Revamping Our Approach to Behavioral Emergencies

Why EMS Must Move Beyond “Control” and Towards Clinical Excellence

Article by Eric Jaeger, JD, NRP and Faroukh Mehkri, DO, NRP, FAEMS
Edited by Michael DeFilippo, DO, FAAEM, Editor-in-Chief, NAEMSP Blog

Every EMS provider remembers the call.

The patient who is pacing, shouting, frightened, intoxicated, psychotic, delirious, or simply overwhelmed. The scene feels chaotic. Law enforcement is requesting action. Bystanders are filming. Cars might be zooming by in proximity. The pressure to “do something” builds with every passing second.

These are among the most difficult—and highest-risk—calls in prehospital medicine.

Yet despite encountering behavioral emergencies every day, many EMS professionals receive surprisingly little formal education in de-escalation, evidence-based physical restraint, or the safe medical management of severe agitation. The result is wide variation in practice, unnecessary injuries, preventable patient deaths, and increasing legal exposure for EMS agencies and their law enforcement partners.

It is high time to rethink how we approach these patients.

Modern EMS has moved far beyond simply transporting patients. Behavioral emergencies deserve the same thoughtful, evidence-based approach that we apply to stroke, STEMI, trauma, and cardiac arrest. A revamped, evidence-based approach can enhance safety for patients and reduce the risk of liability for providers.

A Changing Landscape

Over the past decade, high-profile incidents involving patients experiencing behavioral crises have fundamentally changed how EMS, law enforcement, healthcare systems, and the public view these encounters.

At the same time, research and national guidelines have continued to evolve.

The joint NAEMSP/IAFC/IACP position statement¹ on the care and restraint of agitated patients emphasizes several key principles:

• Behavioral emergencies are medical emergencies that require clinical assessment.
• Verbal de-escalation should be attempted whenever it can be performed safely.
• The least restrictive intervention capable of maintaining safety should be used.
• Prone restraint and positions that compromise ventilation should be avoided.
• Continuous reassessment, physiologic monitoring, and appropriate pharmacologic management are essential when restraint becomes necessary.

More recently, a multidisciplinary consensus statement jointly developed by NAEMSP, the International Association of Chiefs of Police (IACP), and the International Association of Fire Chiefs (IAFC) reinforced that successful management of behavioral emergencies requires coordinated teamwork between EMS, law enforcement, fire services, and dispatch—not competing priorities.

Emerging Understanding of Physiology

In the past, “excited delirium syndrome” was often used to describe agitated patients suffering behavioral emergencies and to explain the deaths that sometimes occurred following restraint and, in some cases, pharmacological intervention.² More recently, we’ve moved away from “excited delirium” (ExD) as we’ve developed a better understanding of the physiology involved.²

A 2021 report from a committee of the AMA noted that:

“ExD and potentially fatal restraint are “inextricably interwoven.” Some form of restraint was described in 90 percent of all ExD deaths, making it the most common factor that is a plausible cause or contributing cause of the death. …there is no evidence to support ExD as a cause of death in the absence of restraint.”³

Our emerging understanding focuses on the impact of prone restraint (and in some cases pharmacological intervention) on an individual’s ability to breathe.^2,4 The pattern in these cases typically involves a physical struggle, often driven by stimulant substance use, followed by prolonged prone restraint. Prone restraint, when extended, interferes with breathing (and potentially cardiac output). Patients initially compensate, but as they tire, breathing slows and acidosis and hypoxia worsen, eventually leading to cardiac arrest. At this stage, sedating medication may blunt compensatory breathing, further exacerbating these processes.

Behavioral Emergencies Are Medical Emergencies

One of the most important shifts in thinking is recognizing that severe agitation is often a manifestation of underlying disease rather than criminal behavior.¹

The causes are numerous:

• Hypoxia
• Hypoglycemia
• Drug intoxication or withdrawal
• Traumatic brain injury
• Stroke
• Delirium
• Sepsis
• Psychiatric illness
• Hyperthermia and other metabolic derangements

Managing the behavior without identifying the underlying illness places patients at unnecessary risk.

Likewise, prolonged physical struggling or fighting against physical restraints, regardless of the original cause, can contribute to worsening hyperthermia, metabolic acidosis, rhabdomyolysis, hyperkalemia, and ultimately cardiac arrest. Rapid recognition and appropriate intervention are therefore critical clinical priorities—not merely operational ones.

De-escalation Is a Key Strategy

While physical restraint and medication administration are occasionally necessary, de-escalation should be thought of as the primary strategy for managing agitated patients.^5,6

Many EMS providers learn de-escalation through experience rather than formal instruction.

