# Why this is not done!



## reaper (Feb 3, 2010)

This is why you do not lay Pt's face down! Epic fail!

http://www.ems1.com/ems-management/...ambulance-company-caused-mother-to-suffocate/

By John O'Brien
The Post-Standard

FULTON, N.Y. — Oswego County sheriff’s deputies handcuffed a combative, hallucinating woman behind her back to protect her from herself when they responded to a suicide attempt at her home in 2006.

Dorothy Caniff, 42, of Fulton, was strapped face down on a gurney after Menter Ambulance workers arrived May 25, 2006, according to police reports.

In the ambulance, Caniff went into cardiac arrest and died at A.L. Lee Memorial Hospital, in Fulton. A medical examiner ruled that she died because of the position she'd been placed in: prone, arms behind her back and strapped onto the gurney.



This should be covered in EMS 101.


----------



## MrBrown (Feb 3, 2010)

reaper said:


> ...Ambulance workers ....



There's a new one


----------



## JPINFV (Feb 3, 2010)

"Girl friend's gonna get paid!"

[youtube]http://www.youtube.com/watch?v=9SwQtVsRXsc[/youtube]


----------



## mycrofft (Feb 3, 2010)

*Odd, I was just reading up on positional asphyxia yesterday .*

Multiple elements involved in these sorts of cases:
1. Prone patient (this limits respiration from the git-go).
2. Arms pinioned (secured in back) which limits tidal movement.
3. Vicious cycle of struggling subject-kneel on subject to subdue-anoxic subject struggles more-more pressure or restrain applied. Increasing metabolic demands throw pt into panic, then collapse. 
4. Often the subject is intoxicated and/or wrecked from drug abuse already and so more prone to meltdown.
5. Obesity (you're shoving guts and fat into the tidal volume space and the pt is porbably cardiovascularly compromised already).
6. Claustrophobia can lead to the struggle/smother cycle above.

So called "recovery position" or "semi-recumbent" does not have these drawbacks. I've seen more people die of airway embarassment AFTER/due to being placed supine (soft tissue, secretions, blood, vomit and anything else fall back into the upper airway). But then you have to consider spinal immob....
Follow your protocols, and use your eyes and ears to tell you when the pt NEEDS some real airway assistance. Practice *EFFECTIVELY* clearing airways on immobilized pts, and if LE or you have effectively immobilized anyone, take immediate and continuous care of their status.


----------



## 46Young (Feb 3, 2010)

Me personally, if the LEO has to put someone under, and handcuff them to the cot (not prone, of course) I prefer to be given the officer's key which I place in my shirt pocket. The officer rides in the cruiser behind the bus. Upon arrival, the officer gets the key back. I don't like there being a gun within reach of an EDP/perp, especially within an enclosed space.


----------



## spinnakr (Feb 3, 2010)

46Young said:


> Me personally, if the LEO has to put someone under, and handcuff them to the cot (not prone, of course) I prefer to be given the officer's key which I place in my shirt pocket. The officer rides in the cruiser behind the bus. Upon arrival, the officer gets the key back. I don't like there being a gun within reach of an EDP/perp, especially within an enclosed space.



This won't be a problem if you know the officer, but how do you go about explaining it to the LEO?  (I'm not trying to be confrontational; I'm just curious).

Also, this is yet another reason why a backboard sandwich is an inappropriate means of restraint.


----------



## Shishkabob (Feb 3, 2010)

So, excited delirium?


----------



## Veneficus (Feb 3, 2010)

Linuss said:


> So, excited delirium?



no such thing


----------



## JPINFV (Feb 3, 2010)

Sounds more like positional asphyxia.


----------



## JPINFV (Feb 3, 2010)

spinnakr said:


> This won't be a problem if you know the officer, but how do you go about explaining it to the LEO?  (I'm not trying to be confrontational; I'm just curious).



A better option would be to transfer the patient to restraints made for medical patients. All ambulances should have a set of leather restraints on them.


----------



## spinnakr (Feb 3, 2010)

JPINFV said:


> A better option would be to transfer the patient to restraints made for medical patients. All ambulances should have a set of leather restraints on them.



That was my thought too - but I'm still curious.  I'm not sure how most officers I know would feel about giving up their keys...


