When overdoses go wild: Protecting the EMS provider

EMS providers face a variety of hazards while on the job. About 10 percent of all EMS provider injuries are a result of some form of violence [1]. An unknown percentage of these violent acts involve patients who have abused some form of drug or medication, and present in an altered state. This article explores violent patient behavior associated with substance abuse, as well as how to anticipate and manage these situations as to minimize their danger.

Epidemiology of patient violence
While there is are no definitive statistics specific to the incidence of substance abuse-related violence against EMS providers, a 2002 study that looked at the nature of prehospital violent behavior concluded that the perceived presence of alcohol and drug use was predictive of violent behavior, along with police presence, the presence of gang members and perceived psychiatric disorder [2].

Chemistry of emotion and behavior
How humans create, experience and regulate emotion is not well understood. Chemical neurotransmitters such as dopamine, serotonin, and GABA are known to be involved in feelings such as being happy or being sad.

How we react to certain situations is rooted within the body's autonomic nervous system. Two branches, the sympathetic and parasympathetic systems work in conjunction in each other, regulating most bodily functions on a minute-to-minute basis.

The sympathetic system is the source of the well-described "flight or fight" reflex, where the body is programmed to react to sudden stress by increasing heart rate, contractility, and respiratory rate. Blood is shunted away from the skin and GI tract and toward the heart, lung, kidneys and the broad muscle beds. The brain experiences fear, stress and anxiety. Altogether, this response to a stressor serves the body well in protecting it from harm. But this same response may be triggered by the effects of substance abuse and overdose, creating a potentially dangerous situation for patients and EMS providers alike.

Specific drugs related to violence
There are a wide variety of drugs that can be used recreationally and sometimes, illicitly to solicit a sense of pleasure and euphoria. A subset of drugs have been associated with aggressive or violent behavior. Additionally, prescription medications designed specifically to manage various psychiatric conditions have known to trigger acts of verbal and/or physical aggression, sometimes unexpectedly. Here are the drugs EMS providers commonly encounter.

Ethanol
Ethyl alcohol, or ethanol is the intoxicating ingredient in beer, wine and spirits. Ethanol is a central nervous system depressant, raising levels of GABA neurotransmitters that first cause a euphoric effect, followed by a general slowing of bodily functions. Excessive amounts will cause both cognitive and physical dysfunction.

Alcohol is considered to be the most common drug associated with violence. People can become angry and aggressive while under the influence of ethanol. Being verbally or physically abused by another person is twice as likely to occur if ethanol is involved [3].

What makes ethanol-driven violence more unpredictable is that there is no dose-effect relationship. It is unclear why ethanol can make one person feel happy and sleepy, but cause another person to be hostile and violent.

Ethanol is also commonly used in conjunction with other drugs. It can have an additive effect, especially with other GABA related drugs such as benzodiazepines (diazepam and midazolam, for example.)

Stimulants
As the name indicates, this general classification of drugs stimulates the central nervous system, specifically the sympathetic portion. A common subclass of stimulants is amphetamines. Drugs such Adderall (dextroamphetamine), used to treat attention deficit disorder, belong to this category, as well as illicit drugs like methamphetamine.

An emerging stimulant, alpha-PVP is a strong stimulant with highly addictive properties. It belongs in the same classification as "bath salts." People who have used alpha-PVP, also known as Flakka, have been known to be very physically violent, paranoid and difficult to control. The behavior is reminiscent of the older drug phenycycline, or PCP.

Antipsychotics
There is a wide regiment of prescription medications that are used to treat a variety of psychiatric conditions. Several have been linked to high incidences of aggressive or violent behavior [4]. The five most common medications in this category are listed in the following table.

Drug name

Trade Name

Used to treat

Fluoxetine

Prozac

Depression, obsessive-compulsive disorder

Paroxetine

Paxil

Depression, obsessive-compulsive disorder, anxiety

Fluvoxamine

Luvox

Obsessive-compulsive disorder

Venlafaxine

Effexor

Anxiety disorders

Desvenlafaxine

Pristiq

Anxiety disorders

Anti-smoking medication
Varenicline (Chantix) is an anti-smoking medication that works to reduce nicotine cravings by affecting the nicotinic acetylcholine receptor sites in the brain. It is 18 times more likely to be linked with violent behavior when compared to other medications [4].

