# Psych pts



## akemt (Nov 4, 2017)

experiences with psych patients? How do you handle them/tips on working with pysch pts


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## hometownmedic5 (Nov 4, 2017)

The best advice I have is let them talk. Find out what their issue is(the most pressing issue this minute) and if possible, solve it. For example, I have taken many patients who know their going to the hospital, have accepted that they're going, but would like to smoke a cigarette before they go. Given that you cant hardly smoke anywhere anymore, this usually becomes a huge problem causing almost irrecoverable escalation. What started out as a simple problem frequently ends in restraints. 

That being said, not all patients have rational, solveable problems. When faced with that situation, I have a simple rule. I dont fight anymore. I will try to negotiate with you for as long as it takes to get you on the stretcher without force, but if its going to go the hard way, I'm bringing a lot of guys and loaded syringes. Back in the day I would have happily gone to town with you physically, but no longer. The commonwealth has bestowed upon me the great honor and responsibility of a big box of shut the eff up and I'm happy to use it. 

Solve their problems if you can, sedate them if you have to, but never ever place yourself in a position where your patient can harm you.


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## WolfmanHarris (Nov 4, 2017)

I make every effort to treat the mental health condition as I would any other. I don't hesitate to ask them about their medications, symptoms, triggers etc they way I would a cardiac history or COPD. I find that is the key to a non-judgemental approach.

Of course when patient's are in a major crisis or suffering from psychosis this isn't necessarily workable but the key thing to remember is these patients are a very small subset of the total population of persons with mental illness. 

In severe cases when the patient is violent or a risk to themselves, I vastly prefer chemical sedation to physical restraint to reduce agitation. Do not hesitate to call for ALS back-up in these cases. Also remember while law enforcement may have a necessary role in maintaining safety for providers and the patient, this is still a medical issue and you must continue to advocate for the patient.


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## E tank (Nov 4, 2017)

Believe that they believe to their very core the things they say to you no matter how unbelievable.


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## Aprz (Nov 5, 2017)

I don't feel like there is anything special I do about psych calls. I'll usually ask questions like what happened that lead up to me being there? Do they want to hurt themselves or others? If they plan to hurt themselves or others, how so? Have they ever had this problem before? When and what happened? If they are on psychiatric medications, are they compliant with them? Any recent changes with their psychiatric medications? I try to make sure I know their specific psychiatric issue (usually limiting it to depression, bipolar disorder, and schizophrenia rather than just lumping it all together under "psychiatric"), patients are usually in the know with what they have have and are honest about it. Are they having auditory or visual hallucinations? If so, what are they seeing or hearing? Any drugs or alcohol involved?

Among their other vital signs, I make sure to get their blood sugar (if violent and closing their hand, I'll do it on other body parts eg sole of their foot), temperature, and check their pupils. By the way, I'll give them a couple of tries for blood sugar, and tell them I'll do it in a probably more painful and unusual spot before I got to the feet. If they are a suspected excited delirium case, I'll just get it off the IV, which I'll do in it "immobile" spots like the feet (I have a foot fetish) or holding down the hand against the rail. If they are a suspected excited delirium case, I'll usually monitoring their EtCO2 with a nasal cannula as well.

In regard to restraints, I kind of wing that one. I am very liberal with using it. If I feel like the patient is acting squirrely, the restraints are going on. I don't screw around. I'll tell the patient what's going on, and won't lie like "Oh, these are to prevent you from falling off the gurney." Pfff!!! When I did IFT, I don't know why hospital staff liked saying that... If the patient has handcuffs are restraints already, I'll continue it.

In my county, we can give 5 mg Midazolam IM once. We have to call base for further. In my experience, this is 100% complete waste of time. I have yet to have this actually calm a patient. Maybe I am doing it wrong? For me, it just hasn't worked. Get lots of guys and make sure the restraints are good.... If they weren't restrained and all of the sudden want to hop out, I'll try to use verbal reassurance to slow them down or stop them. I will yell for my EMT to pull over, so they can safely get out. I, of course, try to minimize those incidents, and thankfully haven't had one leave yet. I did have one patient that went from being a calm and cooperative psych call to pulling off their seat belt, acting antsy, and having my EMT pull over. With verbal reassurance, we manage to get them to get to the hospital with restraining them or having them jump out, but I was very scared.

