Managing Assaultive Behavior

AT 1820 HOURS, YOU AND YOUR PARTNER ARE dispatched to an unknown medical complaint in an affluent area of the community. On arriving at the residence, you are greeted by a woman who says her husband “doesn’t seem himself.” As you walk into the house, you ask the woman about any pertinent medical history and learn that the patient was in the hospital last year because of depression. He is currently taking BuSpar^® for his anxiety and Effexor^® for depression. The woman also says that he may not have taken his medications for the past few days.

The woman escorts you into the master bedroom, where you find a middle-aged male sitting quietly on the bed. He appears to be staring at the floor. As you begin to talk with the man, he becomes agitated and, at times, verbally abusive. After a few additional questions, the man starts screaming obscenities at you and your partner. Recognizing the seriousness of the situation, you opt to wait outside until the police arrive. As you turn to walk out of the bedroom, the man jumps from the bed and attacks your partner with a pair of scissors. Fortunately, the injury is minor. After a few minutes of wrestling the man, you and your partner have him subdued on the floor. The man is in a prone position with his arms pulled and held behind his back. Within a few moments, the man becomes tranquil and subdued. But, you and your partner do not release your grip on the man for fear that he will resume his attack.

A few moments later, the police arrive and begin asking about the situation. The officer notices that the man appears “a little blue.” You turn the man onto his back and note that he is not breathing. Airway management along with assisted breathing is provided, and the patient is quickly transported to the hospital. Unfortunately, the man succumbs to his condition and is pronounced dead within 30 minutes of arrival at the emergency department.

Sadly, this scenario is not uncommon. Patients with or without a known psychiatric history may become combative without warning. Further, these assaultive patients may be quickly and improperly restrained in a position that could lead to death.

DISORDERS ASSOCIATED WITH HOSTILE BEHAVIOR

A number of clinical conditions have been associated with aggressive or hostile behavior. Some are medical conditions; others are psychiatric disorders that could lead to aggressive or violent behavior. Most fire EMS professionals are familiar with medical conditions that can lead to hostile behavior. They include the following:

dementia such as Alzheimer’s, vascular (multi-infarct) dementia, and others;
delirium from any number of causes;
diabetes, especially insulin shock;
stroke; and
intoxication on drugs or alcohol.

In contrast, fire EMS professionals may not be as well versed on psychiatric disorders. Psychiatric disorders involve anxiety and may be psychotic disorders. Some do not fit clearly into a specific category. EMTs and paramedics should have a general understanding of the nature of these problems. Disorders associated with anxiety include the following:

Generalized anxiety disorder characterized by chronic anxiety, excessive worry, and tension. Patients may be irritable and hostile.
Acute stress disorder after experiencing an acutely stressful event. Patients may be detached and experience a sense of depersonalization.
Post-traumatic stress disorder after experiencing a life-threatening or life-altering event. Patients may become aggressive when dealing with others.

Psychotic disorders associated with hostility include the following:

Disorder characterized by delusions that are not strange or bizarre, especially in the absence of other mood or psychotic symptoms. Delusions are defined by the American Psychiatric Association as false beliefs based on incorrect perception of reality even though there is evidence that suggests those beliefs are false.¹
Bipolar disorder has been called manic-depressive illness in the past. It causes shifts in mood, energy, and the ability to function. Moods may be profoundly depressed to extremely manic and agitated.²
Schizophrenia is a severe and chronic disabling brain disorder in which patients may hear voices and experience other hallucinations. They may have bizarre delusions, disordered thinking, disordered movement, and deficits in cognition.³
Borderline personality disorder is characterized by unstable moods, problems with interpersonal relationships, and unstable behavior that may become violent.⁴

Other disorders that can lead to hostile or aggressive behavior include the following:

Attention deficit disorder that may include aggression and defiance.⁵
Developmental disabilities that may include aggressive behavior.

WARNING BEHAVIORS

When you encounter patients with a potential for hostile behavior, look for key findings that will give warning clues to aggression. The EMT and paramedic are keenly aware of certain warning signs of pending hostility, such as a history of violent behavior; a tense posture; the presence of weapons or dangerous objects; and intense physical activity such as pacing, glaring eyes, clenched fists, and protecting personal space. However, there are lesser-known common behaviors that should warn the EMTs or paramedics to look for or be aware of assaultive or violent behavior. These behaviors include the following:

Noncompliance-refusing to take prescribed medications or follow caregiver instructions.
Verbal abuse-sulking, strutting, posturing, name calling, threatening, or angry verbal outbursts.
Self-harm-threatening suicide, cutting, overmedicating, or otherwise inflicting harm to one’s self.
Sexual inappropriateness-touching, fondling, groping, disrobing, or other behavior of a sexual nature.⁶

These behaviors suggest that violence may be imminent and that fire EMS professionals must be prepared to protect the patient, bystanders, and themselves.

