restraining techniques that they do not have competent and certified training (and retraining in) is a very bad idea. And any policy that would inhibit them from taking reasonable measures to defend themselves would be an even worse idea. This is where some agencies get too carried away. They are so concerned about being sued for their personnel hurting someone that they forget all concern for their own personnel getting hurt. This is where ignorance is bliss. Don't dictate it with policy, and then only the individual medic is liable when he unlawfully injures someone, not you. But if he gets injured himself, you are not liable for having contributed to that.
All that said, if you find a written policy that is much longer than the four items I listed above, it's probably too much. Keep it simple.
Shishkabob
Forum Chief
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Punch them in the gonads if male, or kidneys if females, laugh cynically, and run away.
Works for me every time.
Works for me every time.
Sasha
Forum Chief
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Punch them in the gonads if male, or kidneys if females, laugh cynically, and run away.
Works for me every time.
Actually kicking a female in the genital area hurts too... Like a male it's not easily guarded, full of nerves, and well, it hurts!
Shishkabob
Forum Chief
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I'd rather not take the risk of them being preggo though and having a manslaughter charge tacked on. I have horrible aim when punching.
Atleast if I do enough damage to the kidneys, they'll need continual transport to the dialysis clinic!
But, it seem as though you have some experience in the matter;
*sits down with popcorn*
Please, do tell.
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Last warning...stay on topic.
DT4EMS
Kip Teitsort, Founder
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Excellent post!
There are several points here. First the actual numbers, according to OSHA show that assaults on health care providers are more likely to happen to health care providers than police officers or prison guards. According to the NAEMT 52% of EMS Providers claimed injury from assault, which was higher than any other reason for on-the-job injuries.
Dr. Brian Maguire, considered to be the leading expert in EMS injuries stated this:” Here is what we know: according to my research, the risk of non-fatal assault resulting in lost work time among EMS workers is 0.6 cases per 100 workers per year; the national average is about 1.8 cases per 10,000 workers per year. So the relative risk for EMS workers is about 30 times higher than the national average. The relative risk of fatal assaults for EMS workers is about three times higher than the national average.”
I do believe people have to be trained in force levels and when it is OK and not OK to use force. If we do not train them they revert to caveman style tactics leaving both the agency and the provider liable. If the family of the Wal-Mart guy trampled to death is suing Wal-Mart for lack of training…..
Training the difference between a patient and an attacker/aggressor is just as important. EMS and ER staff across the country have been fired for assaulting a patient. Clear definitions must be present in training.
1. Maintaining awareness of your surroundings.
2. Maintaining a non-threatening and non-provocative demeanor.
3. Retreating when threatened.
4. Calling for law enforcement support.
Yes! Yes! Yes! But we must define “reasonable” in the training. Even the NAEMSP stated a provider may use “reasonable force” to defend themselves, but fails to define “reasonable”. The problem with the “position” the NAEMSP has taken in patient restraints is they claim it takes 5 people to medically restrain a patient.
Well here we go……… How often in an emergency setting do you have 5 similarly trained, competent people to apply these restraints? More importantly if the person being restrained is actively trying to assault you……. Why are you doing the restraining? This is where retreat should be the issue and allow law enforcement/security to the restraining and then provide medical treatment. Again this is a difference between a patient and an attacker. So now the EMS provider has been painted into a corner.
There must be training designed specifically for the EMS provider. There must be policies in place to let the provider know they do have a right to self-defense against an "attacker" but nver, never assault a "pateint".