I have had two incidents where psych patients go very violent unexpectedly. Once was when I was an EMT, and I was up front driving, and the medic and the patient just started wrestling in the back. He just yelled to upgrade code 3 and ask for PD and tell them to meet us at the hospital. When we got to the hospital, I opened the back door and he had the patient pinned down on the ground, so I hopped in to help with that. The hospital staff and law enforcement came and went to help carry the patient onto the gurney outside of the ER. I just remember it was a chest pain call, and then the guy thought my medic partner was going to cut off his genitals. I then had a call, as a paramedic, where a construction worker was probably high on gas not wearing a mask while painting inside. His co-workers last saw him normal hours ago, and then they saw him walking around aimlessly and yelling. With verbal reassurance, I got the guy to sit on the gurney and tried to assess him. I know that I want to let them go, but for whatever reason, my mind said no, and when he tried to escape, me and my partner grabbed both of his arms. He was a 6' buff construction worker, and both me and my partner are 5'6"ish (at least I am 5'6"). We got tossed around before I yelled for PD who was right outside of our ambulance. They had additional officers show up, I gave 5 mg Midazolam IM which did nothing, restrained him, and then we transported. I was very shook up from that call. I knew that we shouldn't physically try to stop them, especially who definitely could over power me physically. Hopefully I don't make the same mistake again.

Kind of counter intuitive, but if you aren't a threat to the patient, they tend to respond better even if not perfect. I am usually smaller than most of my patient, usually the one doing the most communication with them, and I feel like they respond better to me than some of the buff firefighters or tall medics I've seen; It's like they try to pick a fight. Almost like little dogs growling at the big ones.

Last thing... don't forget to check for weapons or things that can be used as weapons. I don't even bother asking PD if they checked; I confirm it myself. I have pulled out many knives/dagger out of patient's pockets. This is true on a lot of calls, but especially true on psychiatric calls.


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## Qulevrius (Nov 5, 2017)

Read the pt, see who you deal with. There’s a world of difference between a schizophrenic gangbanger with a meth relapse and a depressed 21 y.o. chick who tried to off herself with 5 Tylenols because she had it rough in school. Nothing irritates me more than a brain dead straight-out-of school EMT who shotguns everything and everyone, just because they’ve been told so during their orientation/field training.


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## SpecialK (Nov 5, 2017)

Patients with a psychiatric problem, in the absence of an immediate threat to themselves or others, are an ambulance problem, not a police problem.  The police are not routinely required.  These patients often have had bad experiences with the police before and it just makes things worse!

Many of these patients will require 15-20 minutes of verbal rapport building to gain trust and enable you to approach, assess, treat them etc.  Many personnel just give up after a couple of minutes and this is pointless.  One person needs to speak to them, not 3 or 4.  If friends or family or bystanders don't shut the hell up get them out.  Turn down your handheld radio and turn the telly off.  Offer choices such as a fag or cuppa.  Tell them you're there to HELP them and that you're NOT the police.  Helps a treat.


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## EpiEMS (Nov 6, 2017)

SpecialK said:


> Offer choices such as a fag or cuppa.



Things to not offer your patient in the U.S. 

"You want to give me a what?"

(but yes, agreed - if they want a cigarette, meh, go for it...)


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## DrParasite (Nov 6, 2017)

1) realize you're not going to fix the issues of a psych patient with less than an hour of talking to them.  
2) realize that a psych patient can go from crazy to violent very quickly; however most won't, especially the ones who called you for help.  They just need a ride to the ER to get transferred to a psych place.  But don't let your guard down, because that can change quickly
3) Arguing with a psych patient is like trying to put lipstick on a pig
4) always check your patients for weapons, and potential weapons.  I've been burned in the past.  Ask them to empty their pockets and put everything in a plastic bag.  then confirm there is nothing left.
5) if you do get stuck in the back of the ambulance with a violent psych, GET OUT OF THE AMBULANCE.  Some would say wrestle with him and try to restrain him while you call for help.  I say have your partner pull over, and step outside while you call for help.  Let him trash the truck.  If he wants to flee, have law enforcement chase after him.  
6) psych patients want help.  they are sick people, with an actual condition.  don't demean then, or ignore their concerns as they can't fix themselves.  give them a nice comfy ride to the appropriate facility, and talk to them like they are a real person, not just a psych patient.  and if they don't want to talk, don't push them.  It's not worth aggravating them.


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## iExposeDeformities (Nov 6, 2017)

Number 1 tip: DO NOT EVER let the 5150 pt access your stethoscope. My partner was in the back with a 5150 and the pt tried to strangle him with a stethoscope


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## Kevinf (Nov 7, 2017)

iExposeDeformities said:


> Number 1 tip: DO NOT EVER let the 5150 pt access your stethoscope. My partner was in the back with a 5150 and the pt tried to strangle him with a stethoscope



Most people I've worked with that wear a scope around their neck do a fine job strangling themselves with it without any outside help.


