violent psych patients

[flight-lp]

Should we as EMS providers transport violent psych patients to appropriate facilities, or should that be left to the Police. I have transported with chemical restraints but that does not always work. i mean your in a small area and if the patient decides to get violent there is no where to go, except protect yourself. any thoughts or feelings............................... i feel if they are violent they should go by Police.....................

2 thoughts..........

1. A Zoll monitor usually can slow a patient down if they attack.

2. Chemical sedation is always beneficial, especially if you use Succinylcholine.

[EMS828]

i had one pysch patient who could not recieve sedation it made him worse............ he wold lash out with pens, towels, what ever he could get his hands on, but we transported in six point harness and took 1 driver and 3 in the back............ so sometimes chemical sedation works and then sometimes does not, but i like the zool m monitor idea

lololol

[captainstandup]

I agree this is a sensitive issue and suggest it is multi-faceted. I tend to err on the side of caution when allowing someone that I have been summoned to care for to refuse care or to be "transported" by the Police. It is my suggestion that this issue be approached in the following manner and of course your Physician MD must be on board with all decisions regarding care or refusal of care for a human being.

First the question that must be asked is: Is there a presence of an impairing substance or distracting injury? Is the patient in any distress physiological, psychological or is there any possibility that the psychosomatic effect of the situation is in ANY MANNER compromising the individuals’ immediate hemodynamic / cardio respiratory stability.

Is this individual actually a patient or is the event purely a law enforcement issue? If this is the case, why were you called? Is there any conceivable manner that you can safely care for this individual? To what extent is Law Enforcement willing or allowed to assist? In WNC there is a tremendous aversion among the LE community to "get in the middle" of these kind of situations in absence of a court order.

It seems elementary to believe that regardless of your decision regarding transport, if things turn out badly and the patient suffers a serious condition, dies or is found dead in jail the next AM; the first target of criticism will be prominently posted on the EMS crews chest, since they will have been the "medical professionals" who were on-scene.

Next, in the presence of an impairing substance and or condition (and I feel a psychiatric emergency is an impairing condition in this context) it is unlikely the patient could make a rational decision therefore their opinion is not valid. Depending on your state laws you may have to obtain a court order to forcibly transport the patient.

If all conditions are met and you believe the patient is in need of EMS transport you will likely be forced to consider a variety of restraint options including physical, soft restraints, improvised restraints and finally chemical restraint. Clearly the least invasive and least forceful means necessary to accomplish the task is preferred, bearing in mind the potential for escalation. Ensure that you have adequate personnel and equipment to manage the situation before committing. We actually carry a wide variety of narcotics and benzodiazepine meds along with Haldol and even propofol for anesthesia, not that it would be used for this purpose but who knows?

EMS Personnel should never, never, never, never, never in any manner or for any reason accept a patient that is “hobble restrained” or “hog-tied” (Feet and hands cuffed and the patient face down) this is a prescription for disaster and totally inappropriate without exception! There is a phenomenon known as positional asphyxia that is lethal. Patients placed in this position cannot effectively breathe; you cannot effectively manage airway issues if bad things happen. Furthermore it is believed that patients on certain medications, legal and illicit, can suffer from a form of fatal hyperthermia due to the combined effects of the substance along with a reduced ability to dissipate heat through breathing combined with hypoxia. If you are interested in this issue you can find Charly D Miller on the internet, she is arguably the foremost authority on this subject in the national EMS community.

Finally, whatever you decision please remember yours and that of your partner’s right to be safe supersede everything else on earth including anything going on with a patient! You have a responsibility to yourself, your family and your colleagues and yes even the EMS profession to take all necessary measures to remain safe. This includes maintaining a high degree of situational awareness and being prepared to retreat from an unsafe situation and always being prepared to defend yourself from harm. Please remain vigilant when dealing with patients as psych patients aren’t the only ones that injure and kill emergency providers.

[Roostmonkey]

I've never had to actually hit a pt., but if I believed that a pt. was going to physically harm myself or my partner, and immediate physical intervention was needed to prevent that harm... I would not have any qualms about it. I'd rather have my partner and I walk away to fight another day.

As far as being in the back of the ambo with a pt. who was getting violent... if he/she knocks you on to the floor, there is NO room to fight back up to your feet. You don't let yourself get there. Flee, use force, whatever you have to do. You don't want to be on the floor.

PD rides with me when I have ANY question about the former two situations. That's what they're there for.

[Dustdevil]

There needs to be a written policy within the agency that establishes all of this ahead of time. This is not one of those situations you just leave up to happenstance. Look at tstkstorm's situation. He felt coerced to do things that were against his better judgement. Many, many people in EMS simply will not tell PD when the step off, and this is a real problem for us. Especially when it puts us in danger. You can sit around and second guess people all day, but the truth is that they should not have been stuck in that position in the first place. It is the agency at fault, not the individual who is working with no established guidelines.

• Guideline #1: EMS stands for Emergency Medical Service. If this person is not suffering a medical emergency that requires horizontal transportation or EMERGENCY MEDICAL intervention, then they don't go by ambulance. Just because somebody is psycho does not make them worthy of EMS transportation. If they require no medical care from me, they can ride upright in the police car just fine. This is not the 1950s. We are not the men in the white coats anymore.

