Medic 62 (ALS) and ambulance 65 (BLS) respond and stage to the local college for an overdose.
After the arrival of law enforcement, contact is made with the patient. He is coherent but agitated and upset. He says he took “a whole bunch of pills” and has been drinking. He confirms he was trying to kill himself. (He is 6´3" and a member of the football team.) Scattered around the room on the floor are a multitude of pills and empty bottles.
Dan, one of the EMTs, starts picking up the bottles while Bill, one of the medics, tries to talk to the patient. He is A/O x3 but refuses treatment. Even though Bill is talking reasonably to him, the patient will not budge. The pill bottles contain several different antidepressants in the patient’s name, Tylenol and Advil.
The two medics confer quietly and decide that there isn’t much question, the patient must go to the hospital. Bill speaks to him. “Sir, because you’ve been drinking and have taken these drugs, we can’t leave you here. Your judgment may be impaired. I hope you realize that trying to kill yourself is not normal. You need help. Can we please take you to the hospital?” The patient replies no and reiterates, “I’m not going.”
Bill continues, “Sir, I’m sorry, but we do have a legal right in this situation to take you. One way or another, you are going. We would prefer you come willingly.” At this point, officers Liu and Wallace, recognizing their cue, start to position themselves close to the patient.
As the patient tries to push away, the officers grab his arms and take him down. With everyone’s help, the patient is quickly subdued and handcuffed. He is taken down the stairs, and once in the ambulance, becomes extremely noncompliant and agitated. Due to the close proximity to the hospital, no treatment is done en route. The ED is notified that security is needed.
The patient is medically cleared seven hours later and transferred to a mental health facility on a 72-hour hold.
Patients who are uncontrollably violent or mentally unstable are often transported against their will, and you need to be very familiar with the legal aspects of such instances. However, also keep in mind that just because your patient doesn’t want to go with you doesn’t mean you have the right to be unpleasant to him. If you are able to speak to the patient, explain your concerns and why he needs to be transported. It is good customer service to always give him the opportunity to change his mind, or create the environment he needs in order to cooperate. If he is afraid of demons under the bench seat, show him there are no demons. Listen to what he says and try to accommodate him if possible.
I like the phrase, “Is there anything I can say or do to convince you to go?” It gives the patient the opportunity to address any particular issues he may have. If he says “no,” he is telling you that nothing will work. (This line is adapted from the book Verbal Judo by George Thompson, which teaches tactical language skills for police officers. I highly recommend it for confrontational situations.)
Even if it helps your cause, don’t lie to or mislead patients. If a patient is worried about being placed on a hold, for example, be honest about whether or not that could happen. If you lie, credibility for any future responders will be lost, and the lie could cause a patient to become violent.
Try to let any family or friends know that force may be necessary. If they are surprised by everyone restraining the patient, they may try to defend him. Remove them if you think there will be a problem. They are usually the people who called, so reassure them they did the right thing. They may be useful allies in persuading the patient to get treatment.
Sometimes, no amount of talking will suffice. Having the maximum number of personnel for a takedown is vital. It is important not to injure the patient. A trained person can no doubt knock someone down, but it takes many bodies to do it safely. For both legal and practical reasons, the police should be involved if a patient has to be forcibly restrained.
By practicing, you will become more proficient with takedowns. This will help prevent injury to you, your team and the patient.
If possible, try to form a plan with other responders. Look around for hazards and try to do the takedown in a clear area. Once the patient is restrained, apologize to him for doing so and continue to explain why it is necessary. Look after his comfort if possible and make sure his handcuffs are not too tight. Once under control, he should be secured with soft restraints; all circulation and breathing should remain unimpeded.
The patient is in your care now, even if under arrest. It is your responsibility to protect him from harm. Be aware of positions that can cause asphyxia or injury. If a patient is especially dangerous or violent, he may continue to present a hazard to you or himself, even while restrained. Use chemical restraint if needed.
Knowing your local protocols is important. Simply explaining the law to a patient may make him realize it is necessary for him to be transported.
On other occasions, your patient may not be mentally ill, but merely drunk or unpleasant. Securing the belligerent patient to a backboard seems to be a recurring necessity in EMS. I endeavor to get the patient’s attention and tell him that if he can answer all my questions or repeat what I’ve just said, I’ll let him up. Giving patients options allows them some feeling of control. One of the hardest things to accept when immobilized is the lack of control.
It is your job to protect a patient’s spine. If a patient needs to be immobilized but cannot understand why, consider sedation. Threats and intimidation will not work on someone who is determined to oppose you. Save yourself the aggravation.
Being nice to patients who are cursing you out can be difficult, but don’t take it personally. There is something wrong with them, and, given the choice, I’m sure they would prefer to be happy, healthy individuals. Show patients respect and you respect yourself at the same time.
Paramedic and nurse Chris Hendricks has been in EMS since 1994 when he joined the Ortley Beach First Aid Squad. When he authored this article, he was a field instructor with Pridemark Paramedics Services in Boulder, CO. He now works as a paramedic and ER nurse, and serves with the Wyoming Air National Guard as a flight nurse. He will be receiving his Masters of Science in Nursing Education in summer 2011 and is a certified emergency nurse and a certified forensic nurse.