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## Qulevrius (Nov 7, 2017)

iExposeDeformities said:


> Number 1 tip: DO NOT EVER let the 5150 pt access your stethoscope. My partner was in the back with a 5150 and the pt tried to strangle him with a stethoscope



There are two major issues with the picture you painted: 1) your 5150 wasn’t restrained (which, I am pretty sure, goes against your company’s policy) and 2) your tryhard partner wearing the steth around his neck.


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## iExposeDeformities (Nov 8, 2017)

Qulevrius said:


> There are two major issues with the picture you painted: 1) your 5150 wasn’t restrained (which, I am pretty sure, goes against your company’s policy) and 2) your tryhard partner wearing the steth around his neck.


I can assure you I restrained his wrists. My partner had a full on brain malfunction for a moment and removed a restraint to take a bp


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## Akulahawk (Nov 8, 2017)

akemt said:


> experiences with psych patients? How do you handle them/tips on working with pysch pts


Most psych patients aren't violent. Most know what's going to happen as it's not their first rodeo. My rule about how the ride goes is very simple: the patient's behavior determines it. Patient acts like a decent human, I'll treat them like a decent human. Patient acts like an animal, I'll treat them like one. For my part, I'll always act like a decent human. I'll ask them very directly if they're hearing things, seeing things, if they feel like hurting themselves or other people. I'll ask them if they've used alcohol, tobacco, recreational drugs or marijuana (because some people consider that a medication). I'll ask about their medical and psych history, if they're supposed to take medications, and if they're taking the meds as prescribed. I'll ask them if they feel safe at home, wherever that is. Just make sure you're completely non-judgmental when you do this and make it sound completely normal and routine. I don't care that you just saw the patient yelling at a tree because the color purple is not a natural part of a baby's foot all the while listening to demons singing mahna-mahna. In their reality, that's what's happening and while it may not even make sense to them, it's a part of their reality and it just _is._


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## Akulahawk (Nov 8, 2017)

iExposeDeformities said:


> I can assure you I restrained his wrists. My partner had a full on brain malfunction for a moment and removed a restraint to take a bp


Once I gave a ring-down to the hospital, from the front, with the partition closed. The patient was screaming so loudly and incomprehensibly that all the hospital could make out was my unit ID and the ETA. I was speaking loudly and clearly with the microphone about 2 inches from my mouth. Non-violent patient but... very loudly disorganized. That was a fun one...


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## Bullets (Nov 8, 2017)

Let PD transport


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## DrParasite (Nov 9, 2017)

Qulevrius said:


> There are two major issues with the picture you painted: 1) your 5150 wasn’t restrained (which, I am pretty sure, goes against your company’s policy) and 2) your tryhard partner wearing the steth around his neck.


I have one major issue with your two issues  1) I'm 100% positive that it's not a requirement for me to restrain all my psych patients.   This includes 911 calls and IFTs.  In fact, I would estimate that 80% of my psych patients were willingly going to the hospital, either the ER or the psych intake (depending if they were a 911 call or a transfer). 

I routinely wear my scope around my neck; but never when I'm on psych calls.  leave it in the bag or in your pocket.


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## NomadicMedic (Nov 9, 2017)

Be polite and honest. 
Use restraints if you need them. 
Ketamine.


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## Qulevrius (Nov 9, 2017)

DrParasite said:


> I have one major issue with your two issues  1) I'm 100% positive that it's not a requirement for me to restrain all my psych patients.   This includes 911 calls and IFTs.



A company’s policy isn’t a requirement for you ?


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## Bullets (Nov 10, 2017)

Qulevrius said:


> A company’s policy isn’t a requirement for you ?


Your company requires you to restrain all psych patients?


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## Qulevrius (Nov 10, 2017)

Bullets said:


> Your company requires you to restrain all psych patients?



5150s ? You betcha. As a matter of fact, I’d like to see _any_ county in CA that doesn’t have restraints for involuntary psychs in their respective EMSA protocols.


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## DrParasite (Nov 10, 2017)

Qulevrius said:


> 5150s ? You betcha. As a matter of fact, I’d like to see _any_ county in CA that doesn’t have restraints for involuntary psychs in their respective EMSA protocols.


Another reason i'm very glad to have never worked in CA.... my agencies actually trust me to use my clinical judgement when it comes to the application of restraints.  I bet you give every medical patient a NRB at 15 LPM, and every trauma must be strapped to a backboard right?

So no, I have never restrained 100% of my psych patients, and most psych patients I have handled aren't involuntary.  And its not in any state protocol to require all psych patients to be restrained.


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## iExposeDeformities (Nov 10, 2017)

Bullets said:


> Your company requires you to restrain all psych patients?


