This series, introduced in the January issue, discusses patient restraint procedures that have resulted from the work of more than a dozen Colorado EMS providers. These providers are currently studying the feasibility of predicting violence in the field and restraining high-risk patients preemptively. In the conclusion to this series, this article reviews a provider's vulnerabilty to attack during patient assessment. To read this complete series online, visit www.emsresponder.com.
Anytime we are within arm's reach of a patient, we are at risk. Taking a BP, listening to lung sounds or starting an IV places our patient's hands in close proximity to our bodies. Following are examples of right and wrong patient-handling techniques.
Safety during assessment
Figure 1 shows an EMT starting an IV. The patient in the picture has ready access to the provider's groin area, due to hand placement. Caregivers are generally focused on the patient, which makes them vulnerable to attack, and a painful one it is!
To start an IV, place the patient's arm in an almost hyperextended position over the cot rail (Figure 2). This arm bar lock is very effective in controlling a patient's arm during an IV attempt. The lock can be held alone, but it is easier and more effective if done with your partner's assistance. Be cautious about going too far when extending the arm, since a fracture/dislocation of the elbow can occur. The restraint method suggested by my co-author of this series, Thom Dick, in the March issue, of crossing the patient's arms over his chest is a great way to gain IV access to the "handcuff" vein.
Figure 3 shows another mistake that is commonly made. The EMT has tucked the patient's arm under her outside arm, which subjects her to being pulled onto the patient's lap. The area between your potential assailant's arms (in martial arts this area is referred to as "the inside gate") should be considered an area of highest danger! As often as possible, work on the outside of the person's arms (the outside gate). This reduces the chance of injury and offers a better chance to escape. To avoid the dangers shown, simply move the patient's arm to the area between him and you, tucking only his forearm under your own. This makes it more difficult for him to strike you, and makes it easier for you to escape. If you place the patient's hand under your arm, you risk pinches and muscle grabs that are quite distracting.
Approaching the patient
Rolling over a patient who is prone or in a fetal position also leaves us vulnerable to being struck, grabbed, stabbed or having a gun drawn on us by the patient.
When approaching a prone patient, avoid rolling him so he faces you, as that enables him to attack your legs, pelvis or torso with a weapon while your hands are busy (see opening photo on page 71).
If the patient is prone, roll his far shoulder toward you to weaken his ability to attack (Figure 4).
Approaching the patient from the rear, place one foot approximately 8"-10" behind his head and your other foot far enough to the rear of his hips (generally 10"-12") to allow you to lean forward and place your knee against his posterior hip, as seen in Figure 5. This will keep him from making a fast roll toward you and make it nearly impossible to kick at you with the upper leg. Place the hand closest to the patient's head on the shoulder that is, or will be, on top. Place the hand closest to the patient's hip on his top arm on or above the elbow as you roll him over. As you roll the patient toward you, his top arm comes free of the ground, and firm, but gentle, pressure to his upper arm just above or at the elbow will allow you to feel if he makes any sudden or forceful move to clear himself to attack or use a weapon. If he moves to get something from under his body, or you see something in his hand, force his arm and hand down to the ground using your weight and strength to pin his hand and the weapon to the ground. At the same time, lean forward with both knees, bringing the knee that was behind him down onto the side of his head. The knee that was resting against his hip is forced forward, effectively pinning him to the ground (Figure 6).
If the patient has a weapon, yell "weapon" as you execute the methods described above to alert everyone in the area to the threat. If you choose to jump out of the way rather than pin the patient, you may be able to get clear, but a firearm will still reach you. If you pin him, a struggle may ensue, so getting additional help is critical.
Practice this technique during training to become familiar with how it feels to have someone come up with a weapon and how much force is required to force the attacker's hand to the ground and hold it there.
NOTE: Always approach the patient who is in a fetal position from his blind side.
Consult your agency command about how to handle incidents like this. Anytime a patient starts to fight or becomes a danger to you or himself, alert your partner immediately and call for help. It is best to restrain patients who may become dangerous early while fire department and law enforcement personnel are still on scene to help.
Alone in the ambulance
Consider another dangerous situation providers may find themselves in. You have been called to a local bar on a drunken fall victim. On arrival, you are met by police officers, who say the patient was in a heated disagreement with another patron and fell while backing up. The patient did not lose consciousness and denies CTLS spine pain, but complains of an injury to his right shoulder and asks to be transported to the ED for evaluation. He seems cooperative and climbs into the back of your rig without assistance.
This has just become one of the most dangerous aspects of an EMS call: being alone in the back of your rig without the backup you had on scene and with a patient strapped in an upright position on the cot.
As one of the first steps to self-defense, consider how you strapped the patient to the cot, beginning at the head. If your agency does not use shoulder straps, perhaps it's time to consider installing them. Shoulder straps not only assist in keeping the patient on the cot in a "hard-stop" situation; they also limit the patient's ability to reach you with his off-side hand (Figure 7). The leg strap can be brought up and through the foot end of the handrails and across the patient's legs just above the knees, making it more difficult to kick you (Figure 8).
As you are setting up an IV, the patient grabs you by the throat with his left hand, occluding your airway. You know you must act quickly before you lose consciousness, or before the patient drags you closer and strikes you or chokes you with his other hand.
The ABCs apply to us as well as to our patients, and the first thing you need to do is clear your own airway! Grab the patient's wrist with your left hand while reaching toward the ceiling with your right hand, palm toward you, as seen in Figure 9. Bring your right elbow down with as much force as you can muster on the patient's arm at the elbow. At the same time, pull his hand away from your throat using your left hand. Notice in Figure 10 that the right hand is now in a position to either block an incoming blow from the patient's left hand or turn his head away from you, making it much more difficult to strike you. (This technique will work in most cases using just the right hand, but it is safer to use both hands.) Now that you have cleared your airway, press the arm the patient was using to choke you across his chest, shift your rear down the bench seat toward the front of the ambulance (see Figure 11) and move behind the head of the cot. Quickly reaching under the patient's chin with both hands, pull back and down against the cot, using your elbows as a fulcrum to pull his head back against the cot's mattress. Crouching behind the patient's head (Figure 12), have your partner pull over, call for help and then get into the back to help you.
If you had strapped the patient with a shoulder harness and placed the cot backrest in the fully down position, he could not have reached your throat.
Self-defense is first having a mindset that you will not become a victim and, second, making a conscious decision to defend yourself. When I first got into self-defense, I was told, "Your assailant will always be stronger, move faster and hit harder than you expect." Good words to remember!
By preplanning responses and practicing them, you will be calmer and able to control your fight-or-flight instincts more effectively. This will reduce the chance of injury to you and your patient, as well as legal liability. Best of all, it will allow you to go home safely at the end of your shift.
Steve Rollert's martial training spans 29 years, including karate, kung fu, Korean hopkido, combat hopkido, Kun Tao Silat and Pa Kua. He has taught self-defense classes for military, police, ambulance and fire personnel and civilians for the past 18 years. Steve has worked since 1989 as a full-time EMT-B and is currently employed by Platte Valley Ambulance. He has been a volunteer firefighter in the Southeast Weld Fire Protection District in Colorado for the past 21 years. Steve also manufactures training knives used by military and law enforcement agencies to learn defense techniques against knife attack. These can be seen at www.keenedgekinves.com.