You’ve just witnessed a piece of EMS history.
You’re in the back bedroom of a neat little home in a quiet neighborhood. Here, sitting in a corner on the floor, a profoundly hostile six-year-old has just offered you an unfortunate appraisal of your heritage. He’s also speculated about your sexual practices and assessed your net social worth, all with a gutter-level eloquence that would embarrass the worst slimeball you’ve ever seen in your life.
You’ve never heard that language in a child’s voice, and for a moment you’re catching your breath. Your partner glances across the room at you, dumbfounded. For the first time in the 20-some years you’ve known him, he’s clearly shocked. No, stunned. And the engine company is snickering. You have witnesses.
But that’s not all. As the boy’s dad kneels in front of him, attempting to explain that he needs to go to the hospital, the child spits at him full in the face from a distance of 14 inches. The father doesn’t even flinch, pleading with his son to calm down and accompany you to a hospital. At that point, the child jumps to his feet and wedges himself into a corner.
“I’m not going anywhere,” he says, glaring at each member of the crew. “And if any of you touches me, I’ll kick your f_____g ass.”
At this, the tearful dad apologizes profusely to all of you. Then, wiping his face with a towel, he assures you this is not his son’s normal behavior. The child has no pertinent medical history at all, but was reported absent at school today and came home agitated, fidgety and non-communicative about the events of his day. You can’t get close enough for a physical exam, but the boy’s obviously perspiring; and looking around the room, you notice he’s unique in that regard.
Q. What are we supposed to do with a kid like this? We have a restraint procedure, but all of our equipment is designed for adults.
A. I think your observation about the kid’s perspiration should be taken as an adrenergic sign, and so should his behavior. Considering his behavior is not normal and the fact that you can’t account for a big part of his day, I think you have to suspect he ingested a stimulant–cocaine perhaps, meth, bath salts or a mix of something from somebody’s medicine chest. This is a medical emergency until proven otherwise. He’s also threatening you verbally, and he’s escalating. Kid or no kid, I think your first thought should be for your physical and legal safety, and right after that should come benzodiazepines, ASAP.
Q. What do you mean by physical and legal safety, and what can we do about either of those?
A. I think you all need to glove up and be wearing safety glasses. However your restraint procedure works, one of you will have to control this kid’s head so he can’t bite. Clean, split-leather gloves are excellent for that, especially if he’s perspiring. Somebody also needs to barricade his spitting. A good way to do that quickly is by means of mask oxygen, plus a spit hood like the Spit Sock, especially if he struggles persistently.
As for legal safety, I think you’re smart to have a cop on scene before you restrain anybody. Police are trained witnesses, and they wield an escalating system of control over human behavior which we simply do not. In fact, I have believed for years that when necessary, take-downs should be done by police and not EMTs.
Q. So, how do you control a six-year-old who wants nothing to do with you and is threatening you verbally and physically?
A. I think that depends on whether you’re part of a BLS system or an ALS system. If this kid is chemically stimulated, the safest way to control him is to physically hold him down, administer benzos, and hang on until they take effect; then transport him emergently and in restraints. The last thing you want to do is allow him to struggle persistently.
In a BLS system with no access to an ALS intercept, I think you have to restrain this kid supine any way you can (possibly padded and taped to a scoop, in case he vomits), and get him to an emergency medical facility as soon as possible. Either way, communicate as early and as clearly as possible with the receiving physician. That, and document every physical parameter you can throughout contact.
Note: For a much more thorough discussion of restraint strategies, please consult “Coping With Violent People,” a five-part series that appeared in Emergency Medical Services (now EMS World) in January through May of 2007.1 There was also an excellent discussion of reading violent behaviors in the November 2011 issue of EMS World,2 and an historic NAEMSP position paper in Prehospital Emergency Care in December of 2002.3
1. Dick T, Rollert S. Coping with violent people. Emerg Med Serv, 2007 Jan-May.
2. Collopy KT, et al. Recognizing and defusing aggressive patients. EMS World, 2011 Nov; 40(11):37–45.
3. Kupas DF, Wydro GC. Patient restraint in emergency medical services systems. Prehosp Emerg Care, 2002 Oct–Dec; p. 341.
Acknowledgment: Special thanks to Michael Atkinson, BS, ATC, LAT, EMT-B, for his submission of the idea for this installment.