Interfacility psychiatric transfers are far more complex, especially when relegated crews who may lack training and experience. We ask interfacility crews to decide if the patient should go in restraints, consider whether sedation is indicated, if the patient should walk to and from the ambulance, and where the patient should sit.

If someone is going to a treatment facility, an ambulance is indicated. Arguments that the ambulance is somehow “dangerous” are not made with the patients who put EMS providers at the greatest risk: the disinhibited or disoriented. Thousands of times a day, across the U.S., EMTs and paramedics treat potentially combative patients who are intoxicated, post-ictal, brain-injured, hypoglycemic, demented or intellectually disabled.

No one would think to transport a head-injured patient who has been combative, but needs no further intervention, in a police car. Yet, these are one of the most dangerous patient’s EMS providers come into contact with. A 2009 article in JAMA: Psychiatry found that mental illness alone does not make psychiatric patients any more dangerous than those in the general population. Yes, some psych patients are dangerous, but it is inappropriate to automatically equate psychiatric illness with dangerousness.


I think it is dangerous and misguided to consider psychiatric patients differently than medical patients. Doing so perpetuates the stigma against the mentally ill which, in part, may come from ancient beliefs about aberrant behavior being caused by possession of demons or by evil spirits.

Thinking that psychiatric patients should not be transported by ambulance because they are dangerous harkens back to a dark time in this country’s history and is part of a long history of discriminating against the mentally ill, including lengthy detention, forced sterilization and the stripping of civil rights. It has only been since a 1975 Supreme Court decision ordered that states could not treat all mentally ill people as if they were dangerous.

Patient always on the cot

The safest place for any patient is on the ambulance cot or stretcher with all of the seat belts in use. It has the lowest center of gravity and allows for easy monitoring of the patient. Be certain the side of the seatbelt buckle that reads “PRESS” is turned upside down. Direct all patients to not touch the seat belts. The provider in the back needs to be aware of the patient and his/her hands at all times.

Distress signal

The patient attendant and driver need to have a pre-arranged distress signal that indicates things are going south in the back and that the ambulance needs to be brought to a stop. Any patient who touches the seat belt, for example, is not following directions. The ambulance should be brought to a stop, its location broadcast, and the provider who is driving should come back to help restrain the patient. If needed, all providers should flee and seek cover or concealment from a violent and combative patient. The scene is unsafe.

Thorough patient history

EMS providers need to insist that the handoff they get from a sending facility about the patient they are transferring includes whether the patient has a history of violence; if restraint, sedation, or redirection have been necessary; and whether the patient has previously tried to elope. The sending mental health professional should give a recommendation to the transport crew if restraints are indicated.

Early patient notification of transport

Discourage sending facilities from not telling the patient about their transfer until the last second so as “not to cause problems.” Just before departure is not the time to learn whether the patient is going to escalate.

Restraint and sedation protocols

All EMS providers should have clear protocols that allow for patient restraint and sedation. Indeed, it is incumbent on ALS providers to keep hospital staff safe by adequately sedating the patient before arrival at the emergency department.
EMS systems and providers are sophisticated enough to handle a wide variety of patients, psychiatric and otherwise. Ambulances can be made safe by the providers who work in them. EMS system administrators, chiefs and other stakeholders need to insist on training for psychiatric patient treatment and transport.


Houston Behavioral Healthcare Hospital; 2801 Gessner Rd; Houston, TX 77080 (832.834.7710)

Center for Success and Independence; 3722 Pinemont Dr; Houston, TX 77018 (713.426.4545)

Sun Behavioral Houston Hospital; 7601 Fannin St, Houston, TX 77054 (713.796.2273)

West Oaks Hospital; 6500 Hornwood Dr, Houston, TX 77074 (713.995.0909)

Lone Star Behavioral Health – 16303 Grant Road; Cypress, Texas 77429 (281-516-6200)

Cenikor Foundation – 5629 Grapevine Street; Houston, TX 77085 (713-726-0922)

Our Mission Statement

My Armor Services Incorporated is a dedicated team of professionals who strive to make each intervention/transport, positive, secure, and most of all safe.
It is our mission to treat your loved ones with Respect, Dignity, Relationship, Resolve, Hope, Resolution, Motivation, and Love. That in the moment of critical exchange they were treated with respect, dignity, and love and that they arrive to their designated program safely and in a positive frame of mind.