# Question about possible restraints on a psychiatric call.



## SC Bird (Nov 4, 2007)

During my second internship on Friday, we had a relatively slow day.  Three calls until about a half hour before I was scheduled to get off shift.  Call goes out for an Alpha Response for Psych. - Threatening Suicide.  Police on scene.  We respond to the location to find two officers already talking to the 20 y.o. pt. inside his house with family present but located in different part of the house.  Per family, pt. had been severely agitated earlier in the evening including "tearing up his room, swinging the dog into a wall and threatening us (family) and himself up until the police arrived."  Also per family, pt. has history of autism, bipolar disorder, and paranoid schizophrenia.  

Pt. admitted to responding officers that he had not taken his medications in three weeks and knew he needed help. (I know from class that admission is key in dealing with behavorial pts.)  However, upon our arrival, pt. refused to talk.  

Crew chief goes with family member to retrieve medications while myself, another EMT, and two officers try to persuade pt. to go to get checked out at hospital.

Crew chief comes back down and informs myself and the other EMT that pt. has completely destroyed his room and is a first degree black belt and has multiple Jujitsu certificates.  Basically he tells me, just be alert and on my toes.

Well pt. finally decides to stand up and begin walking to the truck accompanied by EMS personnel and police.  Police perform a quick search to make sure he doesn't have any weapons on him.  We get him secured on the stretcher, and transport without any problems.  No restraints were used throughout the call...and especially looking back on it, I don't feel as though they were necessary.


This was my first psychiatric call, and I was really glad that I got to observe a patient who presented with more than a girl who just broke up with their boyfriend of two weeks.

While I felt completely safe throughout the entire call, there is still the little part of the back of your brain that sees something like him clenching his fist as he's walking to the truck as a possible sign that this guy might be ready to snap.....or he could have been cold....

So now for my questions....
Are restraints only used when a patient presents aggression while on scene??  Or to EMS personnel/police/etc??  My textbook says that "you may use restraints only to protect yourself or others or to prevent a patient from causing injury to himself/herself."

Could someone offer some insight on when you might see fit to use restraints??   I know some of it is probably shades of gray...

-Matt


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## Epi-do (Nov 4, 2007)

I don't think I would have restrained your particular patient either.  Speaking in very broad generalizations, if a ppshcy patient goes willingly, I don't think I have ever restrained one.  If a patient has been ID'ed, then it really depends upon the actions of the patient and how much of a rapport I have been able to establish with the patient.  Patients that are physically acting out, are being abusive to those around them, etc, most definately get restrained.  Granted, part of my protocols state that restraints are for the safety of the patient, but for me, alot of times it is for my protection.  In fact, I can't say that I recall ever restraining a patient "simply" for their safety.  Psych runs can be complicated, and there are defiantely countless shade of grey involved.  I have found that the best thing to do is to just trust your gut/follow your instinct.


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## SC Bird (Nov 4, 2007)

During the whole time we were on scene, he was almost tranquil.  Complete opposite of how his family had described his actions pre-EMS/LEO arrival.  However, since he had hx of psych disorders, restraining orders against him, and evidence of some martial arts training I was cautiously aware around him.  Wanted to give him his personal space (as well as protect my own) both on scene and while in the back of the truck.

Thanks for the reply...

-Matt


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## MMiz (Nov 4, 2007)

It is my policy that:

- If we arrive and a patient is in restraints or being restrained, the patient stays in restraints.
- If we arrive for a BLS transport and the patient is in restraints, the patient stays in restraints.
- Otherwise it's really up to me and my partner.  If I'm responding to a location and putting a patient in restraints, I *always* have PD present.  There have been some times when PD has had to step in.


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## bstone (Nov 5, 2007)

When I get to an ER or facility or meeting the cops and a patient is being restrained, I'll take that into consideration but I often will establish a rapport and explain to my patient I have no desire to restain him/her but will if they are violent.

