Keeping everyone safe: How paramedics handle difficult situations

Every emergency call is different. While many patients are cooperative and grateful for help, ER24 paramedics regularly deal with people who are confused, frightened, or combative. 

Understanding why people become difficult

Sometimes, it isn’t the patient causing difficulty, it’s the people who love them. Handling these moments safely is key.

“As emergency medical professionals, we often meet people at the worst time of their lives,” says Alet Reed, Branch Manager of ER24 Johannesburg North. “Their negative reactions aren’t intentional; they’re simply operating out of fear and pain. For family members, panic, grief, helplessness, and distrust can quickly spill over into obstructive behaviour.”

Reed adds that families who search online for medical information are often quick to instruct paramedics on what to do and how to do it. However, paramedics are the official medical experts on scene and are trained not to let bystanders intimidate them.

“They often don’t understand our protocols and procedures, and this is compounded by incorrect information they find online. When a patient or family members aren’t able to communicate in their home language, it can also cause extra frustration and stress.”

Mental health crises such as psychosis, severe anxiety, or personality disorders, as well as substance use involving alcohol or drugs, can also contribute to distressing encounters. “In addition, some medical conditions such as hypoglycaemia, head injuries, stroke, or hypoxia (lack of oxygen) can cause confusion and aggression,” Reed says. 

De-escalation: The first line of response

Reed says the most valuable lessons in managing difficult situations are learned on the job. In practice, de-escalation relies on five core principles:

1. Focused care. “When emotions run high, briefly separating family members from the patient can help reduce tension and make it easier for paramedics to focus on providing care,” says Reed. “We often assign one crew member to focus on the family while another concentrates on the patient. This helps prevent mixed messages and ensures both parties feel heard.”
2. Honest, reassuring dialogue. Paramedics are trained to be transparent with both the patient and family. “Building trust is essential,” Reed says. “When a family asks, ‘Will he survive?’, we make sure to respond honestly, but compassionately. We acknowledge the seriousness of the situation while reassuring them that we’re doing everything we can to help and that the patient will be transported to hospital for further care.”
3. Simple communication. “We avoid medical jargon and, if possible, try to speak in the patient’s home language. A calm, confident presence is one of the most powerful tools for paramedics to gain the trust of patients and family members alike. People become less obstructive when they understand what’s happening and why.”
4. Involvement. Reed says giving family members a role, such as gathering medications, or holding the drip, helps them feel they’re making a difference. “In resuscitation situations, we give them the option to witness crews performing CPR. This allows them to see we’re doing everything possible.”
5. Setting firm, respectful boundaries. Paramedics assert their professional authority without escalating conflict. For example, “Please may I ask you to refrain from grabbing my uniform. You are hindering my attempts at helping the patient.”

When de-escalation fails

If crew safety is at risk, paramedics cannot place themselves in danger while attempting to treat a patient. If de-escalation is unsuccessful, Reed explains that they follow a clear procedure:

• They’ll immediately call for emergency help by contacting the ER24 Contact Centre (code 999). They can do this by radio call or by pressing the panic button.
• The situation is escalated progressively, first to the branch, then to the regional manager, and then to the quality control manager.
• Depending on the situation, SAPS and/or Metro Police are contacted. 
• If the patient seems like they might become violent, the crew will move to a safe distance or safer spot. But they will keep talking to the patient, trying to calm them and de-escalate the situation while they call for police backup.
• Treating crews will treat and manage the patient accordingly.

At the heart of it all, paramedics are more than emergency medical professionals. They bring calm to chaos – whether it stems from a patient or from a panicked or grieving loved one.