TCPR: You’ve worked for a long time as an emergency psychiatrist. Do you have any advice on how psychiatrists can de-escalate situations with agitated or even violent patients?
Dr. Fishkind: When I work with an agitated patient, I start by saying, “Hi, I’m Dr. Fishkind. My job is to keep you safe today.” Your first job should be to take away any possibility that the person thinks you’re dangerous or that you’re there to cause harm. So, start by identifying who you are, what you do, and that you are there to help.

TCPR: That’s a sound approach, but are there things we should prepare for even before we get to introduce ourselves?
Dr. Fishkind: There’s a useful guide called the The 10 Commandments for Verbal De-Escalation (see page 5). They are set up to help you prepare for things that can happen even before you say anything to the patient (Richmond JS, West J Emerg Med 2012;13(1):17–25). For example, there’s a way you should stand, and a certain distance you should stand away from the patient. I always keep my hands facing forward and open. That way the person can see I have no weapons and that my hands aren’t up in the air making it look like I might take a swing at the person. I usually keep my legs sort of pointed to the side, so my body language can’t be interpreted as being ready to kick the person or sprint toward the person. So, there are things that can happen before you introduce yourself.

TCPR: In these situations, there are always a lot of different people involved, from law enforcement to EMTs and emergency department personnel. But can’t that “show of force” make the situation even worse?
Dr. Fishkind: Absolutely. It’s provocative. The person feels that the odds are unfavorable. It’s like the end of the movie Butch Cassidy and The Sundance Kid. Many times, especially in a state of psychosis, these patients feel like they have nothing to lose, are cornered, and have no choice but to fight for their lives. So, having more people involved is not always the best thing. There’s no consensus on how many people should be involved, and obviously the safety of the staff and the police are just as important as the safety of the patient. No matter how many people are involved, what’s most important is that you have people with the right temperament for this work—and have 1 staff person do all the talking.

TCPR: How should we advise the people who do this work with us?
Dr. Fishkind: Help them understand that patients have wants and feelings just like everyone else. When people want something they’re not receiving, they get angry. If they want to make sure something bad doesn’t happen to them, they get anxious. If they want something and they’ve given up hope of ever having it, they get depressed. And if they want something and they get it, they’re happy. Basically, if people rid themselves of wants, they rid themselves of anger, fear, and depression. So, if the patient appears angry, one can say to the agitated patient directly, “You look angry. You must want something you’re not getting. Can I help you get what you want?” The minute patients see that you are interested in what they want, you start to very quickly establish a bond, and perhaps help the patients understand that you’re listening and not just there to put them in restraints.

TCPR: It sounds like compassion, patience, and a willingness to listen are key.
Dr. Fishkind: Yes. Listening is the big one. We used to send residents to calm down a patient, and the resident would come back 30 seconds later and say, “Well, they’re not calming down because they’re just not listening.” I’d say to the resident, “Well, you might have to repeat yourself a few times and listen a little longer. Why not wait for them to tell you something?” You can also try agreeing with the patient as often as you can, agreeing to disagree if you can’t reach consensus.

TCPR: It sounds like we need to “walk around in the patient’s shoes.” What else should we do?
Dr. Fishkind: Offer the patient options. Obviously, there are a lot of times where you can’t reason with a highly agitated patient, and for the safety of everyone involved, and as a last resort, you’ll need to move to seclusion or restraints. But if it’s not too late, try saying, “Look, I can’t let you cause any harm to yourself or anybody else. I have medication that can help you feel better. You can either have this medication by mouth or we can give you an injection. What would you like to choose?” The more choices you offer, the better. Intervening early to help them manage their emotions is important, and research shows that discordance between patients and professionals—including a lack of patient trust—is a major cause of injuries to staff, law enforcement, and the patient (Wong AH, Jt Comm J Qual Patient Saf 2018;44(5):279–292).

TCPR: So, that’s all good advice for the ED. But how do we handle agitation on the inpatient unit, such as when a patient wants to be discharged quickly?
Dr. Fishkind: You could say, “I can’t discharge you right now, but I’m working toward that.” Follow this up by actually creating a plan with the patient that works toward discharge. Working on this plan is calming to many patients. Frequently, they want a cigarette, which they can’t have, and then suddenly they’re mad enough to throw a table. But at least you’re identifying what they want and engaging them in a conversation. That can lead to offering them choices and empowering them to make another choice. When patients want to leave the hospital, I will say, “Look, if you can follow this path—and I have a lot of faith that you can do it—we can get you home. Let’s make a plan together to get you out of here.”

