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.
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.