My company does


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## iExposeDeformities (Nov 10, 2017)

DrParasite said:


> Another reason i'm very glad to have never worked in CA.... my agencies actually trust me to use my clinical judgement when it comes to the application of restraints.  I bet you give every medical patient a NRB at 15 LPM, and every trauma must be strapped to a backboard right?
> 
> So no, I have never restrained 100% of my psych patients, and most psych patients I have handled aren't involuntary.  And its not in any state protocol to require all psych patients to be restrained.


I’ve heard being on 15 LPM on NRB is like sticking your head out the window of a moving car. That’s definitely gonna worsen a lot of patients conditions where they don’t need it whereas not putting a restraint on some psychs won’t necessarily make a lot of difference so it’s really not analogically the same


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## Qulevrius (Nov 10, 2017)

DrParasite said:


> Another reason i'm very glad to have never worked in CA.... my agencies actually trust me to use my clinical judgement when it comes to the application of restraints.  I bet you give every medical patient a NRB at 15 LPM, and every trauma must be strapped to a backboard right?
> 
> So no, I have never restrained 100% of my psych patients, and most psych patients I have handled aren't involuntary.  And its not in any state protocol to require all psych patients to be restrained.



I can’t decide what I find more curious - your inability to comprehend written text or your affinity for baseless ad hominem attacks.


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## Bullets (Nov 10, 2017)

Qulevrius said:


> 5150s ? You betcha. As a matter of fact, I’d like to see _any_ county in CA that doesn’t have restraints for involuntary psychs in their respective EMSA protocols.


Even if they arent violent? You restrain cooperative patients? I dont think thats really great for their mental health


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## Jim37F (Nov 10, 2017)

I've worked for companies that required restaining 100% of all 5150 (psych) patients, regardless. Yes, even the calm, cooperative ones. Yes, I hated it. I explained it was a policy outside my authority and loosely restrained the minimum to comply with the requirement and all the patients I had in those cases didn't make a fuss.

That being said, it's certainly not an LA County requirement to restrain every psych as the majority of places I worked there did not have that requirement. I am aware of more than a few employers who have those policies but I am not aware of any of the county LEMSA's dictating those policies be in place county-wide.


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## Qulevrius (Nov 10, 2017)

Bullets said:


> Even if they arent violent? You restrain cooperative patients? I dont think thats really great for their mental health



1) Which part of ‘County EMSA Policy in regards of restraining involuntary psychs’ confuses you ?

2) Are you a trained, qualified & licensed mental health professional ?


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## EpiEMS (Nov 10, 2017)

Qulevrius said:


> As a matter of fact, I’d like to see _any_ county in CA that doesn’t have restraints for involuntary psychs in their respective EMSA protocols.



Not to get involved in a...heated discussion, but I'm quite curious - why would it be mandatory to physically (or chemically?) restrain a person with a psychiatric problem who is being treated against their will? Plenty of folks get treated against their will without being violent or posing a risk of harm.


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## Qulevrius (Nov 10, 2017)

EpiEMS said:


> Not to get involved in a...heated discussion, but I'm quite curious - why would it be mandatory to physically (or chemically?) restrain a person with a psychiatric problem who is being treated against their will? Plenty of folks get treated against their will without being violent or posing a risk of harm.



The only person who can answer that for you would be the county’s medical director.


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## DesertMedic66 (Nov 10, 2017)

My county and company also require restraints on 100% of patients on a 5150 hold (72 hour psych hold) with no exceptions. It doesn’t matter if the patient is 9 or 99, calm or aggressive.


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## Bullets (Nov 10, 2017)

Qulevrius said:


> 1) Which part of ‘County EMSA Policy in regards of restraining involuntary psychs’ confuses you ?
> 
> 2) Are you a trained, qualified & licensed mental health professional ?



I didnt understand that your county can set policy for an agency that it doesn't directly control. Not being familiar your local EMS system and all. We dont have county based, well pretty much anything, here. Each agency has a medical director who sets our clinical best practices. 

my medical director i guess trusts me any my staff to, as you said, "Not shotgun everything". We view restraints as a treatment, with clinical criteria for such. Just making a statement that activates a hold isnt criteria for such, just as saying "i have chest pain" isnt automatically getting 15LPM NRB O2.

Im not trying to attack you personally, it just seems shocking to me that such a policy existed in such a wide area.


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## EpiEMS (Nov 10, 2017)

Qulevrius said:


> The only person who can answer that for you would be the county’s medical director.



So that's a policy coming from medical direction/protocol, ok. Seems a little unjustified...
Just to note, looking at protocols for the 2 most populous counties in CA, San Diego and LA , I don't see any requirement to restrain, and they both have some variant of what I would call the reasonable policy of 'restrain only if necessary to prevent the patient from being injured/injuring others'. I'd be curious to see a policy stating that everybody gets restraints -- and the language used to justify it.