----------



## CAOX3 (Feb 3, 2010)

Oy Vey!

Fired.

And no one gets handcuffed in my ambulance unless a cop is riding.


----------



## Hal9000 (Feb 3, 2010)

Well, that's an ultimate facepalm.  I met some EMTs who wanted to put metal scoop stretchers over their patients to "calm them down," after which I pointed out the, well, flaws in their plan.  They decided it would be best to roll the patient into a prone position and then apply the metal scoop.  This website does not really have appropriate emoticons for this sort of thing.


----------



## dmc2007 (Feb 3, 2010)

spinnakr said:


> That was my thought too - but I'm still curious.  I'm not sure how most officers I know would feel about giving up their keys...



That and we're not trained or get any practice in quickly removing handcuffs.


----------



## spinnakr (Feb 3, 2010)

dmc2007 said:


> That and we're not trained or get any practice in quickly removing handcuffs.



Well, most of us.  Some might have had handcuff experience before...  but hopefully from other jobs!  (for the record, that was a joke).

You bring up a very good point, though.


----------



## DrParasite (Feb 3, 2010)

interesting......  the ambulance company isn't exactly denying that it was done, only that they aren't responsible because it was the sheriff's deputies that restrain the patient, and placed them in that position, not the EMS people. 

I find this to be even more interesting:





> Blake is not suing the Oswego County Sheriff’s Department. Kenny said the evidence indicates deputies did nothing wrong. They had to restrain Caniff because she was combative, he said.


So the Sheriff's who actually did the restraining don't get named?  usually when a lawsuit happens, it's like a shotgun, shoot at everyone and let them fight it out in court.

question for all involved: when dealing with violent EDPs who are restrained using police issued restraints, do the LEOs have overall control of the scene and restraint placement, as well as positioning of the violent person, or is that responsibility given to EMS?


----------



## Sasha (Feb 3, 2010)

spinnakr said:


> Well, most of us. * Some might have had handcuff experience before...  but hopefully from other jobs!*  (for the record, that was a joke).
> 
> You bring up a very good point, though.



or the bedroom.


----------



## CAOX3 (Feb 3, 2010)

Sasha said:


> or the bedroom.



Bad girl.........


----------



## spinnakr (Feb 3, 2010)

Sasha said:


> or the bedroom.



Like I said, from other jobs.

Parasite, I'd say that ultimate control over a _patient_ lies with EMS, and ultimate control over a _detainee_ lies with LEO's.  It's up to you to decide which is which.


----------



## DrParasite (Feb 4, 2010)

spinnakr said:


> Parasite, I'd say that ultimate control over a _patient_ lies with EMS, and ultimate control over a _detainee_ lies with LEO's.  It's up to you to decide which is which.


So again, I ask, the patient is restrained using LEO tactics by LEOs who are using LEO equipment.  So, who is in charge of how the LEO's place the patient, or how they apply the LEO restraints?

or let me be even more specific, if the LEO's handcuff the patient with their arms behind their back, are you within your rights to tell them to restrain them another way?  you can ask, but what right to you have to tell a LEO how to restrain a person, when they are the experts in restraining, and have received many hours in how best to restrain someone for everyone's safety?

now, assuming they place this violently combative person in a prone position on the stretcher, and then straps the person down in hopes of limiting the patient's ability to swing and kick, what right do you have to tell the LEO anything else?  after all, they are the experts in restraining, and have received many hours in how best to restrain someone for everyone's safety.

We all know EMS can ask for a LEO to do something to make out jobs easier, but if they refuse, then what position does that leave EMS in, esp when their actions are not done in the best interests of good patient care?


----------



## spinnakr (Feb 4, 2010)

DrParasite said:


> So again, I ask, the patient is restrained using LEO tactics by LEOs who are using LEO equipment.  So, who is in charge of how the LEO's place the patient, or how they apply the LEO restraints?



If they truly refuse, and there's absolutely no way around it - in short, if the patient becomes a detainee first and foremost, then documentation is key.  Write it in the narrative and maybe an incident report.  Make sure the liability is on the LEO's side.

You could always try to convince the LEO to handcuff the patient to the cot instead of behind his/her back.

