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Recognizing Medical Emergencies

Breakout Session: Recognizing Medical Emergencies

Meet Michael W. Weaver, of Everett, WA. A former United States Army Ranger, and a fifteen year veteran of Everett Fire Department as a firefighter/paramedic, he has provided instruction for many years in the safe handling of combative patients. He is a Fire Engineering author and 2009 FDIC instructor on the subject of tactics for combative patients. He has taught these same tactics to students of the Harborview Paramedic Program in Seattle Washington as well as local EMS conferences to as many as 200 attendees. Now, he is going to teach a breakout session at the 2011 PBUS Winter Conference to help you as Bail Agents deal with those of your clients who may need special handling. He will be teaching Thursday, February 23rd from 8:30 to 9:30am before Breakfast with the President. This is one session you won’t want to miss


The Agitated Patient Emergency!

By: Michael W. Weaver

Nearly all Law Enforcement Officers, Corrections Officers, Bail Agents, Recovery Agents and Fire/EMS that serve in the field have been assaulted during their careers. The outcome of a high percentage of these assaults end with physical and psychological injuries that remain with us until we retire. Others are not as fortunate. Since 2004, roughly twelve percent of all Law Enforcement fatalities, secondary to violent conflict, were in the process of dealing with an unarmed suspect.

Reactionary policy due to the negative public perception of in-custody deaths has created an environment where the officers are hesitating when confronting an unarmed suspect. Along with hesitation and bad policy, “training” consists of a power point presentation without practical application. Real world hands on techniques and tactics are needed when everything goes wrong. In the absence of correct procedural memory (hands on application), the brain will utilize a previous event to dictate what actions to take. These actions may not coincide with current policy and will likely set us up for failure, even if we do survive the critical event.

Unfortunately, the current economic crisis will only increase the likelihood of first responders being forced to deal with agitated and/or violent individuals. As funding is redistributed from “non-critical” social programs to maintain the day to day business of our local government, a large number of mentally ill clients/patients will no longer have managed care available to them. Some may have received enough therapy and rehabilitation to manage independent living if they can maintain their drug therapy regimen, others may have family that will assume responsibility of their care and provide them a place to live. Some of these individuals, lacking the support and/or ability to maintain independent living, will relapse or become victim to “friends” that will help them spend their Income on various forms of entertainment to possibly include illicit drugs. Mental illness alone does not represent great risk, but when combined with low income, homelessness, non-compliance with prescription medication, alcohol and illicit drug use, we now have the potential for disaster.

Law Enforcement has suffered greatly from negative public perception. Fire/EMS has only recently begun to suffer the scrutiny of an emotional uninformed public whipped into frenzy by media sensationalism. Unlike public service entities and Private Ambulance Companies, most Bail Agents and Recovery Agents lack the resources needed to fight a large wrongful death lawsuit. This solidifies the need for proper instruction on how to recognize the individual in medical crisis and expediently transfer that person to the correct receiving facility. When an agitated or violent individual is subdued, restrained and “packaged” for transport, the entire world gets to witness the chaos thanks to the World Wide Web. If injury or death occurs, whether it is in a patrol car, a jail cell medic unit or in the process of being detained to face trial, all of us feel the impact. What could be a routine procedure is now a critical event due to lack of communication and relevant training.

It is my hope that all First Responders (to include Bail Agents and Recovery Agents), receive the best education, training and equipment necessary to safely do their job and return to their families at the end of their shift. Do note that this author makes a distinction between education and training. The First Responder that serves in the field must be able to retain high levels of knowledge in multiple fields acquired through video, PowerPoint, verbal instruction, research and other classroom learning. This is done through education, and is representative of technical proficiency. The First Responder must also be able to perform dynamic physically manipulative tasks, this is accomplished through training and is a demonstration of tactical proficiency. So, a competent First Responder displaying knowledge and skill in their profession can be termed as technically and tactically proficient.