I then take a few minutes to interview them, determine what's going on and assure them I am there to help them. That is usually enough to enable an incident and restraint-free transport.

On my old BLS service we'd get 2-3 psychs per SHIFT. So yeah....I've done a lot of them. The old ladies usually need to be restrained more often than the big, huge men.


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## skyemt (Nov 5, 2007)

after RMA's, restraints are the second leading reason for lawsuits in EMS...
they are to be used (at least in our district) if the pt presents an IMMEDIATE 
danger to himself or others... there is no mention of "potential dangers".

if something were to go wrong with the restrained pt, and you could not prove than an immediate threat to your safety existed, it will be an expensive day in court, and the end of your EMS career.

if we feel insecure about a pt such as the one you described, we typically have PD ride in the rig for that very reason.


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## Ridryder911 (Nov 5, 2007)

http://www.merginet.com/index.cfm?searched=/clinical/psychiatric/PatientRestraint.cfm

http://www.merginet.com/index.cfm?searched=/operations/field/RestraintIssue.cfm


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## BossyCow (Nov 5, 2007)

I've only had to use restraints twice.  Once was an itty bitty little gal who was suicidal.  The other was a recreational chemical user.


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## Ridryder911 (Nov 5, 2007)

I use restraints at least daily to weekly either in the field, CCU or ER setting. It must be weighed heavily upon the reason, the type and course of the restraint. 

We have the policy they are only to be placed upon a patient that may endanger themselves or others. This interpretation as includes "endangerment to themselves" as pulling at tubes, IV's, etc. 

With this there becomes proper documentation. Type restraint, length of time, good circulation and sensation distally, as well as no-injuries related to the patient. In hospital, the documentation is MUCH greater as most has to be ordered by a physician (within a reasonable time) and re prescribed (usually it has to be reordered within 12 -24 hrs) to justify restraining. Exceptional charting of the padding of the restraint, ability of circulation, again movement and sensation and offering of toilet. Many might find humorous, but as well most facilities, one must offer secondary choices prior to restraining. Such as discussion of why restraints is needed, etc. May appear silly, but the courts do not think so. 

The point I am offering is to be sure you have a policy in place, that each member is properly trained and have demonstrated in training, safe techniques, and then exceptional documentation afterwards. 

R/r 911


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## SC Bird (Nov 5, 2007)

Ridryder911 said:


> I use restraints at least daily to weekly either in the field, CCU or ER setting. It must be weighed heavily upon the reason, the type and course of the restraint.
> 
> We have the policy they are only to be placed upon a patient that may endanger themselves or others. This interpretation as includes "endangerment to themselves" as pulling at tubes, IV's, etc.
> 
> ...



Thanks for the advice on just how precise documentation should be (particularly in this instance) noted.

I appreciate all of the responses.....

-Matt


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## havok965 (Nov 13, 2007)

i work in a psych ward, and have dealt with all kinds of combative patients. You wouldn't use restraints until he got out of hand, or at least started to get out of hand. Once verbalizing the intent to harm, then have the right personel to take down the patient, but restraining them should be the last resort. You are taking away their rights as a person, but for the safety of them and others. And i know what you mean by 'being on your toes'.


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## Onceamedic (Nov 13, 2007)

What do you think about the easy, very little documentation required, easy to justify form of restraints - the c-collar/spine board ?


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## triemal04 (Nov 13, 2007)

Kaisu said:


> What do you think about the easy, very little documentation required, easy to justify form of restraints - the c-collar/spine board ?


Have you ever tried to take someone who is sitting on the gurney in the back of the ambulance, throwing punches, kicking and screaming, and between you and your partner put them on a longboard?

Just wondering.


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## Onceamedic (Nov 13, 2007)

its as least as easy as 4 points..... gotta control them for a little while..  get some stuff tied down and it gets easy...


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## triemal04 (Nov 13, 2007)

Kaisu said:


> its as least as easy as 4 points..... gotta control them for a little while..  get some stuff tied down and it gets easy...


So you've never tried it.