It should not be that way.

Communication, environmental modification, positioning, tone of voice, and understanding patient psychology are interventions every bit as important as airway management or hemorrhage control. In addition, many of these chaotic scenes are caught on video and as such, demonstration of competence, confidence, and compassionate de-escalation attempts are protective for first responders.

Done well, de-escalation⁶ can:

• Reduce the need for force
• Reduce injuries to patients and responders
• Avoid unnecessary restraint
• Improve patient trust
• Lower medicolegal risk

It can often be successful even in situations where it seems unlikely to succeed, including where the patient initially seems uncooperative.⁶ De-escalation often requires extended efforts to be successful. The psychiatric literature indicates that inexperienced providers often give up too soon.⁶

Like any other clinical procedure, these skills require effective education and deliberate, simulation-based practice.

A Better Understanding of Physical Restraint

Physical restraint, including prone restraint, is occasionally necessary for law enforcement or EMS to rapidly gain control of an agitated patient, but understanding the associated risks is crucial. Once immediate control has been established, a patient in the prone position should be moved into a seated or other face-up position. The latest police guidelines⁷ developed to reduce the risk of restraint-related death state “once a person in the prone position is handcuffed, they should be moved to a position that promotes free breathing as quickly as possible.” While death remains a rare event, restraining an individual prone for an extended period of time carries a real risk of ventilatory compromise that can result in profound acidosis or hypoxia.² Death can occur suddenly with little warning.

When EMS providers arrive on a scene where police are restraining an individual in the prone position who is in distress, that individual is an EMS patient from the moment that EMS arrives on scene.⁸ EMS should intervene professionally to assess the patient and urge police to move the patient into the lateral or, preferably, seated position.⁸ EMS and law enforcement must take seriously when a restrained individual states “I can’t breathe!” or has a change in mental state, and physical movement. The typical reply to this entreaty—“If you can speak, you can breathe”—is a myth; the amount of air needed to produce speech is far less than an effective tidal volume breath.^2,9

Other key aspects:

• Coordinated team roles that are voiced to the entire team before the moment of action
• Brief, controlled physical interventions; avoiding prolonged struggles
• Early reassessment and appropriate physiologic monitoring

Restraint is not an endpoint.

It is a temporary bridge that allows definitive medical care to occur safely.

Pharmacological Intervention as a Deliberate Procedure

Pharmacological intervention should be reserved for situations where the patient remains an active danger and only after less invasive strategies including de-escalation have been exhausted. It must be avoided in patients who are already exhibiting signs of altered consciousness, poor respiratory effort or other signs of clinical deterioration.²

Emergent pharmacological intervention for acute agitation can be safely performed by paramedics, but a more rigorous framework is required akin to procedural sedation in the emergency department (ED) or rapid sequence intubation. Procedural sedation in the ED requires a deliberate approach^10,11, with a shared team mental model, preparation of appropriate monitoring and resuscitation equipment, and articulated backup plans. Approaching pharmacological intervention precipitously, without preparation for potential adverse consequences, carries high risk.

Assessment before proceeding is crucial. While full vital signs may not be possible, mental status, respirations, pulse and skin signs can be assessed. Never sedate a patient in the prolonged prone position²; it carries a high risk of death. All monitoring and resuscitation equipment must be at the patient’s side; providers have been caught off guard by sudden deterioration without the tools to address it. Do NOT wait to move the patient to the ambulance to begin monitoring. This is a situation where we need all our equipment with us at the patient’s side. In ED procedural sedation, monitoring is initiated before sedation is administered. While this may not be possible with an agitated patient, “peri-sedation monitoring” with a focus on airway and breathing is essential. As soon as feasible, start monitoring with heart rate, blood pressure, end-tidal capnography, cardiac rhythm, and oxygen saturation.

Beyond Protocols: Culture Matters

Perhaps the greatest opportunity lies not in changing protocols but in changing culture.

Behavioral emergencies require EMS professionals to balance compassion with safety, urgency with restraint, and clinical judgment with operational realities.

These incidents often involve multiple agencies, rapidly evolving circumstances, public scrutiny, and emotionally charged decision-making. On-scene coordination and collaboration is essential. EMS and law enforcement need to work together before an incident takes place to build appropriate protocols and, once protocols are established, must engage in scenario-based training together.^1,7

Improving outcomes depends on preparing teams before these calls occur—not simply reviewing them afterward.

