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. The resulting strategy is comprised of the following steps:
- Identifying people and circumstances in advance that are most likely to produce violent behaviors
- Verbal de-escalation
- Mitigating the effects of fight-or-flight syndrome (in patients and caregivers)
- Take-downs (which we leave to police)
- Application of two levels of physical restraint, both manual and with the use of appropriate equipment
- Use of chemical restraint
- Self-defense techniques that have proven their worth when situations escalate unpredictably
- Some useful documentation skills.
Steps 1-4 and 8 were discussed in the January issue; level 1 physical restraint in the February issue; and level II physical restraint in the March issue. This article reviews the ways in which EMS providers may be attacked and appropriate self-defense techniques.
Self-defense is a skill that requires practice, just like starting an IV or intubating a patient. The aim of this article is not to make you a martial arts expert, but to begin giving you skills that will allow you to survive a violent encounter. I will discuss only one technique for handling some possible assaults; however, there are many different responses to each. If you are interested in learning a defensive art, I recommend finding a martial arts school that teaches grappling, as well as defenses against strikes, kicks and weapons. See http://ichf.com for an example of one such art.
Types of Assault
Assault can be broken down into four basic groups: strikes with empty hands, strikes with objects used as weapons, kicks and grabs. Assailants can be any age, size or ethnicity, and from any income bracket. Attacks can come at any place or time, but will most often occur in a private area like a residence or the back of a rig. An attacker may be calm or loud, drunk or sober, and may be someone who, outside of this situation, would never dream of doing you harm. There are several reasons that a person may become violent outside of intent to do us harm. Fear, hypoxia, a diabetic incident or a closed head injury may cause patients to become violent, but their violence is a result of survival instinct, not malice.
Let the Search Begin
One of my coworkers transported a patient who had been frisked by the police, but seemed uncomfortable being immobilized on a backboard. On arrival at the ED, an x-ray revealed a mid-size handgun between his posterior cheeks! I once transported a patient from an MVA who pulled a short-handled cobbler's hammer from under his "beer gut" to get comfortable. He said he usually carried the hammer when he went into places where he did not feel safe, and simply shoved the handle down the front of his pants and allowed his belly to cover the hammerhead that rested just above the belt.
Always make sure your patient is unarmed before transporting. If you don't have the option of having a police officer do the search, you can effectively search a patient without seeming any more intrusive than your normal head-to-toe evaluation.
Instead of taking your hands off the patient between palpating key body parts, lightly run your hands over the areas mentioned above, or add a point or two to palp that you might not normally evaluate. If at any time you find a weapon, you can decide how to approach the situation based on your patient's behavior. In many states, citizens have taken steps to obtain concealed-carry permits that allow them to legally carry guns. These folks will generally let you know that they are carrying a firearm. Many adult men carry some type of knife. Large or small, it is best to know about its presence. When we ask patients if they are carrying a knife, they usually tell us. We then tell them that our policy is no weapons on the ambulance, request that they give any weapon to us during transport and assure them it will be turned over to ED staff on arrival and returned to them when they are discharged. Honest citizens generally comply; if they refuse, we step out of the ambulance and request police response. Our safety comes first.
Common Hiding Places for Weapons
Long hat pins, needles and small knives may be hidden in the bill and inside the sweatband of a patient's hat.
The underside of a shirt lapel may conceal a small, clip-it-type knife in a slit cut through only the bottom layer of cloth approximately ¾" up from the front edge. The rear of the collar is a traditional place to carry a knife mounted vertically and extending down the back.
Another favorite spot is under the arms, where knives, guns and flexible weapons can be hidden.
Even more common is the belt line, all the way from the front to the back, as well as the buckle and pants pockets.
One area that may be overlooked is the side seam down the outside of the pants legs. I've only seen it used once, by a man who threaded a thin guitar string down the outside seam of his jeans. The only thing I noticed was the little brass bead used for mounting the string to the guitar, which was showing on the top of the seam near the edge of a pocket. The young man asked if I would like to see how it was used. Starting with his thumbs in his pockets, he caught the bead with his index finger and, in one fluid motion, whipped it out and used it in a whip-cracking action. (I tried it at home later using a piece of fine wire and lacerated a raw chicken carcass more than an inch deep and 3" long.) The patient then demonstrated a motion that he would use to garrot a victim.
Female patients can have concealed weapons on a thigh or calf, as well as tools hidden under a skirt or between or under their breasts.
Finally, there are classic ankle and boot knives and guns.
Don't Be Your Own Worst Enemy
Prison inmates have been video-taped practicing snatching pens from breast pockets and badges from shirts and then stabbing them into the chest of the intended victim (Figures 1 and 2).