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## Onceamedic (Nov 13, 2007)

nope - thats why i was asking


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## triemal04 (Nov 13, 2007)

Kaisu said:


> nope - thats why i was asking


Ok.  Sorry.  It's not a bad way, but not the best either.  To do it will take more than two people...getting the person flat on the ground...onto a board...holding them down long enough for 4-6 straps to be put on...not fun, or easy.  But, if you've got the manpower and the room to work (cramped quarters aren't fun for this) then go for it.  Toss a couple of soft restraints around the wrists, and you're golden.  

When you don't have the manpower, or are stuck in the back of the car with them, use soft restraints, or even flexcuffs if you carry them.  Tie the hands to the gurney, then move on to the feet as neccasary.  If possible get one arm above their head to limit body movement.

Or just flip them face down, tie the hands behind their back and smile.  Course, there's a lot of explaining to do with that way.


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## Onceamedic (Nov 13, 2007)

thanks...  appreciate it.

BTW..  we had one patient with BS OD - bunch of her roommate's beta blockers as well as a lot of ETOH.  Stong little gal.  She pulled her hand out of the leather and messed up her IV.  The security guys (this was in the ED) tied her arm up as you suggested.  She was on the monitors and her cuff was on the arm that was over her head - needless to say, the BP reading on that arm got a little unrealiable....


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## firetender (Nov 14, 2007)

Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney. 

Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...

...and never undersetimate the temporary power of duct tape.


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## ffemt8978 (Nov 14, 2007)

firetender said:


> Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney.
> 
> Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...
> 
> ...and never undersetimate the temporary power of duct tape.



And a lot of protocols have been written to specifically preclude you from using a "sandwich" method of restraining a patient due the bad press about it.  I have always wondered though, if I would get in trouble for "sandwiching" a patient using two Stokes Baskets and some zip ties.  h34r:


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## Gbro (Nov 14, 2007)

We used to transfer psychiatric's often to the main regional Cuckoo bin(80miles) and i had a few that constantly companied about the 4-points, always wanting them loosened, etc.
I would have the ER staff lock the 4-points to our cot and I would check everything and then the staff would, as prearranged, put the key in their pocket. I already had one in my pocket, but the Pt. doesn't need to know i have a key. The question came up often, how are you going to get me out of here in an emergency?, My EMT sheers. They will cut a penny in two.
It made for less hassle.

One of my more memorable psychiatric calls;
dispatched to a rural residence, report of a 70YOM chasing the chickens with a butcher knife, In the nude!, all kinds of mental pictures popping into the head enroute. Once on scene, it only took about 5 minuets to determine the 70YOM was the most lucid member of the whole family.(he found his bib's by the time we arrived)


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## firetender (Nov 14, 2007)

ffemt8978 said:


> And a lot of protocols have been written to specifically preclude you from using a "sandwich" method of restraining a patient due the bad press about it. I have always wondered though, if I would get in trouble for "sandwiching" a patient using two Stokes Baskets and some zip ties. h34r:


 
When the safety of you and the people around you is compromised, asking for forgiveness makes more sense than waiting for permission.


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## Arkymedic (Nov 14, 2007)

SC Bird said:


> During my second internship on Friday, we had a relatively slow day.  Three calls until about a half hour before I was scheduled to get off shift.  Call goes out for an Alpha Response for Psych. - Threatening Suicide.  Police on scene.  We respond to the location to find two officers already talking to the 20 y.o. pt. inside his house with family present but located in different part of the house.  Per family, pt. had been severely agitated earlier in the evening including "tearing up his room, swinging the dog into a wall and threatening us (family) and himself up until the police arrived."  Also per family, pt. has history of autism, bipolar disorder, and paranoid schizophrenia.
> 
> Pt. admitted to responding officers that he had not taken his medications in three weeks and knew he needed help. (I know from class that admission is key in dealing with behavorial pts.)  However, upon our arrival, pt. refused to talk.
> 
> ...



