Chapter 54. The uncooperative or violent patient
Ambulance crews are frequently exposed to violent situations and threatening behaviour from patients and bystanders. Ambulance control should communicate to crews any factors that may increase their risk when attending a scene. Factors suggesting the possibility of violence include:
• Location – such as night-club, party, rave, etc
• Historical – are violent incidents known to have happened at this location in the past?
• Type of call – fighting, stabbing, domestic violence
• Illness related – head injury, pain, delusions.
Police support should be requested early.
Prior to arrival
It is important to think about equipment that may be used against personnel, e.g.:
• Equipment bags
• Scissors, pens, pencils
• Stethoscopes.
All communication equipment, including hand-held devices, must be checked to avoid communications breakdown when help is needed in a violent or potentially violent situation.
On arrival
On arrival, initial considerations must include:
• Protective clothing – is there a need for a helmet and eye protection? Should high-visibility clothing be worn?
• Vehicle positioning – position safely with an easily accessible exit
• Survey the scene
• Establish if there are other services present. Who is in charge?
• Determine whether support (ambulance officer, police, fire brigade) will be needed
• Clear bystanders.
Systematic approach to the uncooperative or violent patient
• Maintain safety
• Introduce yourself
• Establish a rapport
• Set the ground rules
• Seek a history
• Seek clarification.
Principles of assessment
As mentioned above, it is essential to complete a brief survey of the scene.
• Is it safe to enter?
• Where is the person? Is he standing, sitting or lying?
• Is the person calm, upset or angry?
• Are there objects nearby he could use to inflict harm? (If there are, they should be discreetly removed to a safe distance.)
Attempt to treat the person in the same manner in which one would like to be treated oneself, with respect and maintenance of dignity.
Attempt to establish a rapport with the patient by engaging them calmly, clearly and in a non-threatening manner.
Try and identify if a specific issue is making the patient angry.
Assessment and identification of the problem are vital to:
• Provide a clear history
• Prevent frustration
• Prevent violence and non-cooperation with ambulance personnel and others.
Transportation of the uncooperative or violent person
• Consider whether it will be necessary for a police officer to accompany the patient to hospital and to ensure that ambulance control is fully aware of the situation
• Before entering the ambulance with the patient, any potentially dangerous objects should be stowed securely away
• Remain calm
• Ensure that there is an exit
• Maintain a 2-metre distance from the person and stand side-on
• Maintain non-threatening eye contact
• Seek extra help (in the background, e.g. in another room)
• Be careful what one says
• Try to negotiate and so defuse the situation
• Do not lie, or promise outcomes one cannot guarantee
• Recognise the need for rapid intervention if the situation deteriorates further.
• Immediately call for police assistance
• Use only the minimum of physical restraint to control the situation
• Never restrain a person in a way that could impair breathing, e.g. pushing the person’s face down or sitting on his chest
• Never restrain the person around the neck
• When restraining, use only the legs and arms
• Check pulses in these limbs to ensure circulation
• Reassure the person at all times
• Keeps calm and avoid threats
• Negotiate with the person
• When the person is calm, slowly release the physical restraint
• Liaise with the police to decide appropriate management – hospital care or police custody.
• Attention should be paid to the seating arrangements, bearing in mind the patient’s potential for violence or escape and crew safety
• Only when it is clear that one has enough information should a decision be made to transport the patient
• Reference should be made to service guidelines and policies on transporting violent or uncooperative patients
• If the person is to be admitted under the Mental Health Act 1983, then an Approved Social Worker or Community Psychiatric Nurse may accompany the patient
• If male ambulance personnel are transporting a disturbed woman, then a female chaperone is essential to protect the crew from allegations of misconduct.
What to do after an incident
• After an incident involving violence has occurred, ambulance control must be informed
• Medical attention should be sought for any injuries and the police will need to be informed
• An incident form should be completed. Completing the incident form is the responsibility of the staff member involved in the incident. Other personnel may be at risk in the future if the form is not completed.
For further information, see Ch. 55 in Emergency Care: A Textbook for Paramedics.