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## DesertMedic66 (Nov 10, 2017)

EpiEMS said:


> So that's a policy coming from medical direction/protocol, ok. Seems a little unjustified...
> Just to note, looking at protocols for the 2 most populous counties in CA, San Diego and LA , I don't see any requirement to restrain, and they both have some variant of what I would call the reasonable policy of 'restrain only if necessary to prevent the patient from being injured/injuring others'. I'd be curious to see a policy stating that everybody gets restraints -- and the language used to justify it.


Here is our protocol:


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## Qulevrius (Nov 10, 2017)

EpiEMS said:


> So that's a policy coming from medical direction/protocol, ok. Seems a little unjustified...
> Just to note, looking at protocols for the 2 most populous counties in CA, San Diego and LA , I don't see any requirement to restrain, and they both have some variant of what I would call the reasonable policy of 'restrain only if necessary to prevent the patient from being injured/injuring others'. I'd be curious to see a policy stating that everybody gets restraints -- and the language used to justify it.



Not every psych is a 5150, but all 5150’s are involuntary psychs. If it’s a voluntary psych, the county’s guidelines are ‘restrain if/as needed’. Bit if it’s a 5150 who is, by definition, an involuntary psych and danger to himself and/or others, the only difference between counties is how many restraints they should have. REMSA and OCEMSA require 4-points, LACo and VEMSA require 2-points etc. As I said, I’ve yet to hear about any county in CA that does not have mandatory restraints for involuntary psychs in their protocols.


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## NomadicMedic (Nov 10, 2017)

In reading that riverside policy, it clearly says "physical restraints are to be used in necessary". 

In reading that, it seems as though when you transport a 5150, IF RESTRAINTS ARE NECESSARY, you need to use 4 points. 

Am I missing the point?


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## DesertMedic66 (Nov 10, 2017)

NomadicMedic said:


> In reading that riverside policy, it clearly says "physical restraints are to be used in necessary".
> 
> In reading that, it seems as though when you transport a 5150, IF RESTRAINTS ARE NECESSARY, you need to use 4 points.
> 
> Am I missing the point?


The county and company view it as anyone on a 5150 hold makes it necessary.


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## NomadicMedic (Nov 10, 2017)

DesertMedic66 said:


> The county and company view it as anyone on a 5150 hold makes it necessary.



Thats a pretty poorly written protocol. 
If the patient MUST be transported in 4 point restrains as a nonnegotiable, it should state that. However, it states, in the heading, restraints should only be used if necessary. A calm, cooperative patient does not require restraint. 

I’d probably pitch a stink about that.


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## DesertMedic66 (Nov 10, 2017)

NomadicMedic said:


> In reading that riverside policy, it clearly says "physical restraints are to be used in necessary".
> 
> In reading that, it seems as though when you transport a 5150, IF RESTRAINTS ARE NECESSARY, you need to use 4 points.
> 
> Am I missing the point?


It is poorly written however it is implied as “these are the conditions when it is necessary: danger to themselves/others, 5150 hold, in PD custody”. Company policy backs it up.


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## soloBLS (Nov 10, 2017)

just affirm there's no medical need for transport and have the cops take them ¯\_(ツ)_/¯


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## DrParasite (Nov 11, 2017)

iExposeDeformities said:


> I’ve heard being on 15 LPM on NRB is like sticking your head out the window of a moving car. That’s definitely gonna worsen a lot of patients conditions where they don’t need it whereas not putting a restraint on some psychs won’t necessarily make a lot of difference so it’s really not analogically the same


I think you should try one day on yourself.  Seriously.  it's nothing like as you describe, which would be more on the level of a N/C at 15 LPM.  You won't suffer any ill will.  There are issues with 15 LPM (free radicals, etc), but it's more along the lines of "why are you doing something that won't actually help the patient?"

The question really becomes if a person wants helps, is willingly getting help, why are you treating the like a violent psych and putting them in 4 point restraints?  imagine the impact on their already damaged mental status.  Also, think of every psychiatrists/psychologists office: how many mandate that every patient they see is secured in 4 points?

I'm  going to just ignore @Qulevrius for obvious reasons........



Bullets said:


> my medical director i guess trusts me any my staff to, as you said, "Not shotgun everything". We view restraints as a treatment, with clinical criteria for such. Just making a statement that activates a hold isnt criteria for such, just as saying "i have chest pain" isnt automatically getting 15LPM NRB O2.


the shotgun approach, overly broad policies and knee jerk responses show, in my opinion, that the medial director doesn't trust the people under them to use their clinical judgement as to when they should or should not apply or utilize a particular treatment.