It is our policy that we have to have medical control's permission to apply ONLY soft restraints and have very good reasoning. If the pt wants to fight so hard as to hurt someone then the hell with it they can go to hospital by PD. It's not worth my partner nor my career or our health. Skyemt was exactly right when he posted of the legal ramifications of using restraints, especially unapproved restraints. Though it may have been the only way using a spineboard and scoop to sandwich, using kerlix, c-collars turned backwards, flexicuffs, duct tape, face down with hands tied together, etc
all appear barbaric in court and compromise pt safety. Yes I work in the field and deal with psychs and have used some of those methods too before coming to the present service I work for however it's just something to thank about. Your safety is first, your partner second, and then the pt and bystanders.


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## BossyCow (Nov 14, 2007)

Great timing on this one!  At 0'Dark thirty this morning I was standing a safe distance from the gurney watching 5 LEO's deal with a combative pt.  This guy bucked so hard handcuffed to the gurney that we were all waiting to see the gurney go over with him on it.  

We ended up getting the soft restraints on him but he was so combative they couldn't get enough halodal into him to get him transferred to the ER bed. 5mg im x2, still thrashing, 8 mg iv, still thrashing.  Turns out he had a skull fracture from the butt end of a 'buddy's' shotgun, a blood alcohol level of .356 and quite a healthy libido based on the comments he made about me on the 35 minute transport to the ED.   We were gonna go out for drinks after, but they admitted him.  (Just kidding, the bars weren't open)


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## Gbro (Nov 15, 2007)

Bossy, 
That is where the KED shines.


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## triemal04 (Nov 15, 2007)

Gbro said:


> Bossy,
> That is where the KED shines.


That's the second time you've shown that picture.  Why I don't know.  For anyone who's looked at it, remember:  do not, repeat DO NOT restrain your pt's face down.  Ever.  And especially if they have been fighting, are whacked on drugs, or a combo of both.  Doing so is asking for them to become hypoxic and/or stop breathing and potentially code.


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## BossyCow (Nov 16, 2007)

Gbro said:


> Bossy,
> That is where the KED shines.



I'm not sure how a KED would have been easier to apply than the 4 point restraints we used.  Personally I didn't want to get close enough to have to do up all those buckles.  We ended up duct taping a towel to the guy's head to stop him from spackling the inside of the rig with his blood, covering it with a pillowcase and duct taping that to the gurney.  Between the soft restraints and the gurney straps, he was pretty tied down.  

Turns out he had a blood alcohol of .356, and according to the deputy I talked to afterwards, his pal had broken three different shotguns while beating the guy with the stocks.  

As an addendum, the third guy in the room when this happened wrapped his car around a tree and died the very next night.


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## OreoThief (Nov 16, 2007)

Generally speaking, if I have a PT that needs to be restrained due to risk of violence, our protocols dictate to call the police, and have them available and on hand just in case. If things are still too risky, they are usually more than happy to take a ride with you in the truck.  Scene safety.... scene safety..... scene safety.


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## Ridryder911 (Nov 16, 2007)

firetender said:


> Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney.
> 
> Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...
> 
> ...and never undersetimate the temporary power of duct tape.



...._Patients should never be transported while hobbled, hog-tied, or restrained in a prone position with hands and feet behind the back, and never be transported while sandwiched between backboards or mattresses _


Sandwiching is a guaranteed litigation deal. It has been proven to be dangerous and harmful, Be sure that any restraint device must be able to be removed in a hurry and be safe to the patient. 

R/r 911


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## OreoThief (Nov 16, 2007)

Wow... never even heard of "sandwiching" before..... maybe I'm just too new to this.


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## eggshen (Nov 17, 2007)

The scoop sandwich is, without a doubt, the best way to restrain a pt. That is unless you don't wish to keep your job and livelihood intact. Years ago they were great. That was prior to the whole postitional asphyxia thing becoming apparent. Nevermind if your pt. is some kind of sympathomimetic OD. In fact, if you have never seen it, forget you ever heard about it. 

