Violent Person? Don’t miss this possibility.

firetender

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I found a thread in another section that I wanted to bring out here. It has to do with handling violence.

This is one of those things where after repeated exposure to a certain type of situation, I got tuned-in to a way of responding that I had been missing up to that point.

After a number of incidents over a brief period of time where I was called to the scene of three, four, five or more cops damn near getting killed trying to restrain a violent person (Whom, it was assumed at the time by most involved was under the influence of something like PCP where you can fight back for hours, even getting a few broken bones in the process and not back off or feel the pain!) I started to notice a pattern in certain cases.

I’d arrive on the scene and the (usually) guy, exhausted, was down on the ground, the cops on top of him. When the cops had enough assistance to get the guy down in a position where he couldn’t move, there were a few moments where, holding him immobile they sort-of relaxed and stopped moving forcefully. Part of that was because they were exhausted, too.

I observed that while the cops were taking a breath before the next phase of restraint, the person on the ground would suddenly “switch.” One moment he was a ball of threat and the next, he’d be speaking rationally (maybe even pleading something like, “Hey, Guys, what’s the big deal!”), his body would relax, and – this is a big sign to note – that red/purple face of rage would soften and get back its normal coloration. That sign is obvious but what I began to notice in conjunction with it was the respiratory rate of the person being restrained dropped to near-normal levels.

In similar situations I had watched this drama play out a couple times, where an enraged person would fight off cops relentlessly then, all of a sudden, while they were backed away, he’d calm down for a couple minutes, speak rationally making them think things had calmed down and then, sparked by God knows what, suddenly burst out in rage again.

What I observed was that there was a repetitive cycle of (usually extreme) hyperventilation, accompanied by almost superhuman acts of endurance and strength (and stupidity!), followed by brief periods of recovery and respiratory rate relaxation.

Following the rhythm of a call, finding the place where you can “fit in” often makes all the difference. Once, in a lull such as described, I got permission from the Officers to approach the man who was making their lives miserable. Using those moments of recovery as leverage, I talked with the man and found that if I posed no threat – thereby not prompting the fight or flight response of increased respiration that would then multiply -- he could maintain his composure and we could take the next step.

But where I really learned the lesson was when, right up with the guy, I’d find myself saying something that (inadvertently, of course!) threatened him and there he’d be, suddenly taking in progressively deeper breaths and not blowing any CO2 off, face turning beet red and within seconds, he’d explode. I’d run like hell and pray the cops’d pounce before he got me.

After a couple times of this, though, when I’d come into such a scene and identify that the guy was hyperventilating, I’d use those moments of calmness to kind of “sit with” the guy and briefly explain that he was overdosing on oxygen. We can be the “Good Guys” in such situations. How we respond can be used as leverage to get the person trusting someone enough to let reason come in.

But it wasn’t about reason. It was about just getting the guy calm and trusting enough to allow me to slip a paper bag over his mouth and nose and let him get some O2/CO2 balance.

Once the crisis passed without anything to trigger a further reaction of hyperventillation, and the cops saw that I had “control” of the situation, in subsequent calls I was often allowed to walk the person into the rig or patrol car.

Now, of course some drugs and other influences (prime example – an unrecognized head injury) will throw a person into a relentless state of aggression, but when you see a person in alternating periods of calm and rage, you may just be able find the place where you can fit in and use a simple therapeutic procedure to take the edge off and make it so nobody gets hurt.
 
Firetender, I would suggest that you educate yourself on some of the recent material on Excited Delirium. One of the patterns that is clinincally recognized is just what you have noticed. There is a period of relative calm after the storm. Unfortunately, it is usually followed by sudden death. Do not be lulled into believing that you will be safe during the brief lull in the violent behavior. If it has worked for you a few times, consider those the exceptions and not the rule. There is a lot that still needs to be learned about psychosis and excited delirium, but what is currently known should guide your actions and perhaps can advise the officers on a scene that this is an immediate medical emergency that needs to be treated quickly. It is that precise moment of tranquility that signals the body is shutting down. These folks die on the side of the road, the back of an ambulance or police car and, on the operating table at the ER.
 
All I can speak to is my experience. I never lost any of the patients whom I encountered in this way. Rather, I'd say at least three times I was successful at what I term recognizing hyperventillation and taking the actions I described to overcome it. That meant NO ONE got hurt. Since I only made choices under circumstances like this three times, that's three for three and not likely to have been the clinical syndrome you described.

As for danger, and so much of what being a paramedic is about, it's a process of making moment to moment choices based on what is in front of you informed by your knowledge, not ruled by it.

Still, you're absolutely right on getting more informed. The name of the game is to fill that bag of tricks to overflowing!
 
I applaud your initiative to try to resolve the situation, which you apparently did well. You are right that the job is about informed choices, emphasis on informed. I have been successful doing things that I would never teach or encourage others to try. The question you have to ask yourself afterward is this: Was I successful because of my decision, or his? I am also impressed with your observation skills. You developed a tactic after spotting a pattern. How many others would have the presence of mind to analyze what they saw?
 
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