Thankfully, I have never had to work in a system with that type of medical director.


DesertMedic66 said:


> It is poorly written however it is implied as “these are the conditions when it is necessary: danger to themselves/others, 5150 hold, in PD custody”. Company policy backs it up.


Anyone who has worked in this field long enough knows that company policy is looking out for the interests of the company first, not the provider and not the patient (unless they happen to line up with the company's interests, which isn't always the case)


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## DesertMedic66 (Nov 11, 2017)

DrParasite said:


> Anyone who has worked in this field long enough knows that company policy is looking out for the interests of the company first, not the provider and not the patient (unless they happen to line up with the company's interests, which isn't always the case)


I completely agree. However there are a lot of instances where the company policy protects the company, employee, and patient (i’m not saying our policy on 5150 holds is an example of this).


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## Qulevrius (Nov 11, 2017)

It only takes 1 (one) error in judgement from a provider who chose to disregard the policies, because they thought they know better. That’s when a seemingly cooperative involuntary psych is either left unrestrained, or loosely restrained; then there are psychs jumping out of the rig on a freeway, crew members being punched in the face etc. pt’s advocacy is good and dandy, but there’s also the matter of clinician’s safety. I know for a fact that I am not there to diagnose or decide how to fix them, because it is way above my pay grade. What I can do, however, is make sure I, my partner & them get from point A to point B safe and unharmed. Building a rapport and making every possible accommodation is an added bonus.


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## StCEMT (Nov 11, 2017)

I get there are definitely ones that slip through, but for the most part psych calls either run A. calm and voluntary or B. involuntary and/or violent for whatever reason. Usually it is category A and I see no reason to use physical restraints "just in case". I am more than happy to just sit and ******** with them for a few minutes to try to make that experience slightly better for them. If they are category B, they are most likely getting both chemical and physical restraints.


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## Qulevrius (Nov 11, 2017)

StCEMT said:


> I get there are definitely ones that slip through, but for the most part psych calls either run A. calm and voluntary or B. involuntary and/or violent for whatever reason. Usually it is category A and I see no reason to use physical restraints "just in case". I am more than happy to just sit and ******** with them for a few minutes to try to make that experience slightly better for them. If they are category B, they are most likely getting both chemical and physical restraints.



Mandatory restraints apply ONLY towards involuntary psychs. Why on earth would I restrain a voluntary one  , if they’re calm and cooperative ??


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## StCEMT (Nov 11, 2017)

Qulevrius said:


> Mandatory restraints apply ONLY towards involuntary psychs. Why on earth would I restrain a voluntary one  , if they’re calm and cooperative ??


Guess I misunderstood parts of the Cali rules. Even then, I've had a very small percentage of folks who weren't voluntary as well that I didn't restrain. They weren't threatening me, they just didn't want me there to begin with and we're given an A or B option by PD. They were cool with me and I gave them the space they wanted.


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## Qulevrius (Nov 11, 2017)

StCEMT said:


> Guess I misunderstood parts of the Cali rules. Even then, I've had a very small percentage of folks who weren't voluntary as well that I didn't restrain. They weren't threatening me, they just didn't want me there to begin with and we're given an A or B option by PD. They were cool with me and I gave them the space they wanted.



We’ve been beating the same dead animal for 5 pages now, and I explained the policy in post #35.


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## Tigger (Nov 12, 2017)

Qulevrius said:


> It only takes 1 (one) error in judgement from a provider who chose to disregard the policies, because they thought they know better. That’s when a seemingly cooperative involuntary psych is either left unrestrained, or loosely restrained; then there are psychs jumping out of the rig on a freeway, crew members being punched in the face etc. pt’s advocacy is good and dandy, but there’s also the matter of clinician’s safety. I know for a fact that I am not there to diagnose or decide how to fix them, because it is way above my pay grade. What I can do, however, is make sure I, my partner & them get from point A to point B safe and unharmed. Building a rapport and making every possible accommodation is an added bonus.


Meanwhile, the rest of us don't seem to be having an issue. Cannot remember the last time I physically restrained someone. I medicate lots of people, but tie em up? No thanks. This sort of defensive medicine is asinine and providers should be ashamed of themselves if they can't identify who needs restraint and who doesn't.


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## iExposeDeformities (Nov 13, 2017)

Holy monkey nuts this discussion about restraints has gone too far


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## Akulahawk (Nov 13, 2017)

The way I read the policy, it's a three part policy. Part 1 is for patients that do _not_ fall into either part 2 or part 3 (most patients). Part 1 allows the crew to restrain patients as necessary to prevent harm to the patient themselves or to anyone else. This would include dementia patients that grab at everything and try to pull everything off or the drunk/high patients that are combative. Part 2 applies only to 5150 patients. By definition these are involuntary psych patients so they may or may not be willing to go along with the program. Some have been known to act calm/cooperative only to suddenly flip, assault the attendant, and fly out the back doors at freeway speed. (I was very late to work one day because this happened...) Part 3 applies only to patients that are in custody (under arrest OR already in inmate status). Notice that the wording used states either "restrained" or "handcuffed." This implies strongly that a patient that is in custody also must be restrained in some manner and conditions are placed according to which method is used. 