FOUR PHASES OF ASSAULTIVENESS

There are four phases of assaultiveness: Trigger, Escalation, Crisis, and De-escalation (Figure 1).

Trigger. The patient may be upset or emotionally unstable, but there is something that sets off the spiral into violent behavior. The trigger could be an additional stressor, something a friend or family member said, the presence of EMS, or other source that starts the progress to violence.
Escalation. After the trigger, the patient’s emotional stability deteriorates. Friends, family, caregivers, and EMS may attempt to calm the patient with inappropriate words such as, “Everything will be alright,” “You need to calm down,” or something that may cause the patient to feel invalidated. Additionally, aggressive behavior toward the patient may serve to escalate the patient’s hostility.
Crisis. Crisis occurs when the violence erupts; it may be short-lived or prolonged. The patient is a danger to himself or others and may lash out at others with the intent to do harm. During this stage, violent patients may need physical restraint to protect themselves and others.
De-escalation. After the crisis has passed, de-escalation occurs. The patient returns to a previolent nature. The tension may still be present, and the patient may still be disposed to violence.⁷

Figure 1. Four Phases of Assaultiveness
Illustrations by author.

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CRISIS INTERVENTION: DEFUSING BEFORE THE VIOLENCE

In most cases, fire EMS personnel will not be present during the trigger phase. However, in some cases, they may be the trigger that starts the escalation. Simply asking the patient, “What’s wrong?” may be a sufficient trigger. In any case, there is a crisis in the patient’s life and fire EMS has been called to intervene. Communication during the escalation phase is key. Effectively defusing the escalation can prevent an outbreak of violence and keep the patient and fire EMS crew out of harm’s way. Whenever in contact with the patient, keep several important aspects in mind:

Low and slow speech. Use a low volume and slow speech to suggest that you are aware of the situation and in control. Avoid rapid talking, which could further escalate the stress. Use a friendly, concerned tone.
Beware of nonverbal communication. Monitor body language to keep an open line of communication. Do not fold arms or cross legs. Look directly at the patient without staring.
Remember the “Rule of 5s.” During the escalation phase, keep communications short and direct. The “Rule of 5s” means that your sentences should contain no more than five words and words should have five or fewer letters. Long, wordy sentences have no impact and might escalate the situation.

Keep in mind that fire EMS’ response can play an important role in the cycle of response (Figure 2).

Figure 2. EMS Response in Crisis Cycle

The patient has experienced a significant event, stressful situation, or incident that creates unsettling feelings. The patient may respond to and act out on those feelings with abusive or violent behavior. The response of EMTs and paramedics may make the situation better or add to the stress that, in turn, impacts the patient’s feelings. If fire EMS can diffuse the stress early, the tendency toward violence may decrease.

WHEN THINGS TURN VIOLENT

In spite of best efforts to de-escalate a situation, physical assault can still develop. The physical assault may be directed at self or others. The patient may attempt to harm himself through self-mutilation or suicide. When the patient attempts to harm others, police and EMS personnel, family members, or bystanders may be at risk for injury. In either instance, physical containment may be required to avoid injury.

Physical restraint necessitates a coordinated effort among all rescue personnel. If only EMS personnel are on the scene, it may be necessary to wait until police officers or other reinforcements arrive. If possible and safe, leave the immediate area and wait until help arrives. If it is unsafe to leave, remain in place and continue trying to verbally de-escalate the situation until assistance is available.

A minimum of four people is needed to safely restrain a violent patient. A fifth person would be beneficial in positioning the gurney. Do not attempt to physically restrain the violent patient with fewer than four rescue and police personnel. Use the following procedures when restraining a violent patient:

Clear the area of family or bystanders. Ensure the safety of others in the immediate area.
Remove all items from your pockets, including pens, scissors, and other EMS tools. Also remove any item from around your neck, such as a stethoscope.
Herd the patient into a closed area. There should be no place for the patient to run or escape.
Approach the patient from both sides. A frontal allows the patient to kick and, perhaps, disable a rescuer. A side approach distracts the patient.
One person is “assigned” to each extremity. Each rescuer will grasp and hold onto one arm or leg.
Use the trigger word “down” to initiate the process. Avoid using the common “On three.” It warns the patient and enables him to prepare for the takedown.
Place the patient on a chair or gurney, apply the physical restraints, and completely assess him. Perform a comprehensive primary and secondary survey. Evaluate the restrained extremities for color, motor function, sensation, temperature, pulse, and capillary refill. Readjust the restraints if any of the above functions are abnormal.