Anti-malaria medication
Mefoquine (Lariam) is used to treat malaria, and has been long associated with increased violent behavior.

Anabolic steroids
Anabolic–androgenic steroids are synthetic forms of testosterone, the male sex hormone. Anabolic steroids are used by some athletes to improve physical performance. High doses of anabolic steroids have been linked to greater irritability and aggression, although the relationship is highly variable.

Cannabis withdrawal
Several studies have found a possible relationship between marijuana use and interpersonal violence [5], especially in teenagers [6]. However, there is no clear link established. People who are withdrawing from marijuana use have reported greater irritability which can lead to aggressive behavior in people with a previously known history of aggression [7].

General safety practice guidelines
EMS providers are responsible for the safety of their patients, as well as the care they receive in the field setting. The potential for violence when a patient is under the influence of a drug or medication increases the chances of danger to the caregiver. Under extreme circumstances where the rescuer's life is in danger, the patient ceases to be a patient and should be considered an assailant. Retreating from the scene in these circumstances and waiting for law enforcement assistance is appropriate.

However in most circumstances EMS and other public safety providers must quickly develop a plan to safely manage a potentially violent patient. Maintaining a heightened sense of situational awareness by all rescuers can keep the scene in control and anticipate sudden changes in the patient's behavior. The EMS provider rendering direct patient care should be covered by another member of team who can quickly assist if the patient's behavior changes during the assessment and management phase.

Consider the possibility of sudden violence if the patient is exhibiting one or more of these behaviors:

• Sudden erratic movements
• Tightening of facial muscles, arms, hands into fists
• Darting eye movement
• Fixed stare
• Shifting balance into an aggressive posture
• Raised voice, rapid speech
• Rapid breathing

The initial management approach is to stay calm and listen. Allow the patient to vent while sizing up the situation for potential weapons and escape routes. Actively engage with the patient's conversation; acknowledge what the patient is saying or feeling while not injecting your own opinion into the discussion. Affirm the patient's statements ("I hear you saying…."); this may help the patient calm down some and establish a working relationship or rapport with you.

Avoid trapping patients into situations where they feel they have no options. Give options whenever possible. An example might be the choice of walking to the unit or being wheeled on the gurney. The choices should be realistic; someone with altered mental status would not have the option of refusing care.

If verbal defusing techniques are not effective, a plan must be rapidly developed to restrain the patient physically, chemically or both. No fewer than five rescuers are needed to safely restrain a patient. The team must quickly decide who will gain the patient's attention while the other embers surround the patient. Control is taken in one simultaneous motion and soft restraints applied.

Patients must be restrained in a supine position. Chemical restraint with benzodiazepines or haloperidol have been demonstrated to be safe and effective. If you suspect excited delirium consider ketamine for patient sedation.

Most importantly, EMS providers must remain in control of their own emotions in these highly stressful situations. Remaining calm reduces the chances of escalating an already bad situation into a disastrous one.

References

1. Centers for Disease Control and Prevention. Emergency Medical Services Workers: Injury and Illness Data. http://ift.tt/1q3uzqj. Retrieved 10 January 2016.

2. Grange J and Corbett SW. Violence against emergency medical services personnel. Pre Emerg Care 6(2): 186-90. 2002.

3. Morgan A, McAtamney A. Key issues in alcohol-related violence. Australian Institute of Criminology, December 2009.

4. Moore TJ, Glenmullen J, Furberg CD. Prescription Drugs Associated with Reports of Violence Towards Others. PLoS ONE 5(12): e15337. December 2010. http://ift.tt/1OMzP80"id=10.1371/journal.pone.0015337 retrieved 12 January 2016.

5. Moore TM, Stuart GL. A review of the literature on marijuana and interpersonal violence. Aggression and Violent Behavior 2005;10:171-192.

6. Copeland J, Rooke S, Swift W. Changes in cannabis use among young people: impact on mental health. Current Opinion in Psychiatry 2013;26(4):325-329.

7. Smith PH, Homish GG, Leonard KE, Collins RL. Marijuana withdrawal and aggression among a representative sample of U.S. marijuana users. Drug Alcohol Depend. 2013 Sep 1;132(1-2):63-8.

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