Egg

Also, the way that KED pt. is sorted? We try NOT to kill people.


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## BossyCow (Nov 17, 2007)

So it used to be okay to kill pts?


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## Gbro (Nov 20, 2007)

BossyCow said:


> I'm not sure how a KED would have been easier to apply than the 4 point restraints we used.  Personally I didn't want to get close enough to have to do up all those buckles.



No KED straps need to be used. I just lay the KED on the Pt. and it is held in place by the cot straps, just snug enough to keep in place.
Now for anyone who thinks this is a dangerous method is just being "PIG HEADED".
The Pt. in the Pic was delivered, and the ER staff each took their turn trying to control this one and had No problem with the restraint in use. The Cuffs are much more likely to do damage. 
BTW, the local ALS service is the one that showed me this technique.


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## Comedic (Nov 21, 2007)

If I feel that if the pt is going to hurt myself, my partner or be a problem. I am going to restrain them before transfer. No questions ask. Haldol sucks it's to slow and if PD is there use them.

It's a judgment call. Your the one in back and the one that has to deal with them during transport. 



A scoop and backboard sandwich funny stuff. I head about it and also heard how Pt's had died. So maybe not so funny, but still funny.

We all get tired of the combative drunks and the suicidal Pt's. That hates the world and wants to fight.
But it's our job to take care of them in there time of need. 
Don't get me wrong I make jokes about them all the time and cuss them at 2am when I have to get up cause Frank is trashing his house again and wants to fight. Who doesn't like a good fight.


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## triemal04 (Nov 21, 2007)

Gbro said:


> No KED straps need to be used. I just lay the KED on the Pt. and it is held in place by the cot straps, just snug enough to keep in place.
> Now for anyone who thinks this is a dangerous method is just being "PIG HEADED".
> The Pt. in the Pic was delivered, and the ER staff each took their turn trying to control this one and had No problem with the restraint in use. The Cuffs are much more likely to do damage.
> BTW, the local ALS service is the one that showed me this technique.


So what was the point of the KED again?  And while you're at it can you explain what positional hypoxia is and why it's a problem?  I'd really appreciate it.  I guess all the evidence is wrong...and everyone who says it's right is wrong...and it doesn't matter if the pt dies...after all, we're just pig headed.


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## jmaccauley (Nov 21, 2007)

How many of you are required to transport a violent pt. to the mental health facility if there is no injury? Just curious, because generally if the police are on scene and can establish that the pt. is or has been violent, they transport, and apply restraints for everyone's safety. Whether he is suffering excited delirium or is off their meds, they can flip in a heartbeat, so why would you take their word that they will be calm for the ride? Just asking.


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## jmaccauley (Nov 21, 2007)

triemal04 said:


> So what was the point of the KED again?  And while you're at it can you explain what positional hypoxia is and why it's a problem?  I'd really appreciate it.  I guess all the evidence is wrong...and everyone who says it's right is wrong...and it doesn't matter if the pt dies...after all, we're just pig headed.



Just to add to the debate and confusion over positional asphyxia/hypoxia. That has always been a major concern and many medical authorities warned of the danger. However, the debate has recently challenged that postion. For example there have been studies done (admittedly with low numbers of volunteers) to question how long a person would need to have their upper thorax region constricted before it became critical. The original tests often involved healthy young adults, but have now included various other age groups. Anyway, the weight being on the chest was usually blamed for sudden death syndrome, but now it has been more widely accepted that other factors probably contribute as much or more to the breathing complications. It's still a good idea to at least not appear to have contributed to the patients death.


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## Ridryder911 (Nov 21, 2007)

The main point is to have a plan, the right equipment, and to *safely* use it. I question why EMS would have to transfer any seriously "violent" patient and for what medical reason? 

Enough personal and planned delivery of application of approved restraint devices, should be implemented after the decision of "restraining" devices. 

