4 D’s of Critical Decision Making Essential for Healthcare Providers Facing Violence

By: Kip Teitsort


In medicine, we are unique. Not another person on the planet must recognize the difference between a true patient or a criminal attacker in a split second. Not a police officer, not a lady walking in a park, not a guy in a bar, no one.  This means our situation stinks. Once the professional healthcare provider realizes this as fact, they will understand the importance of mission specific training for the use of force and workplace violence prevention in medicine. When the provider trains specifically for what they face on the job, it allows the decision making process to be easier. Learning to reasonably defend yourself while being attacked is not only foolish, it’s dangerous. The same can be said about using martial arts or police style techniques in the medical field.

There are 4 D’s in the decision making process for the healthcare provider while on the job. They are: Directions, De-Escalation, Disengage, Defend. While each of the D’s have multiple parts contained within them, the provider must understand the difference of each D.

When dealing with a person initially labeled as a patient, the provider must observe for clues the person may become an aggressor. The clues start with an overview of the initial surroundings, the body language of the person (patient) as well as family members and/or bystanders.  Healthcare providers oftentimes either miss, or ignore, body language suggesting violence is imminent. Our research revealed this is due to the phrase “Combative Patient” in which we say there is no such thing…..

During an initial patient assessment, body language is observed and the use of verbal communication as a tool to assess the situation. It is imperative to recognize there is a distinct difference between fearful, uncooperative language and that of actual threats toward the provider.

When offering clear patient care DIRECTIONS to the person initially called a patient, the provider may DECIDE at this stage to treat a patient, DISENGAGE or attempt to DE-ESCALATE the situation. If criminally attacked, the provider should use reasonable force to DEFEND themselves and DISENGAGE.  *DT4EMS’ EVE teaches force as a last resort, however, we understand it may have to be used first. We do not expect a provider to try and “talk-down” a person who is actively (physically) assaulting them.* We recommend that anytime a provider uses force in self-defense, they notify their supervisor and law enforcement. That notification process is essential for changing the culture.



Critical Thinking for the Violent Encounter

Critical Thinking for the Violent Encounter




Simply training in a particular physical self-defense skill (technique) does not afford the provider the critical thinking skills required for what they truly face in medicine. One must be reasonable in their choice of technique. The image below is an example of the critical thinking process the provider is faced with when attacked and the split-second decisions they must make. The skills employed must be and appear non-aggressive. Then a distraction must occur, verbally or physically allowing for a provider to decide if they are dealing with a confused patient or an actual criminal attacker/aggressor. Like I said earlier, it sucks, but it is the reality of what the provider actually must deal with on the job.

When attacked by surprise

When attacked by surprise

We spend a great deal of time in our classes training staff on how to recognize the difference between a confused patient or an aggressor. How can you tell if you are dealing with a patient or an attacker? In a perfect world, being 100% right in a split-second would be optimal.  Knowing 100% doesn’t exist in the real-world, one must simply be reasonable in their perception based upon their training and experience. Below is an excellent way to reasonably determine if you are dealing with a true medical patient or a criminal attacker.

Patient or Attacker



If the provider is attacked by surprise ( pushed, grabbed, slapped, punched, etc.) the provider must understand how to respond reasonably. The danger in how a provider responds physically in a given situation is this… Could a confused nursing home patient grab a provider in the same manner as a drunk or drugged criminal aggressor? So, the way a provider would respond physically, to an elderly confused patient, would be different than that of how they would respond to a person in their 20’s high on drugs or alcohol.  (ARG below)

If you are dealing with a confused medical/trauma patient, you simply provide excellent patient care. If your perception is you are dealing with a criminal attacker, the image below explains what actions would be considered reasonable if the aggressor was the same size, sex, skill level, fatigued, age, etc. as the defending staff member. 

Assault Response Guidelines


Take the time to really research this subject. If you are planning to have a career in medicine, you will undoubtedly encounter a use-of-force situation (patient restraint or self-defense). People ( media, peers, administrators, jury) will have weeks, months, and years to dissect the decisions/actions you made in a split-second. You are ultimately responsible for your actions. Train accordingly.

Like it or not, on the job,  the 4 D’s required are present in order to make a decision (decide) on how to respond reasonably: Directions, De-Escalation, Disengage, Defend. 


As I have said thousands of times: