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CorrectCare
Reader
Response
Violent and Agitated
Inmates: A Response
by Jeffrey
E. Keller, MD, FACEP
I read with
interest Scott Savage’s excellent article “Violent
and Agitated Inmates: A Review of Management and a Call for
Research.” I applaud Dr. Savage for bringing this important
topic onto center stage. Dr. Savage is correct that virtually
nothing has been published on this subject in the correctional
medicine literature. However, there is another medical specialty
that deals frequently with agitated and violent patients:
emergency medicine. And there is a vibrant and large body of
emergency medicine literature dealing with violent and agitated
patients.
I know this
also from personal experience. Before I discovered my true
calling in correctional medicine, I worked for 22 years in
emergency departments. Violent and agitated patients were not
uncommon. Every emergency department sees such patients and has
to have procedures for dealing with them. I saw and treated
many, many such patients before I ever began working in jails.
Dr. Savage’s
article motivated me to reread the emergency medicine literature
on the topic. The subject is mentioned in all of the major
emergency medicine textbooks. A particularly good and lengthy
discussion of the use of physical and chemical restraints on
agitated patients is found in Roberts and Hedges “Clinical
Procedures in Emergency Medicine (Fifth Edition),” chapter 71,
Physical and Chemical Restraint. I would recommend this as a
great starting place for those interested in this subject.
As I reread the
emergency medicine textbooks and research articles on emergency
restraint, I was struck by the fact that this is not a
controversial subject in the emergency literature as it
sometimes is portrayed in correctional medicine. Chemical
restrain of agitated patients, in fact, is the standard of care
for out-of-control agitated patients in emergency departments.
Chemical sedation is considered to be safer and more effective
than physical restraint. In fact, physical restraint is used
basically to facilitate chemical sedation of violent patients.
As Dr. Savage
discusses, there are a variety of agents that can be used for
chemical sedation and restraint of violent and agitated
patients. Which agent is used depends on the situation. However,
the agent used most commonly in emergency departments across the
country for chemical sedation of violent patients is haloperidol
(often given with a small amount of a benzodiazepine).
Haloperidol can be used safely IM or even IV push. No drug is
totally without risks, but haloperidol is overall very safe and
effective. It is certainly safer and more effective than
prolonged physical restraints.
Studies of many
other agents have been reported in the emergency medicine
literature. In my opinion, no agent has yet been shown to be
safer, cheaper or otherwise an overall improvement over
haloperidol and benzodiazepines. Interestingly, ketamine is now
being used by paramedics in some emergency medical services
programs to ultra-rapidly sedate patients suffering from excited
delirium (Emergency Medicine News, October 2010, “ExDS Protocol
Puts Clout in EMS Hands”).
The management
of the violent and agitated patient is an essential topic taught
in depth in all emergency medicine residency programs. In fact,
it is a core competency in emergency medicine. It should become
a core competency in our profession, as well.
—
About the author: Jeffrey
E. Keller, MD, FACEP, is president of Badger Correctional
Medicine, Idaho Falls, ID.
[This letter first appeared in the
Fall 2010 issue of CorrectCare.]
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