This is one of the highest litigation areas in EMS and medicine itself. Not assuring patient safety after recognizing that the patient has a recognized or known psychiatric disorder is going to be reviewed and scrutinized if any unfortunate event occurs. Remember, almost each state has special considerations for those with known emotional and psychiatric medical problems. Undue roughness, hostile treatment, etc. should *NEVER* be placed onto those individuals, that is if one would like to continue to work in any medical profession. 

Yes, it may appear unfair, but patients with known or those presenting emotional behavioral problems are protected that they are not aware of what they are doing. That is why it is VERY important to have documented special training in restraining and restraint training. As well a very thourough protocol on how and when should be implemented. 

Any indication of "sandwiching" patient for restraints is opening the door for litigation. It has been documented and *proven to be harmful* and anyone wanting to continually use it does not value their career.  

If my service area has a high percentage of emotionally distraught or pyschiatric patients, then I would recommend to discuss programs that teach proper restraining patients, and self defense against those that possess known disorders (yes, again those with known history have special rights), as well as to invest in approved restraint devices. Those patients that definitely demonstrate severe violent behavior should be restrained and transported by other means than EMS, again justifying why EMS should even be considered? 

R/r 911


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## jmaccauley (Nov 21, 2007)

A violent patient is generally treated as a medical emergency by law enforcement. We may have to restrain them in order to get them the help that they need. We are also very aware of Sudden Custody Death Syndrome and will probably have a restrained, violent person transported to the nearest ER by ambulance. I would expect most crews to request an officer ride with them, but it doesn't always happen. From LE's perspective, we logically assume that there is a high probablility that a patient suffering from drug psychosis or excited delirium is in the downward leg of living. Given a choice of having them die on the ground with our restraints in place, or in the ambulance, guess what the choice will be? Our paramedics face the same decision and feel that the patient should die on the operating table rather than in their rig. It's all about perception and recognizing that bizarre and violent behavior is something that can blow up instantly, taking reputations, careers and lives along with them.


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## BossyCow (Nov 21, 2007)

Ridryder911 said:


> The main point is to have a plan, the right equipment, and to *safely* use it. I question why EMS would have to transfer any seriously "violent" patient and for what medical reason?
> 
> R/r 911



We transported one just the other day.  He had a fractured skull and is still in a medically induced coma at the nearest trauma center.  He was the victim of an assault and was in serious need of medical treatment.  He also is a well known instant a:censored:e.. just add alcohol and presto.. a:censored:e! 

In this case, Law enforcement was on scene and cleared us for entrance.  The guy had bouts of combativeness and violence followed by periods of well behaved compliance.  There was generally no warning prior to the outbursts so we had him restrained to the gurney with 4 point restraints.  To use a KED would have required a whole lot more cleaning than I wanted to do.  The deputies cuffed him to the gurney and stood over him while I ducked in around them and secured the restraints.  The soft restraints allowed me to restrain one limb at a time instead of offering myself as a target to his outbursts.  I can't imagine using a KED for this!  But I'm funny that way, I prefer to use tools for their designed use.  KED for spinal immobilization prior to extrication, restraints for restraining pts.


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## chadwick (Dec 20, 2007)

We were sent to the county jail for a middle aged white female who was having "apnea". Upon arrival on scene, pt found laying in bed holding her breath between random strings of gibberish. Vitals all normal, pt was rubbing and scratching her face wildly so I loosely immobilized her hands with a triangle bandage and the belly strap on the stretcher. Upon arrival @ the ER, the ER paramedic went in and started talking to her, she was healed instantly. She sat up in the bed and started talking and acting normally. The nurse said "She must have detected that she could get some sympathy out of you" and before I could say a word my partner said, "Nu uh, he was hollering at her to stop faking and doing sternal rubs on her". I provided adequate care and got her to the ER without her clawing her eye out.  