Where I used to work, we also required (by company policy) 100% restraint of 5150 patients. Whether we did 2 point or 4 point was up to the discretion of the crew _and_ the behavior of the patient. Patients that had to be restrained for their own safety usually were only 2 point restrained. Only a couple times did I have to transport patients in 4 point and required mitts. Those patients scratched at everything... including themselves.


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## Qulevrius (Nov 13, 2017)

Akulahawk said:


> The way I read the policy, it's a three part policy. Part 1 is for patients that do _not_ fall into either part 2 or part 3 (most patients). Part 1 allows the crew to restrain patients as necessary to prevent harm to the patient themselves or to anyone else. This would include dementia patients that grab at everything and try to pull everything off or the drunk/high patients that are combative. Part 2 applies only to 5150 patients. By definition these are involuntary psych patients so they may or may not be willing to go along with the program. Some have been known to act calm/cooperative only to suddenly flip, assault the attendant, and fly out the back doors at freeway speed. (I was very late to work one day because this happened...) Part 3 applies only to patients that are in custody (under arrest OR already in inmate status). Notice that the wording used states either "restrained" or "handcuffed." This implies strongly that a patient that is in custody also must be restrained in some manner and conditions are placed according to which method is used.
> 
> Where I used to work, we also required (by company policy) 100% restraint of 5150 patients. Whether we did 2 point or 4 point was up to the discretion of the crew _and_ the behavior of the patient. Patients that had to be restrained for their own safety usually were only 2 point restrained. Only a couple times did I have to transport patients in 4 point and required mitts. Those patients scratched at everything... including themselves.



My point exactly. I had to restrain a non-5150 only once, because the pt flipped 180 on us. The 5150s, on the other hand, are _always_ restrained (per company’s policy), but how and how many, I leave to my discretion. The company requires 4-points, but if a pt doesn’t pose any immediate threat, I usually do diagonal 2-point. They don’t feel completely degraded, can scratch their arse if needed, it’s impossible for them to break free before I have to intervene & I’m *mostly* compliant with the policies. There was a _single_ instance where I chose to forego the restraints altogether, because the 5150 hadn’t had any psych issues. She was just a silly 25 y.o. who had too much to drink, and was dared by her friends to take 100 Advils.


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## iExposeDeformities (Nov 15, 2017)

Qulevrius said:


> My point exactly. I had to restrain a non-5150 only once, because the pt flipped 180 on us. The 5150s, on the other hand, are _always_ restrained (per company’s policy), but how and how many, I leave to my discretion. The company requires 4-points, but if a pt doesn’t pose any immediate threat, I usually do diagonal 2-point. They don’t feel completely degraded, can scratch their arse if needed, it’s impossible for them to break free before I have to intervene & I’m *mostly* compliant with the policies. There was a _single_ instance where I chose to forego the restraints altogether, because the 5150 hadn’t had any psych issues. She was just a silly 25 y.o. who had too much to drink, and was dared by her friends to take 100 Advils.


“Dared by her friends to take 100 Advil’s” sounds like someone needs new friends


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## VFlutter (Nov 15, 2017)

I am a little surprised restraints are treated so lightly in EMS, I guess for the most part patient's arent in them for very long. Behavioral restraints in the hospital require a Physician evaluation with thin one hour of application and every 4 hours after. Then its 1:1 supervision, Q15min charting, and Q2hr release and re-position.  And if a patient deteriorates or codes while restrained it is a huge deal. Behavioral restraints are very serious legally and medico-ethically.


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## Akulahawk (Nov 15, 2017)

Chase said:


> I am a little surprised restraints are treated so lightly in EMS, I guess for the most part patient's arent in them for very long. Behavioral restraints in the hospital require a Physician evaluation with thin one hour of application and every 4 hours after. Then its 1:1 supervision, Q15min charting, and Q2hr release and re-position.  And if a patient deteriorates or codes while restrained it is a huge deal. Behavioral restraints are very serious legally and medico-ethically.