These attacks can take place in or out of your rig. Outside the rig, you have room to move and try to evade the type of attack mentioned above.
Look at your uniform to see what things could be used against you. Keep in mind that when a badge is forcefully pulled from a shirt, the pin generally pops out of the clasp and sticks out at 90 degrees to the badge, allowing it to be impaled in any soft target (Figure 3). The move used by the attacker in the photo is called an ice pick attack, since it uses the motion of a person chipping at a large block of ice. The motion is used in many overhand strikes, whether the object protrudes from the little finger side of the hand, as in the photo, or if the object is a club sticking out the thumb side of the hand, such as a bat or bottle.
To defend against such a blow, you must execute two movements at the same time. Step to the outside of the assailant on the side he is striking with, and at the same time, raise both of your hands with the palms toward your face to meet the blow in a movement called a "book block" from its resemblance to an open book, as seen in Figure 4. Do not try to stop the blow, but redirect it toward your attacker as you draw your trailing foot out of the way. As you redirect the blow, allow your hands to turn palm down onto the assailant's arm, sliding your hand down his forearm until it runs into his hand. This will allow you to control the weapon, which will travel along the arc of the attacker's arm and pass along the side of his leg, or, if directed more forcefully, may strike his leg or groin area. Regardless of where the weapon ends up, draw the patient's arm to his rear, pull the arm up in the same arc and duck under it while tightly gripping his hand. This motion will crank the arm into a straightlock. If the patient reaches for you, simply increase the pressure on the lock to increase pain, which he will naturally try to turn away from. Continue to verbally direct the patient to do as you tell him so he knows what will end his pain. Do not let go until the restraining process is well underway.
Caution: In practicing these moves move slowly at first. An effective lock occurs early in the pivoting movement, and if not carefully done it can cause a wrist, elbow or shoulder injury.
If you think a scene is going to turn violent or you are going into a dangerous environment, remove all jewelry, wristwatches, badges and pens. If a combative person grabs your hand and tries to crush your fingers, a ring can multiply the pain many times over. A wristwatch can get caught on your surroundings or the patient and stop your defensive move. If your watch has a metal band, it can abrade or lacerate you or the patient.
In addition to badges and pens, we often wear carabiners, key clips, radios, knives, flashlights, trauma shears, pagers, cell phones and utility tools. All these things can be grabbed and used against you as weapons, or held onto to keep you from escaping. Think about how to carry them in a fashion that makes them less available to your patients. Some carry systems designed for police work are made with retention in mind, such as flashlight cases with covers and thermal-formed Kydex trauma shear cases.
Another consideration is how and where we place diagnostic equipment. A stethoscope hanging around your neck during patient evaluation makes it easy for the patient to grab the ends and effectively choke you. I will cover this topic in more detail next month.
Never stand with your hands in your pockets while interviewing someone! You cannot get your hands out of your pockets fast enough to block an attack. Never stand with your arms folded across your chest, because an attacker can easily pin both of your arms to your body with one hand and strike you with the other. By taking such basic steps as changing the way you carry your tools and how you stand or sit near a patient, you can reduce the risk of attack and the availability of tools to be used as weapons against you.
Learn From the Law
Law enforcement personnel practice both response to attack and weapons-retention techniques. Some of the concepts are as simple as keeping one foot a half-step forward of the other and turning the weapon side (firearm side for police; for EMS, the side where you keep trauma shears, knife, utility tool) away from the patient. This "interview stance" can be used any time you are talking to someone within eight feet of you. Police assume this stance at distances out to seven yards. In this stance, you are better able to sidestep an attacker, counter an aggressive move, block a strike, kick, or even run if need be.
Reading body language is also important. A senior DEA field officer conducted a study to understand why some sting operations in which agents were attacked by a person they were investigating went wrong. He reviewed videotapes of a large number of operations that had become violent and concluded that the violent parties all went through four distinct actions--the first two always in order, the last two sometimes switched. The first action was a grooming move, or movement of one or both hands to the face. This can take the form of touching the nose, brushing back hair, scratching an itch on the face or pushing up glasses. Second was a witness or exposure check--a quick glance to one or both sides or to the rear, generally looking for witnesses or others who may interfere with the intended action. The third and fourth actions are interchangeable: a definitive shift in weight or stance, generally toward you, and the reach for a weapon, most commonly to the waist. If you see the first two actions, take a step back to gain reaction time and mentally prepare for an attack. At this point, shouting "hey" or "stop" often stops the patient's action, as it surprises the assailant and lets him know you are aware of his plan. Keep in mind that these actions take place within seconds, and recognizing them takes practice.
Steve Rollert's martial training spans 29 years, including karate, kung fu, Korean hapkido, combat hapkido, KunTao 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.