Force

My mother had to witness someone get tased by police on her street a few weeks ago. This prompted a discussion at the next family visit about how she believes tasing to be inhuman, that "no one should have to go through that."

I'm a taser advocate. I have a brother who's a police officer, he's deployed his taser 3 times in the last year and a half. There are two police officers on my fire department who've conducted taser demonstrations. I like to think I'm pretty well versed in our local PD's use of force protocol.

So I posed the question to my mother, "would you rather he have been battoned, maced, tackled, or shot?" I explained to her that tasing is about protecting the police officer first, and limiting physical harm to the suspect second. It's about using an appropriate amount of force to control the situation, in the safest and quickest way possible. That given the situation, tasing was the most appropriate means of controlling the situation.

This got me to thinking about use of force in EMS, and how we apply force in the field. My protocols allow the use of physical restraints (including handcuffs and soft restraints) and chemical sedation (up to and including chemical paralysis). Use of restraints (meaning all type of restraint by force) is covered under my Patient Restraint protocol in situations where the behavior is a threat to themselves or others. It leaves a lot to interpretation and paramedic discretion.

What constitutes a threat? What defines a violent or combative patient? When do we use force to control the situation?

My definition of combative starts pretty early: abusive language, threatening language, or profanity. For others, combativeness doesn’t start until the patient throws a punch. If my patient gets combative, when do I apply force to control the situation? How much force do I apply? EMS has the ability to use force, but there is no Force Continuum (and no, that’s not a Star Wars reference).

A continuum of force is like a use of force ladder, it describes what level of force is warranted given the circumstances. Police officers use it to determine what to apply various levels of force up to lethal force. Where is our guide book in EMS? When is it appropriate to start right away by chemically sedating a patient? When do we start with just trying to talk? I believe some of these answers come from experience, from talking your way through the emotionally disturbed patient to having your ass kicked by the drunk that just snapped.

Should our application of force be a process we have to learn by doing or should there be more direction? Is it a question of protocol and how liberal or conservative we want them to be? Or should we as EMS responders have anything to do with application of force in controlling a patient? How many times have we heard that our safety is paramount? Call the cops for the combative or violent patient. Sometimes police aren’t available or your call goes suddenly south without warning.

I think as a field we know what not to do. We don’t clamshell our patients anymore. We don’t sit on their chest, place them prone, use a non-flowing non-rebreather, or hit them. We’re cautioned about medication use: Inapsine in rare cases can cause Torsades, Versed can cause respiratory depression. What do we do?

Outside of lackluster protocols, advice is mostly anecdotal. We’ve all heard stories from our coworkers about how they handled the unruly drunk or the tweaking meth-head. Why isn’t there more direction on how to apply force in the field?

It seems that in an emergency services system, where cops are being trained as EMTs and are carrying AEDs, where firefighters were bullet proof vests, and where fire investigators are armed, EMTs just aren’t keeping up.