Guideline #2: If they are under arrest, then they are in police custody. If they are not in police custody, then they are not under arrest. Plain and simple. I will make absolutely no effort whatsoever to restrain this person from leaving. If they turn to me and say, "I want out," then by God, I'm pulling over and letting them out. If the cops have a different idea in mind, then their fat arses need to be there to effect it, not driving behind me or meeting me at the hospital. I can't turn my patients over to cops. Cops can't turn their prisoners over to me. Cut and dried.

Guideline #3: I am not a professional wrestler, and my ambulance is not a UFC cage. As already stated, if they want out, I'm getting out of their way and allowing them out. I will engage in NO physical contact with this person that is not part of MEDICAL care. I will not restrain them. I will not subdue them. If there is any physical contact between us, it will be in the course of self-defence, or possibly (but not definitely) in defence of the cop. Nothing else.

Guideline #4: Patient with proven violent potential or history gets four (4) cops accompanying him, or he walks. He will not be transported in my ambulance with less than four cops.

• Ridiculous, you say? Maybe. But I've never had a psych patient whip my arse or escape from my moving ambulance in thirty-five years. And I'm still alive after thirty-five years to talk about it. Will you be able to say the same?

[CBEMT]

Well, let's look at it this way.

Which lawsuit is more likely to have legs: letting a psych patient go, or taking them to the destination against their will?

[spoil:da3415ac77]Abandonment. Every time. Keeping the patient in the truck against their will will be ruled as the provider acting in the patient's best interest. Dumping them on the side of the road is clearly not.[/spoil:da3415ac77]

[katbemeEMT-B]

What psychiatric education do you have that enables you to reliably determine if there are any questions as to your safety or not? Seriously, how do you know until it happens?

There are always questions as to your safety. Complacency kills.

Dust, I do have some psychiatric education, but that is totally irrelevant here. What you're forgetting is regardless of whether it is a psych patient, medical, or frequent flyer, as EMS personnel, we ALWAYS have to question our safety. At some point, you learn to read people and pick up on those behaviors that cue you in to what is going to happen next. You have to stay a minimum of two steps ahead of your patient. After almost getting smacked in the face by the dumbass who decided he needed to take a bottle of pills chased with ETOH, I have learned this lesson well. I can say the same for a medical patient suffering from a diabetic reaction, except she actually hit me. I can tell you with certainty that when faced with a psych patient, LEO always accompanies us to the hospital. If by chance we have to transfer the patient from the hospital to another care facility, we must be guaranteed the patient is subdued or we will not transfer.

Safety is number one for all involved. While it sounds like a great idea to just let the cops haul some one's ass in, it doesn't work that way. Let's also not forget, a psychiatric event can also be an emergency, hence why we have that little box on the PCR that we check for psych/behavioral.

[Dustdevil]

Dust, I do have some psychiatric education, but that is totally irrelevant here. What you're forgetting is regardless of whether it is a psych patient, medical, or frequent flyer, as EMS personnel, we ALWAYS have to question our safety.

I wasn't forgetting that. It was the very point I was attempting to make.

[AnthonyM83]

Dust, did you find that officers were always able to provide four officers (plus officers to drive patrol car(s) over to pick their officers up...remembering that prisoner cage is a dirty place for them to sit) to ride in the ambulance with you? That's taking a lot of officers out of commission...I worked for a city of 32,000 and four officers made up the entire shift from 3AM to 6AM. Also, did that many officers in the back inhibit patient care? Where they all able to secure themselves with seat belts? Did they mind leaving four patrol cars parked on the street unattended possibly in bad areas?

If a patient has all four extremities handcuffed to the main frame of the gurney, you have an officer aboard, and another patrol car following how much less safe would you be than having four officer aboard. If patient ends up having super human strength (and for some reason you didn't notice was on drugs) and starts getting out of restraints, do you really not have time to pull the ambulance over and step out to let police officers deal with it?

I agree on the other points, though.

BTW, what patient does not have a violent or psych history, but enroute becomes altered to the point of trying to leave (but requires emergency medical treatment). How hard does one as a medical professional try to restrain patient? At what point do you back off? How do you decide?

[Dustdevil]

Dust, did you find that officers were always able to provide four officers (plus officers to drive patrol car(s) over to pick their officers up...

Nope. And obviously, over a thirty five year span, this has not always been my policy. Like most of my SOPs, it is a policy that has been shaped by years of experience, and forever changing. But what it is based on is the police's own current policies. Current national standard taught in law enforcement is that, to subdue a violent psych, an officer must be available for each limb. That's what the physical restraint tactics instructor from the local academy is going to show up in court and testify is the current state of the art for them. Why should it be different for them when the guy is in my ambulance? I want them to take at least as much concern for my safety as they would take for their own. If not, screw them. That's what they have a cage for.

BTW, what patient does not have a violent or psych history, but enroute becomes altered to the point of trying to leave (but requires emergency medical treatment). How hard does one as a medical professional try to restrain patient? At what point do you back off? How do you decide?

Exactly. That's why, at the first sign of trouble, I'm pulling over and letting them out. Letting them out of a STOPPED ambulance. If they drag me out with them, it won't be because I was standing in their way, and it won't be a moving ambulance, as seems to appear in the news regularly.