Much of the information we covered in behavioral emergencies, and in toxicology, will overlap throughout. But it's important to take some time and hone in on something we emphasized over and over again, and that's your personal safety. Particularly, we will discuss the management of the violent patient in this lesson. One of the biggest threats to your safety may be the person you are trying to help. It's important to understand how to safely manage a violent patient, so that both yourself, your crew, and the patient, can have a safe experience. This is much easier said than done. We will go through some basic principles, but we will also go through some of our pearls provided by our very own Arthroplay Corners, a paramedic who works in the field, and sees this every day. Let's start with some basic principles. First, approach the patient as you normally would, slowly and surveying your scene. Make sure that you have an exit strategy, and maintain a comfortable distance between yourself and the patient. Ensure that your patient is not in-between you, and your exit. In a patient who may be violent, avoid immediate physical contact, because this may elicit a violent response from the patient. You may need to provide some comforting words, and ask if it's okay for you to move closer, or check their pulse. Try to communicate with your patient. Don't instantly write them off, and do your best to approach your assessment in the same manner you normally would, with perhaps heightened caution. Try and give them an opportunity to explain themselves, maintain good eye contact, because this shows your confidence in control, and allows you to begin your assessment. However, if a patient tries to fight you, do not approach them, hands up, yell for help, identify yourself, and walk backwards. Call for backup, and do not approach the patient if they are a threat to your safety. The same goes for the back of the ambulance if they try to fight, pullover, jump out, and call for help. Do not jeopardize your safety to fight a patient. Now, let's hit the streets. Arch shared some of his thoughts to the violent patient, and they are certainly worth reviewing. First, not to sound like a cynic, but don't trust any patients. Every patient has the potential to become violent, remember, they are in a terrible situation. But this goes especially for elderly, children, or people that start out as nice. Have your guard up. This is especially true for those under the influence of drugs or alcohol, they can be nice one second, and trying to attack you the next. Next, do not negotiate deals with patients you cannot trust. For example, if you can be nice, we will take these restraints off. If they're in restraints, leave them on until care is transferred. Which brings us to our next point, restraints. If a patient is sick and altered, or intoxicated, or psychotic, and has the potential to escalate, or become a threat to you, consider physical, or chemical restraints. Now, this is something that will have significant variation depending on your local protocols. Some areas have standing orders for the use of sedating medications to improve safety in city patients that are a threat to themselves, or others. Other places use physical restraints, sometimes soft, or velcro restraints. Other areas require law enforcement assistance if any kind of restraint is used. Know your protocol, know what tools you have at your disposal should the need arise. If it comes down to needing to restrain your patient, you should not do this alone. Both yourself and your partner, should have a system. Often this involves each of you grabbing a wrist and an upper arm, and controlling that side of the patient. Prevent the patient from getting their arms loose. Do not allow yourself to be kicked or head butted, and within control of their arms, keep your distance. Also, beware of spitting patients. Consider a face mask for yourself, remember PPE, and your patient. Your system may have an approved spit hood. Also, if your patient is spitting, they may bite. So, beware going anywhere near the mouth, if you're trying to put a mask on your patient. Your adrenaline maybe pumping, and you may be experiencing your own fighter flight instincts in these situations. Take a step back, check your own pulse. Remember, assaulting a patient is never excusable, no matter how threatening they may be to you. Never ever allow a patient's airway to become obstructed during a fight or restraint process. A patient that is violent and then hypoxic, will likely become more violent as they struggle to breathe. A patient should never be restrained or transported prone. This can cause death in the patient with delirium and agitation, and has been proven over and over again in studies, this is never acceptable. Speaking of never acceptable behavior, getting assaulted is not okay. File charges against the patient who assaults you, or injures you. This is not just part of the job, it should not be viewed as such. You need to stand up for yourself in your profession, especially with violent patients, and the legal system is on your side. Press charges and do not make this the norm, both for yourself and for the profession as a whole. Let's revisit some key points. Keep your cool, approach the patient safely, and with a planned exit strategy. Call for backup if the situation is unsafe, be a skeptic, but not a cynic. Know that a sick patient could become violent at any point, and a patient that's demonstrated violence, should not be negotiated with. Know your local protocols for physical and chemical restraint. Your safety is number one, your partner safety is number two. Always keep yourself safe, and always make it home at the end of your shift.