Most employers provide their members with the basic training in First Aid and CPR. The ability to recognize a medical emergency is every bit as important as the treatment of a medical emergency. Below is a diagram of the Pediatric Assessment Triangle, it is part of several courses designed to help rapidly identify a sick child in need of advanced life support (ALS). It is taught to pediatricians, pediatric nurses, flight nurses and paramedics. The concepts of this assessment tool have been incorporated into adult evaluations as well through Competency Based Training (CBT) and Ongoing Training and Evaluation Program (OTEP). These training modules are scenario based and are part of Fire/EMS continuing medical education. An individual lacking a medical background can be trained to determine the need for further Fire/EMS evaluation from a safe distance away using this model. This over-simplified explanation is not a substitute for an accredited scenario based training course. It is only intended to raise awareness of the tools available to recognize an individual in need of Fire/EMS evaluation, treatment and transport.

Appearance: How does the suspect look? Is there blood or other signs of obvious injury? Are they agitated or calm? Are their interactions with the environment appropriate?

Work of Breathing: How much effort and at what rate is the individual making to breathe? A normal breathing pattern is twelve to twenty respirations per minute and is an effortless rhythmic rise and fall of the chest. This range covers being at rest to speaking and walking. Anything below or above this, with or without effort, is worth further evaluation by Fire/EMS.

Circulation to Skin:  The last part of the assessment triangle, it is an indicator of oxygenation and/or how efficiently the heart is pumping. It is the most difficult to assess without touching the individual and is further complicated by struggle and application of restraints. Essentially, the evaluator will have to rely on mottled skin, blue lips, pale gums and mucous membranes as indicators of poor blood circulation to the skin.


While the merits of PowerPoint presentations cannot be disputed, its’ use should be limited to education and not be a replacement for hands on or scenario based training. Relevant training begins with everyone being on the same page. While it is not expected for Fire/EMS to have to physically manage a combative patient, it is a common enough occurrence to warrant basic instruction in Defense Tactics. Likewise, Bail and Recovery Agents are not expected to differentiate between carbon monoxide poisoning and a diabetic event. Though the ability to do so could make it safer for them to do their job and make it easier to request the appropriate resources to the scene. Having all First Responders cross train with each other imparts valuable knowledge to the members and allows an environment where a “Universal Response” to extremely agitated patients/clients can be created. This will make it safer for all involved to include the individual in crisis.


Some agencies have opted to incorporate a restraint system into their equipment inventory to specifically deal with combative individuals. Whatever system that may be in use, all members should have adequate training on when to apply it, how to apply it and how to quickly remove it when necessary. While there may be other restraint systems available, four were available for review and are worth mentioning.

  1. The Wrap (Safe Restraints Incorporated). In use by over 300 Law Enforcement, Emergency Departments or psychiatric care facilities. The system was designed to help Law Enforcement manage “out-of-control” suspects and is suitable for Fire/EMS as well. The Wrap restraint system is compact and fits easily into small compartments until needed. The system is accompanied with easy to follow instructions and is easy to apply by trained individuals.

  2. Reeves Sleeve (Reeves EMS). Designed for the purpose of extricating injured personnel out of confined space areas. Part of many Fire Departments technical rescue equipment inventory. It is designed to be used with or without a backboard. The device has a pocket that the backboard slides into and with the backboard in place, it is pressed into service as a combative patient restraint system.

  3. The Ultimate Restraint System (Gillen Industries). This system was designed for combative/violent psychiatric patients and is in use at various psychiatric care facilities on the U.S. east coast. Currently, the system comes with a stiff board that gives it rigidity. The manufacturer has a new model that was unavailable for review specific to Fire/EMS that can be used with a standard backboard.

  4. The T.A.S.E. kit (US Elite Gear). A kit consisting of items typically found in any EMS transport unit. Designed to consolidate all the necessities of patient restraint into one location. It is a combination restraint system that can be used "as is" or used in conjunction with other existing systems. Low cost, many can be purchased and be distributed or “shared” with other agencies/disciplines to encourage commonality and compatibility.

For a more detailed review of these items and more pictures, please visit

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