On the other hand I don't think there should ever be an absolutely no-dice situation like I described above.  If you think it could kill or harm the patient, or otherwise impede in care, then be honest and upfront about explaining that to the officer.  If the officer still refuses, ask to speak with his superior/OIC.  It's YOUR patient.


----------



## JPINFV (Feb 4, 2010)

If the LEO refuses, then the LEO can transport in his car and take full responsibility for the care of the patient. I'm not going to take responsibility for the police officer's actions that puts my patient at risk, especially for something as stupid as transporting a patient prone like that. If the patient wants to be transported prone, more power to him, however if he patient is being restrained with anything more than seatbelts, then it's going to be done supine. No questions asked. Do not pass go, do not collect $200.


----------



## CAOX3 (Feb 4, 2010)

As JP stated, its my way or the highway.

My truck my way, his car his way.  Pretty simple.


----------



## JPINFV (Feb 4, 2010)

Everyone should read the National Association of Emergency Medical Service Physicians (NAEMSP) position paper on the use of restraints. 

http://www.naemsp.org/pdf/restraint.pdf

Transporting a patient restrained prone is so far from the standard of care it can't even be accepted as an appropriate deviation.


----------



## mycrofft (Feb 4, 2010)

*Unconscious pts die of positional asphyxia before we get a chance, too.*

Postictal folks, pts with neuromuscular problems like MS, or just plain hit their heads and came to rest folded up.
Famous athlete Florence Griffith-Joyner died that way...postictally went face down into a pillow.
Anyone remember the "D-ring litter sandwich"?

Quiet, Sasha.


----------



## dmc2007 (Feb 4, 2010)

spinnakr said:


> Well, most of us.  Some might have had handcuff experience before...  but hopefully from other jobs!  (for the record, that was a joke).


No comment.


> You bring up a very good point, though.



In class we were taught that if a patient is to be transported handcuffed, LE is coming with us.


----------



## JPINFV (Feb 4, 2010)

Class!=field


----------



## LondonMedic (Feb 4, 2010)

JPINFV said:


> A better option would be to transfer the patient to restraints made for medical patients. All ambulances should have a set of leather restraints on them.


Or a haloperidol/lorazepam cocktail? 

(But FFS, sods law states that the 'combatative drunk' punters you do end up restraining are going to be the hidden head injuries...)


----------



## EMTinNEPA (Feb 5, 2010)

Sasha said:


> or the bedroom.



I just forgot everything else I read in this thread.  Thanks, Sasha, now I have to start over.


----------



## 46Young (Feb 5, 2010)

spinnakr said:


> This won't be a problem if you know the officer, but how do you go about explaining it to the LEO?  (I'm not trying to be confrontational; I'm just curious).
> 
> Also, this is yet another reason why a backboard sandwich is an inappropriate means of restraint.



I would think that the officer would rather ride in the cruiser instead of being cursed at and spit on.

I never said backboard sandwich, rathe having one wrist cuffed to the frame of the cot.


----------



## 46Young (Feb 5, 2010)

dmc2007 said:


> That and we're not trained or get any practice in quickly removing handcuffs.



The cruiser rides right behind the bus. It takes less than 30 seconds to pull over and have the LEO jump in back if there's an issue. Anyway, how far is the pt going with an arm cuffed to the cot? No liability there regarding airway, since they're sitting fowler's/semi-fowlers or whatever. It works well for us, and is acceptable under our SOP's.

If the perp grabs the gun, where are you going to hide? I'll accept a 30 second delay in LEO assistance with a pt that is already restrained, should I need to remove the cuff for some reason vs getting shot.


----------



## spinnakr (Feb 5, 2010)

46Young said:


> I never said backboard sandwich, rathe having one wrist cuffed to the frame of the cot.



You misunderstood me.  This part was a non-sequitur, and not directed at you!


----------



## 46Young (Feb 5, 2010)

DrParasite said:


> So again, I ask, the patient is restrained using LEO tactics by LEOs who are using LEO equipment.  So, who is in charge of how the LEO's place the patient, or how they apply the LEO restraints?
> 
> or let me be even more specific, if the LEO's handcuff the patient with their arms behind their back, are you within your rights to tell them to restrain them another way?  you can ask, but what right to you have to tell a LEO how to restrain a person, when they are the experts in restraining, and have received many hours in how best to restrain someone for everyone's safety?
> 
> ...



