Comms Lab: Preparation for De-escalation

Comms Lab: Episode 16

The KEY to De-escalating Aggressive Patients: PREPARATION

In this video, we’ll look at what I’ve found to be the KEY (and most neglected) STEP in de-escalating agitated, aggressive patients: PREPARATION.

My experience in the emergency department tells me that we don’t always have the opportunity to prepare for our difficult conversations with potentially violent patients, but when we do, we should use that opportunity wisely.

There are three aspects that we’ll explore:

  1. Preparing your mind
  2. Preparing your staff
  3. Preparing your environment I realise there are likely to be many different approaches to this kind of situation.

Whether you agree or disagree, or if you’ve got any tips to add, put them in the comments section below.


0:00 – The most important step…
1:10 – Prepare your Mind
3:43 – Prepare your Staff
6:10 – Prepare your Environment
7:42 – Concept: Your leaky Face
8:42 – These are not Superpowers
8:58 – Homage to the Paramedics




Cite this article as: Hayden Richards, "Comms Lab: Preparation for De-escalation," In: LITFL - Life in the FastLane, Accessed on December 8, 2022, https://litfl.com/comms-lab-de-escalation-preparation/.

Comms Lab

A path to highly effective communication skills

Hayden is an emergency physician at University Hospital Geelong and a senior lecturer at Deakin University, Geelong. He is somewhat obsessed with the science and art of effective communication, and in particular: difficult conversations. He believes that we can all get better at having difficult conversations, and that the process of learning to do so can be seriously fun.

Hayden is also an avid but terrible surfer, ad hoc gardener, and dad to two awesome kids.

2 Comments

  1. hmmm…. I offer a different angle, based on my 63 years on the planet, many as a physiotherapist in hospitals including ED, and private clinics.

    The angry male>female often comes to ED agitated by pain +/- recent highly charged conflict/fighting/road rage etc; alcohol/drug influenced; in moderate to severe pain, and expecting to be disrespected/not taken seriously by ED staff based on previous experience.
    The No.1 priority is to make them feel RESPECTED, that you are LISTENING carefully and ACTING promptly and appropriately. Above all else, DO NOT LIE, as in tell them a life threatening injury will be ok. Do not say you will be 3 minutes, then not come back for 10.
    Talking with a calming manner with a poker face, isn’t advice I would give to staff. You want to convey concern, empathy, and urgency.
    If they are in pain, they need to see you are responding quickly to get them pain relief. If you disappear for long periods or otherwise delay pain relief, agitation will build. If you offer weak pain relief (NSAIDs) when they have 8/10 pain, not good.
    If they have already been kept waiting by paramedics or admission protocols, they can be expected to be angry.
    If pain can be reduced quickly, that’s a good trust builder.
    Another is to get the subjective ax completed quickly with only pertinent questions. Don’t be fleshing out a full ax with questions that are superfluous to immediate decisions. Ask clear logical questions that are not ambiguous. Listen carefully. Mis-hearing or mis-interpreting, or forgetting what was said, will stir distrust and communicate disrespect.
    advise the patient at all times what the plan is, and the expected time line. No one likes being kept waiting for hours sometimes, not knowing WTH is going on. If a decision cannot be made until an absent senior staff member responds or a busy imaging dept can scan, try to occupy the patient during that time (do more frequent ax/vitals or reassurances of timeline changes, offer tea/coffee, give a breathing technique, get other staff (physios) involved to get pt more comfortable/ease pain/help time pass quicker.
    If a dislocated shoulder can be made more comfortable propped on pillows or in a sling or sitting rather than lying, then do it.
    often ED staff focus on obviously life threatening injuries, and ignore msk injuries that might be more painful.

    • Hey Bruce,

      Thanks for taking the time to leave a comment. I must say, it seems like we align on everything here. I’m curious to know where you see the differences?

      You’ve gone into really wonderful detail with regard to the particulars of how to manage the agitated patient (particularly one who is in physical pain) ONCE THE INTERACTION HAS STARTED – and I can’t agree more. Some of these principles are addressed in this video here:

      Comms Lab: De-escalation

      The focus of THIS video is really how to best use that segment of time just BEFORE you go in to see someone in an agitated state, and is perhaps more broadly applicable to patients whose agitation is related to emotional pain and associated substance use. My observation is that we are prone to carrying a degree of prejudice and bias in to see these patients, especially when we ourselves are fatigued. I made this video to pass on some of the ideas I’ve learnt for how we might PREPARE ourselves and our team so that we can act in exactly the way that you describe.

      Genuine empathy, respect and concern are obviously key to building trust rapidly (not a poker face, as you say). The question is, how do we generate those qualities when we are feeling depleted, and how do we facilitate those qualities in our team members – that is the very narrow question I try to address in this video.

      I’d love to have your opinion on some of the other videos I’ve posted here. I reckon you’ll find that our perspectives actually line up very closely.

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