The need to restrain individuals for safety and/or medical purposes is not new. In fact, Colorado’s restraint law, entitled “Protection of Individuals from Restraint and Seclusion Act,”[34] was enacted in 1999. It prohibits the use of restraint upon an individual unless, in an emergency, less restrictive alternatives such as verbal de-escalation have failed or would be inappropriate or ineffective under the circumstances. The panel agrees that this requirement should apply to paramedics and concludes that paramedics should attempt verbal de-escalation before administering ketamine as a chemical restraint in the prehospital setting.
Dr. Scott Simpson, Medical Director for Denver Health’s Psychiatric Emergency Services (DHPES), oversees the admission and treatment of approximately 5,400 behavioral health patients in DHPES annually. He described for the panel how his mobile crisis team and DHPES unit staff manage agitated individuals in the prehospital and clinical settings. According to Dr. Simpson, DHPES staff are trained to use verbal de-escalation techniques on these patients. He stressed the importance of conducting formal training of personnel so that they become proficient in de-escalation techniques.
This training benefits both staff and patients. Verbal de-escalation techniques provide DHPES staff with a tool they can routinely and oftentimes successfully employ to calm agitated behavioral health patients. The ability to employ this technique increases staff’s sense of safety when dealing with agitated patients. Patients who respond to verbal de-escalation techniques also benefit by avoiding administration of medications altogether or by receiving a reduced dose of medication.
Dr. Simpson acknowledged that DHPES and emergency departments, unlike prehospital settings, are controlled environments with several levels of medical personnel that can be called upon to assist with patient care when needed. Moreover, health care professionals in the clinical setting can utilize verbal de-escalation tactics under circumstances in which they know the patient’s vital signs as well as the patient’s unarmed status. EMS providers cannot rely on these guardrails when attempting to de-escalate an agitated or violent patient in the prehospital setting.
The panel acknowledges that verbal de-escalation techniques may not be successful, or even possible, when EMS providers are confronted with an extremely agitated, combative patient in the prehospital setting. However, the panel also determined that there is too little emphasis on using verbal de-escalation to diffuse conflict in the prehospital setting. Currently, verbal de-escalation techniques are often taught informally during ambulance ride-alongs.
Therefore, the panel recommends that more training and concrete tools on proven de-escalation techniques should be made available to paramedics who interact with agitated patients in the prehospital setting. To ensure proficiency, training should be formalized and include both classroom and role playing. Classroom training should include techniques that have been proven to work and contrasted with those that do not. For example, instructing an agitated person to “calm down” in a stern voice can actually exacerbate rather than reduce a person’s agitation. The panel also agrees that paramedics should receive training on effective collaboration with law enforcement when attempting to verbally de-escalate a patient in a chaotic situation. In the panel’s view, it would be optimal for EMS agencies to arrange joint verbal de-escalation training sessions with their local law enforcement agencies.
When EMS agencies use body cams or other recording devices as a part of normal operations, review of cases that required verbal de-escalation provides a powerful learning opportunity. Keeping patient confidentiality in mind, review of these recordings offers a realistic opportunity to see de-escalation (successful and unsuccessful) in the challenging prehospital environment. Likewise, incorporation of police video recordings in training enables comprehensive education on de-escalation and teamwork during collaboration between EMS and police.
Verbal de-escalation is an important response to the question of how EMS providers can safely remove a person from a stressful situation. Implementing verbal de-escalation as the first response to agitated patients is a necessary step in the chemical restraint protocol, but it also promotes EMS providers’ tenet of providing compassionate care to all patients, especially those who are difficult to manage.
The panel understands this recommendation may be difficult to implement for rural EMS agencies that are under-resourced. Still, EMS agencies will have to prioritize some form of verbal de-escalation training for paramedics in order to satisfy the chemical restraint law requirement and the recommended ketamine waiver protocol. Online training sessions may help bridge this gap for under-resourced agencies. See, for example, tinyurl.com/verbaldeescalation.