Recognizing and Defusing Aggressive Patients

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1.5 CEUs. There are two ways to take the CE test that accompanies this article and receive 1.5 hours of CE credit accredited by CECBEMS: 1. Click here to download a PDF of the test. The PDF has instructions for completing the test. 2. Or go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

Objectives

1) Identify statistics highlighting violence against EMS providers

2) Explain violence prevention strategies

3) Discuss the stages of aggression

4) Highlight de-escalation techniques

Steve and his partner John, both EMTs, never saw it coming. The two were evaluating Henry, an elderly man whose daughter was worried because he hadn’t been taking care of himself since his wife died three months earlier. The frail man appeared malnourished and his house had not been cleaned in weeks. Henry made it clear that he didn’t want EMS care even though he obviously needed help. Finally, in frustration, Steve said to Henry, “Sir, you have two choices: you can come with us now, or we can get the police here. Either way you need to go to the hospital!” As soon as the words came out of Steve’s mouth, Henry screamed threats at the crew and ordered them to leave at once.

Introduction

I never saw my first experience with violence against EMS coming. I was working overnight in a large urban system and was preparing to transport a child between hospitals. It was late at night and I can only imagine how tired the mother was. As the nurse gave us a report, we assessed the patient and began setting up the equipment needed. At one point I asked the nurse if she would be OK if I changed the IV fluid and its rate. This set the mother off on a series of verbal attacks which began with, “Why don’t you just do your job and stop asking all those damn questions.” In retrospect, I handled things poorly. After several minutes of confrontation, the mother grabbed and hit both me and a security officer. In the end I had a startling realization about how easily our actions and statements can trigger violence against us. —Kevin Collopy

Violence Awareness

Every year there is an increasing number of violent acts against prehospital providers. Current reporting systems truly underreport the violence that occurs, because there is no national reporting system for EMS providers to report verbal harassment or violent acts.

One study found that violence occurs in one form or another on 8.5% of all EMS responses, and this on-scene violence is directed toward an EMS provider in over half of the cases.¹

Patients are responsible for violence against EMS 89.7% of the time; however, that does leave a large number of cases (such as that described in the opening) where a bystander is responsible.

Violence can be verbal, physical or a combination of the two. In this study, physical violence was defined as any unwanted physical contact directed toward the EMS provider including slapping, hitting, pushing, kicking or spitting; verbal violence was defined as any unwanted abusive language, threats of violence or injury, or gestures toward the EMS provider.

As there is potential for violence on many responses, it is important to always look for early warning signs of escalating aggression or violence, such as increased nervousness or an individual beginning to pace or make fists. There is an increased risk for violence whenever there is police presence, a gang member involved, known/perceived psychiatric disorders, or the presence of alcohol/drug use.¹ Consider the violent scenes EMS responds to: stabbings, shootings, domestic violence, abuse, unarmed assaults, rape, motor vehicle crashes—the list goes on.