EMS Reruns addresses dilemmas in EMS. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail Nancy.Perry@cygnusb2b.com.
You're a seasoned paramedic, and you pride yourself not only on your competence, but also your kindness most of the time. You generally like people, and you enjoy helping most of them. You've achieved a balance between taking the job seriously enough, yet not taking yourself too seriously. You rarely let patients dictate your emotions, and you're smart enough to filter everything they tell you—yet, you normally don't fall into the trap of posing as their judge.
One night, you and your partner, Mert, are transporting a nasty drunk to a trauma center after his '75 Chevy pickup was broadsided at an intersection (making him even nastier). Of course, the collision was all someone else's fault. He also wasn't belted, and you've identified some crepitus in the left side of his chest. You stabilize his chest wall, start him on oxygen, connect a couple of lines, get him into C-spine and begin transport to a trauma center. He's restrained, because he's been threatening to kick your asses ever since you encountered him, and he's not aggressively resisting the restraints. But he won't lie still, he won't tolerate a mask, and he won't shut up. His speech reflects his unending speculation about your lineage, your sexual orientation and your pathetic lack of intelligence.
None of that seems too unusual. But as Mert backs into a parking space, this guy hawks a big loogie onto your clean ceiling. You hate that. Appropriately, most of it falls right back onto his forehead. Now, he's the cranky one, and faster than you can stifle a laugh, he turns and nails you full in the face with another one.
Q. Other than physical attacks, spitting is about the toughest thing to tolerate. We seldom get enough warning to duck, and it always makes you so mad you just want to cold-cock the SOB for doing it. A. I'm with ya. Of course, if you do that once, no matter how nasty the patient is, he owns you. In one instant, you've stepped outside your role as a caregiver, become an assailant, and forfeited any legal defense against an accusation (by an accuser who may have nothing to lose and everything to gain from a lawsuit). Bad move!
Q. I know better than to strike a patient, except to save my life. But sometimes they make you so angry, you lose your temper. A. That's precisely what you can't afford to do. As a professional, you will be held accountable in any forum for controlling your emotions. You just can't defend yourself for losing control. One thing you can do is talk to your local cops. Spitting is a form of assault, and assaulting an EMT or paramedic may carry extra weight in your legal system. You may be able to punish somebody like this legally.
Q. I'd rather avoid the experience altogether. Isn't there some way to predict spitting, or at least protect yourself and your ambulance? A. Actually, I think you can do both. You were right to restrain this guy, because he was verbally assaulting you. I can't find this referenced in any EMS texts, but I think it makes perfect sense to expect a verbal assault to escalate—especially one that takes the form of a threat. It also makes sense for you to take precautions prior to being alone in the back of your ambulance, where you make yourself most vulnerable to people you don't know. Finally, I think it makes sense to presume that if you have a patient fully restrained and the only way he can attack you is by spitting or biting, he may resort to either of those options (or both). In fact, I think it makes sense even if he's not angry.
Q. So, how do you keep them from spitting? A. You can't. But you can keep them from hitting anything. The most ethical way to do that is to apply a spit shield. An ordinary oxygen mask is a good primary spit shield, but lots of people can remove their own O2 masks. Beyond that, you might try something like the Stearns Spit Sock. It's quick, compact, inexpensive and effective, and you can check it out at www.spitsock.com.
Incidentally, you can find a comprehensive strategy for dealing with violent people (including a discussion of the Spit Sock) in the January 2007–May 2007 editions of EMS Magazine, or at www.EMSResponder.com/violentpeople.
Thom Dick has been involved in EMS for 38 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at firstname.lastname@example.org.