Engine Company EMS: Sometimes, You Have to Let Them Go

By Michael Morse

It is never a bad idea to pat down an unconscious patient prior to treatment. Neutralizing potential threats before they have a chance to materialize is something each and every one of us should do habitually. The benevolent nature of our work does not make us immune to the malevolent nature that may be lying dormant in our patient when we get to work.

Overdose patients pose particular concerns. Chances are pretty good that laws were broken to get them into the state where they required our assistance. It stands to reason that people who take chances with illegal substances may pose a threat when they are revived.

Many people treated with naloxone rejoin the living in a state of confusion. One minute, they were cruising down the highway of euphoria; the next, they find themselves surrounded by strangers, and their euphoria is gone. A period of respiratory failure likely precipitated the intervention that brought them back, so it stands to reason they would have diminished clarity, fogginess, and an overwhelming impulse to fight or flee.

I was involved in hundreds of successful overdose reversals, and I never had a problem with my patients. That is not to say that, every now and then, one wouldn’t rip an IV from his arm or dash out of the ambulance. Some simply refused to cooperate with our protocols, sign a refusal, or agree to go to the emergency department with us. The vast majority of the time, however, I was able to use those precious moments of what I call “twilight” to address the patient as a legitimate medical concern, establish trust, and convince him that I was his best friend at that moment, and all I was concerned with was his well-being.

It wasn’t difficult to do, because it was true. The ones that got away did so without much fuss, but not without an honest and earnest attempt to get them to continue treatment. Treating a person with naloxone and then opening the door to their escape is negligence at best and abandonment at worst. Demanding a person remain on the stretcher, in the ambulance, and within arm’s reach or under your control is potentially disastrous. We cannot force people to submit to what we want, regardless of how right we might be. If a person is intent on walking (or running) away, even if his clarity is compromised, we sometimes, for our own safety, have to let him go.

To avoid all of this conflict, a police presence is advisable. The police, however, need to be held accountable for their actions, or lack thereof. Requesting police backup should be far more than just having a uniformed officer standing by in case a patient becomes combative. Expecting a full pat down by police during treatment is not unreasonable, and it is vital for the officer to remain vigilant during those critical moments when the patient regains consciousness.

There is no excuse for getting killed or injured by a previously unconscious patient. We are in complete control. It is up to us to maintain that control—or relinquish it. If, after we have done all we can, the police choose not to take custody of our patient for transport—and they choose to elope—it is prudent to let them do so without a struggle. Sometimes, it is the only reasonable thing we can do.

Michael Morse is a former captain with the Providence (RI) Fire Department (PFD), an author, and a popular columnist. He served on PFD’s Engine Co. 2., Engine Co. 9, and Ladder Co. 4 for 10 years prior to becoming an EMT-C on Rescue Co 1 and Captain of Rescue Co. 5.