Join the Conversation

To help advance this discussion, the authors Dr. Faroukh Mehkri and Eric Jaeger, JD, NRP, will present interactive preconference workshops at:

• EMS World Expo (Sept 2026 Eric Jaeger only)
• Texas EMS Conference (Nov 2026)
• NAEMSP Annual Meeting, Austin, TX (Jan 2027)

Revamping Behavioral Emergencies: De-escalation, Physical Restraint, & Sedation

This workshop combines the perspectives of an EMS physician, police officer, paramedic, attorney, and experienced educators to provide participants with practical, immediately applicable strategies for managing behavioral emergencies more safely and effectively.

Participants will explore:

• Evidence-based de-escalation techniques
• Safe physical restraint principles
• Current evidence surrounding sedation for severe agitation
• The pathophysiology of death in custody
• Why terminology surrounding severe agitation continues to evolve
• Human factors, implicit bias, and high-stress decision making
• EMS-law enforcement collaboration
• Documentation and medicolegal considerations
• Video review of real-world incidents
• Hands-on simulation of behavioral emergency scenarios

Rather than relying on outdated dogma, the course focuses on current evidence, national recommendations, and practical skills that providers can immediately incorporate into daily practice.

Whether you are an EMT, paramedic, supervisor, educator, medical director, field training officer, or law enforcement partner, these are conversations that increasingly define modern prehospital medicine.

We hope you’ll join us as we continue working toward safer care—for our patients, our providers, and our communities.

Upcoming Workshop Sessions

EMS World Expo

Avoiding the Major Pitfalls of Physical Restraint and Chemical Sedation:

Managing the Agitated Patient

Monday, September 28, 2026 | 8:00 AM – 5:00 PM

More information: EMS World Expo Preconference

Texas EMS Conference (Fort Worth, TX)
Revamping Behavioral Emergencies: De-escalation, Physical Restraint, & Sedation
Sunday, November 22, 2026 | 8:00 AM – Noon

More information: Texas EMS Conference Preconference Workshops

NAEMSP Annual Meeting (Austin, TX)
Revamping Behavioral Emergencies: De-escalation, Physical Restraint, & Sedation
January 2027 | JW Marriott Austin
Preconference schedule and registration open in October.

More information: NAEMSP 2027 Annual Meeting

References

1. Levy MK, Tan DK, McArdle DQ. Consensus Statement of the National Association of EMS Physicians International Association of Fire Chiefs and the International Association of Chiefs of Police: Best Practices for Collaboration Between Law Enforcement and Emergency Medical Services During Acute Behavioral Emergencies. Prehosp Emerg Care. 2024;28(8):1058-1062. doi:10.1080/10903127.2024.2402530
2. Bivens M, Jaeger E, Weedn V. Handcuffs and Unexpected Deaths — “I Can’t Breathe” as a Medical Emergency. N Engl J Med. 2024;391(22):2068-2069. doi:10.1056/NEJMp2407162
3. Science C, Health P. Use of Drugs to Chemically Restrain Agitated Individuals Outside of Hospital Settings. American Medical Association; 2021. https://www.ama-assn.org/system/files/2021-05/j21-csaph02.pdf
4. Steinberg A. Prone restraint cardiac arrest: A comprehensive review of the scientific literature and an explanation of the physiology. Med Sci Law. 2021;61(3):215-226. doi:10.1177/0025802420988370
5. Thiessen MEW, Godwin SA, Hatten BW, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med. 2024;83(1):e1-e30. doi:10.1016/j.annemergmed.2023.09.010
6. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA de escalation workgroup. West J Emerg Med. 2012;13(1). doi:10.5811/westjem.2011.9.6864.
7. P.E.R.F. 15 Principles for Reducing the Risk of Restraint-Related Death. Policeforum.org. https://www.policeforum.org/trending20sep24
8. Wirth SP, Wolfberg DM. Patients in custody and in need of treatment: 8 recommendations for EMS. EMS1. Published online 09032021. https://www.ems1.com/ems-training/articles/patients-in-custody-and-in-need-of-treatment-8-recommendations-for-ems-P97NCCqvZ3BBlLh3/
9. A Dangerous Myth: Does Speaking Imply Breathing? Ann Intern Med. Published online December 1, 2008. Accessed July 18, 2026. https://www.acpjournals.org/doi/10.7326/M20-4186
10. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med. 2014;63(2):247-258.e18. doi:10.1016/j.annemergmed.2013.10.015
11. Procedural Sedation Consensus Statement. AAEM. Accessed July 20, 2026. https://www.aaem.org/statements/procedural-sedation-consensus-statement/