I don't think it's necessarily that restraints are "lightly treate" in EMS, it's that EMS recognizes that restrained patients are already on 1:1 supervision and aren't in restraints for long enough (usually) to cause an issue. At least in my experience, EMS doesn't do locking restraints but rather just very secure soft non-locking. Field restraint use is aimed at patient _and_ provider safety due to (usually) slow availability of backup. In hospital, we have the luxury of having lots of hands at our call and if a patient in my ED needs to be restrained, within seconds of asking, I have backup. Also any restrained patients are seen immediately (at least in my county) by a physician and they determine if further restraint use is necessary. 

And may the almighty God have mercy on the soul of the crew that had a restrained patient die during transport. It has happened before and it's why sandwiching is never to be done and why we keep a very close watch on our excited delirium patients.


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## Qulevrius (Nov 16, 2017)

Correct, these are soft restraints. And, per protocols, PMS is reassessed every 15 min. Even if the transport is longer than an hr (due to external factors such as distance/traffic), it’s not long enough to cause any physical damage. And once on a wall in a facility, there’s usually no issues with supervision and the restraints can be released.


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## medichopeful (Nov 17, 2017)

iExposeDeformities said:


> My company does



That's battery but what do I know?


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## medichopeful (Nov 17, 2017)

Qulevrius said:


> Not every psych is a 5150, but all 5150’s are involuntary psychs. If it’s a voluntary psych, the county’s guidelines are ‘restrain if/as needed’. Bit if it’s a 5150 who is, by definition, an involuntary psych and danger to himself and/or others, the only difference between counties is how many restraints they should have. REMSA and OCEMSA require 4-points, LACo and VEMSA require 2-points etc. As I said, I’ve yet to hear about any county in CA that does not have mandatory restraints for involuntary psychs in their protocols.



This isn't an attack on you, but that's a ridiculous policy.  If an involuntary patient is trying to escape or actively trying to cause harm, by all means restrain them.  But if they're not, than that restraint is inappropriate and, very possibly, unlawful.


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## Qulevrius (Nov 18, 2017)

medichopeful said:


> This isn't an attack on you, but that's a ridiculous policy.  If an involuntary patient is trying to escape or actively trying to cause harm, by all means restrain them.  But if they're not, than that restraint is inappropriate and, very possibly, unlawful.



There’s a lot of things that I personally find ridiculous, but my only options are a) abide by the policies (and have a job), b) quit the job, c) become an MD (as in, Making Decisions). Everything else is tilting at windmills.


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## Tigger (Nov 18, 2017)

Qulevrius said:


> There’s a lot of things that I personally find ridiculous, but my only options are a) abide by the policies (and have a job), b) quit the job, c) become an MD (as in, Making Decisions). Everything else is tilting at windmills.


Option d) practice EMS in a place that trusts its providers.


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## DrParasite (Nov 18, 2017)

medichopeful said:


> But if they're not, than that restraint is inappropriate and, very possibly, unlawful.


psttt. what do you know?  you aren't from the EMS mecca that is SoCal....

The sad truth is, this practice will continue until someone files a successful lawsuit against the ambulance agency for inappropriate and potentially unlawful restraints.


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## medichopeful (Nov 18, 2017)

DrParasite said:


> psttt. what do you know?  you aren't from the EMS mecca that is SoCal....
> 
> The sad truth is, this practice will continue until someone files a successful lawsuit against the ambulance agency for inappropriate and potentially unlawful restraints.



Sometimes I want to move to California to work EMS because it seems like such an advanced place to work!


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## Jon4010 (Nov 21, 2017)

Lol, I had a psych pt transfer hosp to hosp psych unit. Younggg guy and just suddenly snapped. Pretty sad story really. Aggressive verbally and physically, but I was able to calm him down a little to get on our stretcher. Cursing at us and calling us names during transport, it's whatever. I was driving with my partner (medic) in the back, God bless her. Dude started unbuckling his straps on the stretcher and got up, trying to open the back of the ambulance (that **** was locked). This was right on the interstate too, however my exit was coming up. Upgraded emergency, told my partner to hang on in case I need to slam on the brakes. Pt finally complied and got back onto the stretcher en-route. Sad thing is the guy was the same age as me.


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## DrParasite (Nov 21, 2017)

Jon4010 said:


> Upgraded emergency, told my partner to hang on in case I need to slam on the brakes.


umm why?  Pull over to the side of the road, request additional resources (either additional EMS or local LEO).  

If I have a combative psych in the back of the truck with me, the last thing I want is my driver speeding down the road where he might need to slam on the breaks.


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## medichopeful (Nov 21, 2017)

DrParasite said:


> umm why?  Pull over to the side of the road, request additional resources (either additional EMS or local LEO).
> 
> If I have a combative psych in the back of the truck with me, the last thing I want is my driver speeding down the road where he might need to slam on the breaks.



I'd probably want them back there with me as a second set of hands, but that's just me!


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