TCPR: What else can we say to the patient in these situations?
Dr. Fishkind: First, understand that you should always try to avoid coercion. No one likes being forced or threatened into doing something. So, as you work your statements with patients, always start with the lowest level of coercion (Richmond JS, West J Emerg Med 2012;13(1):17–25). For example, when working with agitated patients, begin by inviting them to share ideas. Say, “So, what helps you at times like this?” You might learn that they’re agitated because the medication they took did not work. Understanding that early on can help. You could say, “I think you would benefit from the medication this time,” which isn’t coercive, it’s just stating a fact. You’re not asking them to do anything yet or trying to persuade them.

TCPR: What comes next if that strategy doesn’t work?
Dr. Fishkind: I would move to the next level of coercion, which is persuading. At that point, say, “Well, I really think you need a little medication. Let me tell you why. If I get some medication into you, we can avoid having you stay in the hospital.” Then, if necessary, you go to the next level, where you might say, “You’re in a terrible crisis. Nothing’s working. I’m going to get you some emergency medication. It’s very safe, and we don’t have any choice at this point.” That then becomes more of an inducement to get the person to say OK. Moving to a last step, you could say something like, “I’m going to have to insist that you take medication because I can’t let any harm come to you or anyone else.” This is the highest level of coercion. At that point, there may be no other choice. So, this is how you can move up the scale as the emergency escalates, from statements that are easy for a patient to tolerate to ones that are more coercive.

TCPR: It sounds like you’re also reinforcing to patients that you’re on their side.
Dr. Fishkind: Yes, exactly. It continues to reinforce the idea that I’m a doctor, and I’m here to keep patients safe. It reinforces with patients that I’m here to work for them. You need to build trust fast and continue to reinforce that trust as you go along.

TCPR: OK, let’s talk about prevention—for example, when a patient is starting to rev up, pacing across the floor. How do we approach that?
Dr. Fishkind: Medication is very helpful in those early phases, so hopefully we’ve established an understandable rationale for meds with patients. Another thing that can work is to let them recognize that you know they’re angry. You can then talk to them the way I mentioned earlier or give them tools such as breathing exercises to keep them from escalating. If they’re waiting to be treated, let them know that they can come to the window to ask a question or let the nurse know what they want. Now, that can be a little annoying to the nursing staff, but it’s worthwhile if it keeps the situation from escalating. You can also write down a list of choices for them and say, “If you feel like you’re getting angry, here are some things we can do for you, including some medication.”

TCPR: This is all great advice on using words to calm the situation. Let’s talk a little more about medication. What’s your preference for calming agitated patients with an antipsychotic?
Dr. Fishkind: I’m a Geodon IM (ziprasidone) fan. Virtually all the injectables work the same, but I like ziprasidone for a couple of reasons: One is that the nurses only have to inject water into the little bottle and shake it for 30 seconds, which makes for quicker administration, and the other reason is that—unlike Haldol and Ativan—Geodon calms patients without putting them to sleep, so you can keep working with them.

TCPR: What would be your typical dose for the ziprasidone?
Dr. Fishkind: I typically go with 20 mg. I think a lot of people give 10 mg because they’re afraid that they’ll have QTc problems with ziprasidone, but that’s a problem with all antipsychotics. Some have more than others, but the QTc increase with ziprasidone IM is roughly the same as with haloperidol IM (Zimbroff DL et al, CNS Spectr 2005;10(9):1–15).

TCPR: I understand you’re developing a new model for emergency psychiatry using telemedicine. Tell us about that.
Dr. Fishkind: I’ve worked in emergency departments for many years, and some of my experiences there have led me to search for better ways to manage psychiatric emergencies. Today I run a telepsychiatry practice called JSA Health. We use telemedicine to help emergency departments, but also to build community-based psychiatric emergency services that we staff via telemedicine. We are also attempting to handle psychiatric emergencies where and when they occur—for example, by using iPads with police officers in the field. We’re trying to move the whole emergency crisis system out further into the community, giving police officers, probation staff, case managers, and visiting nurses the ability to reach psychiatrists faster and quicker to try and solve the crisis before people end up in a hospital emergency department or in jail.

TCPR: Is there any final advice you’d like to give psychiatrists working in emergency medicine?
Dr. Fishkind: Make yourself available. Be out with the patients, not hiding in the nurses’ station or call room. Don’t be afraid to be the one that’s talking to patients during an escalating crisis. Spend time in front of them, and make sure you don’t disappear on them after the first encounter. Be a part of the multidisciplinary team engaging patients with social workers, nurses, and psychiatric technicians—working together to help the patients regain control.

TCPR: Thank you for your time, Dr. Fishkind.