Managing the Combative Patient:
Techniques Used by EMS Providers.

A Survey Study

“Established in 1992 by the UCLA Center for Prehospital Care, the Prehospital Care Research Forum is dedicated to the promotion, education, and dissemination of prehospital research.” Each year since then, the Journal of Emergency Medical Services’ (JEMS) annual EMS Today conference has featured poster presentations and oral presentations of EMS research reviewed and accepted by the Prehospital Care Research Forum. Additionally, the ABSTRACTS of accepted research projects have annually been published in a “Supplement to JEMS.”

This abstract was obtained from the Prehospital Care Research Forum Supplement
of JEMS, March 2003; page S-17.

Managing the Combative Patient:
Techniques Used by EMS Providers.

Thomas Dunn, PhD, EMT-B
Peter Martin, EMT-B
Will W. Dunn, BA, NREMT-P

Introduction: EMS providers often treat and transport combative patients. Coping with these patients can be a far more complicated procedure than in an emergency department. It might be up to only a single provider in the back of an ambulance to deal with a combative patient. Law enforcement or security personnel are often not close at hand. Further, while sedation may be available to some providers, it may be impractical (or dangerous) to deliver in the “heat of the moment.”

Hypothesis: EMS providers use a variety of techniques to manage combative patients, and these techniques might be outside of protocol. Some actions may also be inappropriate.

CHAS NOTE: This study, and its abstract, was completed and submitted for publication well before the January 2003 JEMS Tricks of the Trade column about restraint was published.

Method: A convenience sample of 188 EMS providers (both basic and paramedic) from five agencies in two states was surveyed. Participants filled out anonymous questionnaires to describe the techniques they use most often to control a physically combative patient.
Note: Data collection occurred before the FDA warning about droperidol (Inapsine).

Verbal Intervention: 74%
Physical Restraint: 94%
Chemical Restraint: 72%
Nasopharyngeal Airway: 6%
Nasal Intubation: 5%
Strike with Hand: 6%
Strike with Fist: 2%
Yell or Shout: 38%
Physically Threaten or Intimidate: 38%

These providers were also asked to report whether they had ever witnessed a coworker possibly acting inappropriately during a restraint. Their responses were:

Analysis with inferential statistics found significant differences between male and female EMS providers, as well as urban vs. nonurban EMS systems.

Conclusion: EMS providers use a variety of techniques when dealing with combative patients, some of which are outside of protocol. Some providers behave inappropriately. Additional training and quality assurance and quality improvement on treating patients may be necessary.

Direct correspondence to:
Thomas Dunn, PhD, EMT-B, Campus Box 94, Greeley, CO 80639

CHAS’ Review:

Mr. Dunn’s survey results are quite interesting! It’s unfortunate that the entirety of his study results review will likely never be “published” anywhere. (I Emailed him, and asked if he had written the entire report. He hasn’t. Additionally, he told me that the “Accepted for Publication” heading of his study abstract’s supplement page was an error.) Were he to ever have it published, I would dearly like to read his analysis about the, “significant differences between male and female EMS providers, as well as urban vs. nonurban EMS systems.”

Considering the high percentage of Chemical Restraint use (72%), it’s rather obvious that most of the survey respondents were from urban EMS systems. But, what is most interesting (alarming) were the responses about coworkers being witnessed abusing patients!

These numbers may reflect an equal propensity for patient abuse by care providers in urban and nonurban EMS systems.

Given the frequency and nature of the abuse reported, I think that Mr. Dunn’s “may be necessary” qualification for the conclusion he drew from his study’s finding is entirely inadequate!

His survey results aptly demonstrated that adequate training in effective and appropriate medical application of patient restraint IS necessary!!!

Additionally, effective and appropriate PROTOCOLS for medical application of restraint remain almost nonexistent. I wonder how many of the 72% of survey responders who administered chemical restraint had effective and appropriate Physical Restraint protocols to follow?


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