I was a nurse aid before becoming an EMT so I have over 5 years expirience with restraints, most of the time, if they are coming peacefully I just use the three straps and the shoulder straps. I don't turn my back on them but I try to find calm things that we can talk about. I had a guy one night that scared the crap out of me but as long as we were talking he was fine. It was funny when we started comparing tattoos. If they really freak out enroute the straps should buy me enough time to either tuck and roll out the side door or be looking back at them through the plexiglass window in the door between the cab and the box. I decided a long time ago that I am not getting hurt if I can avoid it. Let me and my partner get our stuff and get out and you can have the ambulance, keys and all. If you prefer to walk I can't promise that I won't tell the police which way you were headed. I have seen hundreds of patients and restrained 1 so far.


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## emtwacker710 (Jan 9, 2008)

soft restraints, cravats are your friend...of if they come from the police always make sure you have an officer ride in the back, trust me, my crew told an officer he didn't need to ride but I wanted him to ride as I had transported this pt. before and they didn't listen to me, long story short we had to strap him down and call a patrol 10 minutes out from the hospital. I also switched crews so people wuld actually listen to me, lol


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## bassman1490 (Jan 31, 2008)

hey when did you change crews, didnt you use to ride with travis. when did you have this call, i didnt hear about that one


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## emtwacker710 (Jan 31, 2008)

I've ridden with all of our crews pat, and this call happened like 2 yrs ago too..but yea that call sucked, we mutual aided Moreau for a seizure pt. and he started getting combative, he used to live in a park in the west end, but he was at moreau family health that day and it happened, and Moreau was out on 2 calls so they called us as it was their 3rd call


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## bassman1490 (Jan 31, 2008)

ohhhhhh i understand now yeah that sounded like it sucked i would not want to deal with that


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## griz1974 (Mar 4, 2008)

*restraints*

when in doubt use local resources i.e. pd let them restrain the pt thats thier job


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## emtwacker710 (Mar 14, 2008)

I actually just found a new way to restrain a combative pt. the other night, take the reeves stretcher and put the pt. face down in it then secure it and flip it over and put the pt. facing up on the stretcher and secure the stretcher straps, a CO in my squad says this works great and does not affect the airway...sorry if someone else mentioned it, I didn't see it when I scanned through this thread


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## JPINFV (Mar 14, 2008)

Is the patient sandwiched between the reeves and the gurney?


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## Jon (Mar 14, 2008)

emtwacker710 said:


> I actually just found a new way to restrain a combative pt. the other night, take the reeves stretcher and put the pt. face down in it then secure it and flip it over and put the pt. facing up on the stretcher and secure the stretcher straps, a CO in my squad says this works great and does not affect the airway...sorry if someone else mentioned it, I didn't see it when I scanned through this thread


This was already mentioned. It is a form of "sandwiching" a patient. Back in the "old days" that was a common way to restrain a combative patient. Now we know better.

What do you mean by CO? Chief Officer? Corrections Officer? Are they an EMT or a Medic? Are they your command doc? If they aren't your command doc, and it isn't a written policy.... I'd be careful and follow your state's policies on patient restraint... because a wrongful death suit isn't cheap. Additionally... how do they KNOW that the airway isn't affected? Are you monitoring SpO2 when you restrain someone? How about ETCO2?

The issue with sandwiching a patient is that you can impair the patient's breathing. In a normal person, it isn't necessary that much... but if someone is hypoxic from exertion, it could be life threatening - especially if the subject continues to fight. 

Since we are talking about restraining a violent patient... Is everyone familiar with the term excited delirium? A decent look at excited delirum can be found here:
http://www.policeone.com/writers/columnists/ForceScience/articles/119828/ this is a police site, but the article disscusses EMS, as well as some of the causes of Excited Delirium. ED is a relitively new term for something that has been seen for years. Many cases that have been considered positional asphyxia actually seem to meet the criteria for ED. Many times, someone exhibiting ED will be restrained against their will, and in a relatively short time, the subject will stop breathing and die... This is still an evolving definition.

