Violent Behavior

a. Violent behavior is behavior that is potentially hazardous to the patient and/or others. It also is not peculiar to any one type of diagnosis; however, there are certain conditions and situations that might indicate a potential for violence. Most of the factors that might precipitate other disturbed behaviors are also known to occasionally precipitate violence.

b. Potentially, violent episodes should be anticipated. Be aware that some (but not all) patients in stressful situations may pass through the four stages of crisis development. If you are able to recognize these stages, you may be able to intervene early and appropriately.

(1) Stages of crisis development.

(b) Acting out orally (patient may become defensive, argumentative, and possibly verbally belligerent).

(c) Acting out physically (patient may lose control and may assault you by grabbing, striking, and so forth; he may or may not use some type of weapon).

(d) Tension reduction (in this stage patient becomes rational again and realizes that he has done something wrong).

(2) Although there are no fail-proof predictors of violence, awareness of the following behaviors may help you anticipate and/or prevent violent episode:

(a) Past history of violence, violent family life, and/or child abuse.

(b) Body language that includes clenched fists, rigid posture, and/or tautness (strained or tight).

(c) Verbalization of hostile threats or anger.

(d) Increased motor activity.

(e) Overt aggressive acts.

(f) Suspicion of others.

c. Procedures for managing an unarmed violent patient are given below.

(1) A violent, agitated patient must be controlled before you attempt to diagnose or make referral.

(2) Verbal control should be attempted first. The following verbal techniques are applicable to any situation in which a patient exhibits confused/disoriented, disturbed, or potentially violent behavior.

(b) Do not threaten.

(c) Provide reorienting information about who you are, where the patient is, and how you can help.

(d) Ask the patient questions relating to why he is agitated. This often gets the person thinking rationally, as well as giving you information. It is often sufficient to calm someone who is not in a panic anxiety state, and is even sufficient for most psychotics.

(3) If verbal control succeeds, continue to reassure and provide orienting information while reinforcing a "medical care image."

(a) Example--"Good. You're looking calmer. I should check your pulse and blood pressure now."

(b) If patient accepts this, the patient is agreeing to sit still. Keep talking and reorienting the patient while preparing to do further procedures or while awaiting assistance.

(4) If verbal control is not successful, the patient must be brought to a horizontal position on the floor to ensure safety of both the patient and staff.

(a) Prefer a minimum of four to five attendants. There should be one attendant to each of the patient's extremities and one to the patient's head to prevent injuries.

NOTE: It is better to wait until there is enough help, unless danger demands high risk intervention.

(b) Action should be quick and decisive rather than ambivalent (uncertain as to which approach to follow).

(c) Spectators should be cleared from the area. Spectators seldom understand and usually misinterpret what is happening.

(d) When the patient is on the floor, a stretcher can be placed under him and sheets or cuff restraints can be used to maintain secure control (or use double litters in field environment). Put patient in prone position with head turned to side. Refer to Lesson 3, Apply Restraining Devices to Patient.

(e) When the patient is on the floor, medication may be given to help the patient regain his own control. However, it is best to wait until the cause is known since some drugs interact with some medical illnesses to produce unwanted side effects (which may be underlying causes of violence). If medication is used, careful follow-up is necessary.

(f) Convey an attitude that you believe the patient is a decent human being who is struggling to control difficult thoughts and feelings.

(g) Assure the patient that no harm will come to him, nor will he be allowed to harm anyone.

(h) Expeditious transfer of the patient should be arranged to a MTF for workup. Transfer the patient to a psychiatric facility only if sure origin is psychiatric.

(i) Continue to evaluate the patient while transporting or while awaiting transport. Observe for underlying or precipitation illness or injury.

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