There's a Male Who is Naked in the Roadway, Yelling At Cars

"Respond to the area of Main St. with police... There's a male party who is naked in the roadway, yelling at cars."

John. It's always John.

(Side note: Sorry Johns... Your name is disproportionately used for placement characters)

Everyone at this EMS service is familiar with John and every EMS service has their own "John." This John is a 34-year-old male who is commonly found around Main St. getting into trouble. He has a long, documented history of schizophrenia and drug/alcohol abuse with very frequent bouts of psychosis and, unfortunately, violence/combative behavior toward police, EMS, and, well, everyone really.

We pulled up with the police just in time... John had just thrown a rock through the windshield of a passerby who did not take kindly to it. Said passerby was now actively fighting John. John was not winning…

Patients with acute agitation and psychosis present a myriad of challenges for EMS. Both from a patient care perspective and a provider safety one. Unfortunately, I have never met a paramedic who has not been assaulted, especially if they work in a city.

Severe agitation is almost always caused by one of two things, at least in my experience. Untreated or poorly managed mental illness and/or substance abuse disorders.

Agitation is not a disease, it's a syndrome. These patients are irritable, have heightened responsiveness, and can be violent towards providers. But it's important to remember that, being a syndrome, there is an underlying cause. As for John, he has severe, poorly managed schizophrenia and likes cocaine.

However, even with patients like John, you need to keep a wide differential. Because while 9/10 John didn't take his meds and used cocaine, there is always that one time that John got hit with a brick and had a TBI (that actually happened... Months later).

Now, these calls can go many ways. But here is how I tend to go about it.

The fight between John and the passerby was broken up by the police almost immediately. John was pulled to one area and was obviously agitated when we approached. He was screaming profanities, punching and kicking police (who were being very reasonable, honestly), and threatening everyone with physical violence should the officer unhand him.

Reuben Strayer describes three levels of severity when it comes to agitation: Agitated but cooperative, disruptive without danger, and dangerous agitation. John was being dangerous to everyone, including himself. John was obviously in the dangerous agitation category.

For me, this category requires immediate escalation in care. What do I mean by this?

Normally, the first step in managing agitated patients is talking to them... Treat them like people. It's really easy to walk into a situation at a 2 and quickly escalate to a 10 if needed. It's REALLY hard to walk into a situation at a 10 and de-escalate to a 2. Your attitude, appearance, and HOW you speak to people matters.

I like to walk into a situation and just let the patient talk. Prevent them from being mad at you and everyone's life is safer and easier. Ask them what's bothering them. Remember that whole Maslow's hierarchy of needs thing? People NEED that. Often times you can de-escalate someone by simply addressing these needs. Physiological, safety, love/belonging, esteem, and self-actualization. Start by hitting those. Ask them about their concerns. Ask them why they are upset. Often times they will become willing participants in their own de-escalation. I've even peacefully offered meds to help them with this.

"Hey man, I'm sorry you're going through that. You seem really upset, and rightfully so. What are your thoughts on some meds to help you relax a little bit on the way to the hospital?" - That type of thing.

John was WAY beyond that. John was in a full-blown psychotic episode.

By definition, John has lost contact with reality. His thoughts and perceptions are completely disrupted at this point and, unfortunately, verbal de-escalation is not going to fix him. In this scenario, the priority is our safety and his safety which requires immediate action.

John's acute agitation and psychosis are at this point prohibiting his care. We can't get a full assessment, vitals, ECG, etc. on him at this point. We needed to rapidly act to gain control of the situation, which, can be a hard decision. The plan is to physically restrain him and give him medications against his will to facilitate his safety and care.

Now granted with John it's usually his schizophrenia mixed with a cocaine-fueled rage... But not all patients are straightforward, and to be fair, John may not be this time like he was last time. There are several legitimate medical reasons to act this way. Reasons we need to assess and manage. Sometimes patients need to be restrained, both chemically and physically, to do this.

So anyway, that was our plan. The police were able to assist John into the ambulance and onto the stretcher. There, with police assistance, we used four-point restraints to secure his limbs with a person on each limb and one to place the restraints on.

These patients should ALWAYS be SUPINE. NEVER PRONE. Prone position is how you kill these patients via suffocation. I always position them supine, with the head of the stretcher at 30 degrees to prevent aspiration. Never tie restraints to railings. Always tie to the base of the stretcher itself. I put one arm up and tied it up behind his head and then one arm down to prevent harmful movement. I also always cross the leg restraints to prevent kicking. I tie the right leg restraint to the left side of the stretcher and the left leg restraint to the right side.

Unfortunately for John we also needed to place a hood over his head - John likes to spit.

Once John was secure, I drew up meds. This is a HUGE passion point for me. Restrained patients are ALS patients. Period. This is in no way, shape, or form a BLS call.

Now that John is physically restrained, he needs to be chemically restrained/sedated. It is not good to have John continue to fight against restraint. This can cause further injury and harm to him. This is also, to me, cruel and unusual punishment. I have taken away John's right to make decisions for himself. I have taken away his rights/means to defend himself. It is now my responsibility to him to treat his agitation and psychosis and not leave him this way.

There are lots of meds and ways to use meds to do this. For me, the decision comes down to three options:

(1) Benzos alone.

(2) Benzos + an antiphysotic.

(3) Ketamine.

I recognize we all have different meds, protocols, cultures, options, etc. Here is how I do it:

If the patient is agitated due to drugs, withdrawal, etc. I will consider just giving a benzo. For me, I'm not wasting time getting an IV first. I give the meds IM and then I'll get an IV once they are settled. So I'll usually do IM midazolam.

If the patient has a history of schizophrenia, psychosis, other mental health disorders/mood disorders, etc., plus or minus drugs, I will give IM midazolam AND IM haloperidol - an antipsychotic. This will calm the patient acutely and will begin to help their underlying condition.

This is what I did with John, here. He got 5 mg of midazolam and 5 mg of haloperidol.

If the patient requires immediate intervention for an imminent risk of injury to themselves or others, I will give ketamine. For instance, the patient who is fighting too much to safely restrain, the patient who is actively attempting to harm themselves while restrained, the patient who is in an excited delirium-like state, etc.

With John, you could make the argument to give ketamine right off the bat. That's fair. If this was Bob, or Daniel, or Kevin, or whoever, I may have done that being that he was actively fighting both police and bystanders. I just knew John. I knew this pathway works well for him. There is also the consideration that ketamine is relatively contraindicated in schizophrenia as it can actually worsen the psychosis. I knew John has this and I knew John doesn't do super well with ketamine. It was an experience-led decision.

Once a little calmer I got some vitals and put him on the monitor. I did a full assessment to rule out other causes of his agitation and gave him a trauma once over from the fight - He had a black eye and bloody nose. You can consider a 12-lead with antipsychotics - they can prolong the QT - but this is generally not an issue with IM dosing. Within 5-10 minutes John was chillin' out on the stretcher, looking around, dozing off. I took the spit hood off to monitor his airway better and put him on an EtCO2 cannula - something that should always be done as soon as practical. Keep in mind, YOU sedated him. YOU own his airway and vitals now. I then started an IV, hung a little fluid, and rode it in nice and easy to the hospital, just like the last 7 times I picked John up.

Thanks for reading! If you have any questions, ask them below!

How do you make these decisions? What meds do you use? What is your trigger point for ketamine vs other meds? Let me know below!

-Dean Stockley