Here is that National Assn. of EMS Physician's Position Statement on Patient Restraint - it is a good discussion of the issue, including what services need to think about in advance. http://www.naemsp.org/pdf/restraint.pdf


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## paramedix (Mar 18, 2008)

As Rid mentioned it depends on the situation at hand. If in doubt restrain. We dont have much space in our ambulances and if that patient start getting violent, there is no way to go or nothing much you can do besides getting involved. 

For safety reasons I would restrain the patient, I would most probably find any reason to tell him that his back or neck might be injured and immobilize him so I could strap him down.

I had one too many patients assaulting me in the back of an ambulance and it could all be prevented.

As for suspects, they get the full monty... cuffs, spider and police restraints with an armed officer in the back with me.


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## emtwacker710 (Mar 18, 2008)

Jon said:


> This was already mentioned. It is a form of "sandwiching" a patient. Back in the "old days" that was a common way to restrain a combative patient. Now we know better.
> 
> What do you mean by CO? Chief Officer? Corrections Officer? Are they an EMT or a Medic? Are they your command doc? If they aren't your command doc, and it isn't a written policy.... I'd be careful and follow your state's policies on patient restraint... because a wrongful death suit isn't cheap. Additionally... how do they KNOW that the airway isn't affected? Are you monitoring SpO2 when you restrain someone? How about ETCO2?
> 
> The issue with sandwiching a patient is that you can impair the patient's breathing. In a normal person, it isn't necessary that much... but if someone is hypoxic from exertion, it could be life threatening - especially if the subject continues to fight.



by CO i mean corrections officer, who also happens to be our squad captian and a critical care tech. (level 3) in NYS, as long as you keep the pt's head out of the reeves, you can attach the pusle ox to the ear and monitor SpO2, and I personally have not used this form of restraint myself, but I have heard of times when it was used and worked, I myself don't know if I will actually ever use this, 99.9% of the time we get a call that poses any danger to us the patrol is already on the scene or is en route and dispatch makes us stage in the area or if we need a patrol at anytime they are 5 minutes away 10 at the most..


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## BossyCow (Mar 20, 2008)

emtwacker710 said:


> by CO i mean corrections officer, who also happens to be our squad captian and a critical care tech. (level 3) in NYS, as long as you keep the pt's head out of the reeves, you can attach the pusle ox to the ear and monitor SpO2, and I personally have not used this form of restraint myself, but I have heard of times when it was used and worked, I myself don't know if I will actually ever use this, 99.9% of the time we get a call that poses any danger to us the patrol is already on the scene or is en route and dispatch makes us stage in the area or if we need a patrol at anytime they are 5 minutes away 10 at the most..



It's one of those situations where practice will change after the law suit. If there is a history of a practice causing a problem, and you follow the practice anyway, and something goes wrong, you or your insurer, will pay a large settlement. Now, there are those who will play the odds and continue to use a practice that 'so far ain't hurt nobody I know of' until their agency is sued. Some of us prefer to use risk managment.


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## Ridryder911 (Mar 20, 2008)

emtwacker710 said:


> _ "....you keep the pt's head out of the reeves, you can attach the pusle ox to the ear and monitor SpO2" ._



You do realize someone can not be breathing for up to 3 minutes before Sp02 will change? 

I would not endorse any circumferential device as a restraint. There has been numerous wrongful death litigation by sandwich devices, and restraining per "wrap around". This is a very touchy legal subject, unless approved by studies and methods, I would not use. 

R/r 911


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## JPINFV (Mar 20, 2008)

Dr. Bledsoe has a good power point  presentation on his website regarding restraints and the appropriate literature. 

http://www.bryanbledsoe.com/handouts

Scroll down to the restraint one.


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## evantheEMT (Oct 27, 2014)

In my state if the pt is already in restraints we can continue into our care.Protocols say we can only have someone restrained for only 30 minutes in the ambulance. If we need to restrain a pt halfway through transport then the pt had to be getting physical with us or hurting himself.In the new protocols this yr we have a certain way of postioning the pt so we can still maintain abc's and vitals.


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