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Manhattan, New York, USA – April 6, 2020: Paramedics loading a patient into the ambulance on 42 Street in Midtown Manhattan deserted because of the COVID-19 outbreak.
By Kate Ofori, NREMTP, BS, LP
In my 10-plus years in EMS, I have been a paramedic, firefighter, field training officer, EMS instructor and lieutenant in multiple states, provided care for various demographics, and have built relationships providing a unique perspective of prehospital paramedicine.
My unique perspective through years of service and love of quality management, mentoring/teaching and risk management has allowed me to notice various problems throughout my career. I think as an EMS and fire community, we tend to shy away from our problems rather than facing them head on. I would like to try to talk about these problems and bring them to the forefront so we can have an honest, vulnerable and genuine conversation.
Let’s talk and delve into sedation management of agitated patients and how we can sort through the complex situations, calls, patients and variables we as emergency 911 medical providers must juggle and critically think through, and how we can determine best practices.
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Chemical sedation
First, let us start with a question. What are the top three medications that come to mind when I bring up: agitated, combative and aggressive patients?
You may say: Ketamine, Haldol, Versed, Geodon, Droperidol, Ativan, Valium, etc.
I likely missed some medications and you probably have your favorites. However, how do you determine, based on patient presentation, vital signs and assessment, what medication you should administer?
“Because I have done this before.”
“I can just see it in their eyes or tell.”
“I did a full assessment and it seemed like the right medication.”
“I use Ketamine because I like it.”
No matter how you justify the above question, most answers come from subjective, personal preference and bias.
So, how do we make the process of sedation and chemical/physical restraint more objective than subjective — something we can measure? How do we justify the human factor, experience and knowledge into reasoning in our reports? How do we make clinical decisions that provide appropriate patient care, and also ensure that we as paramedics, firefighters, AEMTs, EMTs, etc. do not end up on the news?
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Safety first
We am not in the business of wrestling or fighting patients — utilize your resources. Stage when appropriate. Utilize police departments (PD), constables and sheriff’s officers. They are trained in restraining and safely detaining patients. They can also search patients and ensure that we as medical providers are not at risk of being injured, assaulted or physically abused by patients that are altered, agitated or combative.
If the patient is unable to be detained or searched, or you are on scene by yourself, be careful. Maintain situational awareness. Call for a supervisor, law enforcement or fire department support. Do not try to take on a complex problem alone. The more people you involve, the more resources and support you receive.
Talk to your patients. You can gauge a lot by having a conversation. Is your patient altered? Are they at risk of hurting themselves? Do they have the capacity to make decisions? Are they being a risk to others (bystanders, PD, fire, you or your partner)? Is your safety at risk? Your utmost priority should be your safety as well as your partner’s. Keep your eyes open, listen and continuously reassess scene safety. Get the story from the patient, law enforcement, other first responders and bystanders.
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Assessing agitated patients
Keep the following patient assessment steps in mind prior to sedation management.
Obtain a hands-on assessment head to toe. Yes, that is right put your hands, paws, meat hooks on the patient. Feel their skin, temperature, condition; and put your fingers on their pulse. Is it weak, strong, bounding, regular or irregular? Build a connection and obtain all vital signs. Ensure you obtain at least blood pressure, SPO2 and heart rate/4 lead ECG to start. Blood glucose and temperature help rule out potential for hypo/hyperglycemia or hypo/hyperthermia. Determine the patient’s mental status (alert and oriented?), AVPU and GCS. Obtain lung sounds, ETCO2, 12-lead, etc., in a secondary assessment.
Make sure to obtain a full past medical history. These include signs/symptoms, medication allergies, medications they take/should be taking, pertinent past medical history, surgeries, hospitalizations, last oral intake, and events leading up to the incident. Ask questions such as:
- When did the onset occur?
- What provokes the pain/problem?
- Does the pain radiate or go anywhere?
- What is the severity?
- How long have the symptoms been present?
- Has the pain/problem changed over time?
Watch your energy, approach and attitude.
- How are you talking to people?
- What words are you choosing to say?
- What is your tone or facial expressions?
- Are you showing up like you don’t want to be there?
- Do you have a bias predisposition in your head?
- Are you letting your past experiences cloud this interaction or alter this interaction with your patient?
- Are you treating the patient like someone’s loved one?
- Or are you treating the patient like they do not deserve your quality care, assessment and advanced interventions?
I know COVID-19, 911 abuse and even the winter cold/flu season can take a toll on us as providers, but you should still treat everyone, no matter the circumstance, with quality care.
Managing agitated patients: Best practices
With all of this in mind, how do you objectively; based on data or best practices, determine the type of sedation medication and dosage to utilize from the above information?
Well, just like we utilize scales for strokes, pain and trauma criteria, some organizations have created and utilize sedation scales to determine appropriate medications based on a number scale. Some hospitals and prehospital systems utilize the Richmond Agitation Sedation Scale (RASS). RAAS ranges from +4 to –5 with 0 in the middle as calm and alert.
Cambridge University Procedural Sedation (2012) and Columbus Ohio (2024) have different approaches to determine the proper medications and dosages for sedation management. They utilize protocols and guidelines with options and scales, with dosages of various sedation medications and routes of administration.
Organizations should evaluate their patient populations, demographics, medication availability and medication mechanism/pharmacology. Please follow your medical control, local protocols and guidelines.
I would love to hear about your organization’s guidelines, protocols and best practices on sedation management of agitated, combative, aggressive patients. Please email us at [email protected] to share your protocols.
Be safe out there.
ABOUT THE AUTHORKate Ofori is a lieutenant, paramedic and field training officer for San Marcos Hays County EMS (San Marcos, Texas); and a paramedic for Ascension Event Medicine (Austin, Texas).
She has a Bachelor of Applied Studies in Fire and Emergency Response Management from the University of Wisconsin, in Oshkosh, Wisconsin; and is pursuing a Masters of Public Administration from Syracuse University (Syracuse, New York).