SPECIAL CONSIDERATIONS

There are a few important considerations when physically restraining a violent patient. These aspects should be key for every EMT and paramedic in a situation where physical restraint is needed.^8-10

Use the left lateral recumbent position if the airway is in jeopardy. If the patient’s airway is at risk from the possibility of vomiting or excessive secretions, place the patient in the left lateral recumbent position. If turning the patient is likely, restrain one arm along the patient’s side and the other above the head.
Do not use a “backboard sandwich” or a hogtie position (hobble restraint). Patients in a hobble restraint often have become victims of positional asphyxia.
Continuously monitor the patient’s airway and breathing. Restrained patients may not be able to clear their own airway; thus, the EMT or paramedic must frequently assess it.
Restraints should be soft and applied only to the wrists and ankles. A restraint such as a strap or a sheet may be needed across the patient’s chest and thighs. Use leather or cloth restraints. Never use plastic tie wraps. Restraints should never cut off or interfere with circulation.
Use only as much force as necessary. Excessive force is inappropriate. Never strike a patient.
Stay with the restrained patient. Do not leave the patient unattended or in the care of an untrained person.
Do not remove the restraints until you are safely at the hospital and told to remove them.

DE-ESCALATING AFTER RESTRAINING

Once the patient has been adequately restrained, the EMT and paramedic’s job is not over. It is important to continue de-escalation after containment. Consider the patient’s emotional response after being forcefully placed on a stretcher with wrist and ankle restraints in place. The patient’s range of emotions can run from angry to apologetic to despondent. In response to the patient’s range of emotions, one crew member should remain at the patient’s head to continually reassure the patient as de-escalation of the situation continues. This crew member should remain at the head level but one to two feet away from the patient, to prevent biting or contamination from spitting.

Not only does the patient need de-escalation, but the crew also needs to be debriefed. Personnel may be upset by having to physically restrain the patient. They may also feel apprehensive or scared as a result of the assaultive behavior. Finally, they may feel disappointed that their attempt to verbally de-escalate the situation failed. These emotions need to be expressed to the lead team member or other person on the scene. If needed, arrange for professional debriefing after the call.

PAPERWORK IS CRITICAL

At the completion of the call, thoroughly document the entire event. Documentation must include the attempts to verbally de-escalate the assaultive patient as well as the need to apply physical restraints. Important elements to present in the narrative section include the following: a description of the behavior that precipitated the need for physical restraint, a statement that no other means or less restrictive measure was appropriate, the time when the restraints were applied, patient assessment and reassessment times that ensured patency of the airway and adequacy of ventilation, type of restraint used, and position of the restrained patient on the ground and stretcher. Failure to document these items may put fire EMS personnel in legal jeopardy should the patient be injured or the patient’s condition deteriorate.¹¹

. . .

The need to physically restrain an aggressive or assaultive patient, fortunately, is rare; however, it does occur. Be prepared to deal with assaultive patients, and review your local and state protocols on handling them.

References

1. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association, Washington, DC, 2000.

2. “Bipolar disorder,” National Institutes of Mental Health, National Institutes of Health, retrieved 6/16/07 from <http://www.nimh.nih.gov/publicat/bipolar.cfm#intro>

3. “Schizophrenia,” National Institutes of Mental Health, National Institutes of Health, retrieved 6/16/0 from <http://www.nimh.nih.gov/healthinformation/schizophreniamenu.cfm>

4. “Borderline personality disorder,” National Institutes of Mental Health, National Institutes of Health, retrieved 6/16/07 from http://www.nimh.nih.gov/publicat/bpd.cfm

5. Kidd, PM, “Attention deficit/hyperactivity disorder in children: Rationale for its integrative management,” Alternative Medicine Review, 2000. Retrieved 6/16/07 from <http://www.thorne.com/altmedrev/.fulltext/5/5/402.pdf>.

6. Alagiakrishnan, K, et. al, “Sexually inappropriate behaviour in demented elderly people,” Postgraduate Medical Journal, 2005. Retrieved 6/16/07 from <http://pmj.bmj.com/cgi/content/full/81/957/463>.

7. “Management of Aggressive Behavior” compact disc training program, REB Training International, Inc., Stoddard, New Hampshire, 1999.

8. “Managing Assaultive Behavior/Patient Restraint,” Contra Costa Emergency Medical Services, Contra Costa Health Services, Martinez, CA, 2001.

9. Dick, T and S Rollert, “Coping with Violent People: Level I Physical Restraint,” Emergency Medical Services, February 2007.

10. Dick, T and S Rollert, “Coping with Violent People: Level II Physical Restraint,” EMS Magazine, March 2007.

11. Maggione, WA and RB Palmer, “Exercise restraint,” JEMS, March 2002.

ROBERT G. NIXON has been involved in EMS for more than 30 years. He has taught EMT, paramedic, and continuing education programs locally and nationally and has instructed at numerous fire academies and conferences, including FDIC. He is division manager of clinical education for AMR’s Northeast Division and president of LifeCare Medical Training in Auburn, Massachusetts. In addition, he is on the editorial advisory board for EMS Magazine. Nixon has had published nearly 100 articles involving prehospital care and training and has six textbooks on the market through Brady, Jones and Bartlett Publishers, and LifeCare.