Coping with Violent People: A Multi-Part Series

Next to operating an emergency vehicle, nothing is as dangerous for an EMT as restraining violent people.

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Next to operating an emergency vehicle, nothing is as dangerous for an EMT as restraining violent people. Yet even our most widely respected texts portray techniques that are certain to produce injuries to crews. Many instructors freely admit their own discomfort with this topic. Many providers are ill-equipped, armed only with soft ties or Kerlix and tape. At least two states that we know of forbid field use of leather restraints as "hard restraints."

     As of this writing, we can find no studies that illustrate how many patients or their families are likely to become violent in the field. In-hospital studies cite numbers between about 1% and 5%.1 Providers with good interpersonal skills might mitigate those numbers, but even one patient in 100 would make behavioral emergencies more frequent than calls to which we devote much more training, involving obstetrics, hazmat, burns and, of course, weapons of mass destruction.

     These are trying times for even the best of ordinary people, some of whom are overwhelmed, overstressed and generally frightened by the world that surrounds them. In addition, we are about to be faced with thousands of military veterans returning from war. When that happened after Vietnam, EMS providers encountered a significant increase in psychiatric emergencies, related in part to drugs they had never heard of. Our training for current and coming realities needs to be a lot better, and right now.

     The procedures discussed in this series resulted from the work of more than a dozen Colorado EMS providers between 2001 and 2006 (see acknowledgements on page 50), based on hundreds of years of their own collective field experience in numerous parts of the United States. To develop them, we consulted more than 20 EMS texts in search of an existing procedure that was both humane for the public and safe for all concerned. None of those books provided more than some partial procedures and a few tips, some of which we all instantly recognized as hazardous. We also examined some 40 pieces of restraint equipment in the process of choosing our tools.

Our resulting strategy is comprised of the following steps:

  1. Identifying people and circumstances in advance that are most likely to produce violent behaviors
  2. Verbal de-escalation
  3. Mitigating the effects of fight-or-flight syndrome (in patients and caregivers)
  4. Take-downs (which we leave to police)
  5. Application of two levels of physical restraint, both manual and with the use of appropriate equipment
  6. Use of chemical restraint
  7. Self-defense techniques that have proven their worth when situations escalate unpredictably
  8. Useful documentation skills.


     The procedures described in this series are based on some key beliefs: that caregivers should not blindly rush into any situation at their own peril, that patients' rights to care do not outweigh their caregivers' rights to safety, and that violence arises from medical disorders much more often than it does from criminal intent or psychiatric anomalies. Our goals were and are safety for caregivers and humaneness for the public.

Threat Assessment: Will this person explode?
     People instinctively handle crisis in different ways. Some confront it straight on and simply deal with its implications. Others disguise it, dodge it or deny it altogether. A few eventually suffer physiologic sequelae when they can't cope with it. But regardless of whatever else they may do, many people lose control of their emotions in the face of crisis. That occurs most predictably when people ingest certain chemicals, especially stimulants.

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