We have a good relationship with the county PD. Same with the NYPD back in the day. It's really simple. If the police restrain a pt in a way that is potentially dangerous for the pt, then we just don't transport until things are done to our satisfaction. If it's a combativeness issue, we'll drop some versed to smooth things over. Again, if the pt's wrist is secured to the cot's frame, where are they going, and how are they going to attack anyone?

I miss the NYPD ESU, they would secure a combative EDP in what looked like a heavy duty sack. It restrained well, and allowed some movement while inside, just that they couldn't take their arms or legs out to strike or kick.


----------



## 46Young (Feb 5, 2010)

spinnakr said:


> If they truly refuse, and there's absolutely no way around it - in short, if the patient becomes a detainee first and foremost, then documentation is key.  Write it in the narrative and maybe an incident report.  Make sure the liability is on the LEO's side.
> 
> You could always try to convince the LEO to handcuff the patient to the cot instead of behind his/her back.
> 
> On the other hand I don't think there should ever be an absolutely no-dice situation like I described above.  If you think it could kill or harm the patient, or otherwise impede in care, then be honest and upfront about explaining that to the officer.  If the officer still refuses, ask to speak with his superior/OIC.  It's YOUR patient.



Yes, crew and LEO safety at the scene takes precedence, but the position of the pt is a whole other matter.


----------



## 46Young (Feb 5, 2010)

When wrestling with a combative pt, they should be places supine at some point. One person holds the shoulders, another controls the head by turning it one direction or the other. The head follows the body, they can't go anywhere. One person on each leg. Externally rotate each leg, and they can no longer kick. Now you can isolate an arm or a delt for some vitamin V/vitamin A. This works well for the pt in the ED as well. It works way better than everyone wrestling with the pt in an uncoordinated fashion and getting f'ed up.


----------



## JPINFV (Feb 5, 2010)

46Young said:


> I would think that the officer would rather ride in the cruiser instead of being cursed at and spit on.


An NRB or isolation mask solves this.


----------



## 46Young (Feb 5, 2010)

spinnakr said:


> You misunderstood me.  This part was a non-sequitur, and not directed at you!



My bad    XD


----------



## 46Young (Feb 5, 2010)

JPINFV said:


> An NRB or isolation mask solves this.



But there's still the issue of a loaded gun within reach, and nowhere to take shelter.


----------



## JPINFV (Feb 5, 2010)

4 point restraints....


----------



## 46Young (Feb 5, 2010)

JPINFV said:


> 4 point restraints....



Then why the bracelets? If I had the pt secured in that fashion then I wouldn't need an LEO after that point, anyway. I'd probably drop a lock on them while onscene since the extra hands are there, so I can chemically restrain them IV vs IM if necessary.


----------



## adamjh3 (Feb 5, 2010)

Bear in mind that I know next to nothing about emergency medicine right now. 

However, I would like to chime in and say that I think the patient grabbing the officer's gun is a non issue. Most departments issue holsters with active retention. That plus yourself and the officer both fighting to keep the pt from actually getting a hand on the weapon, I'd say the chances are so low as to be negligible. 

Again, just my $0.02, take it for what it's worth.


----------



## JPINFV (Feb 6, 2010)

46Young said:


> Then why the bracelets? If I had the pt secured in that fashion then I wouldn't need an LEO after that point, anyway. I'd probably drop a lock on them while onscene since the extra hands are there, so I can chemically restrain them IV vs IM if necessary.



That's a valid question. However convicts and suspects in police custody should always be transported with a law enforcement/corrections officer and be restrained, up to and including 4 points. If the patient is also spitting, then additional control measures should be taken.  I do agree that psychiatric patients with a properly executed hold does not need police escort during transport.


----------



## DrParasite (Feb 6, 2010)

46Young said:


> But there's still the issue of a loaded gun within reach, and nowhere to take shelter.


easy solution: the officer gives his sidearm to his partner, who is following behind the ambulance.  this way the cuffs can be removed at a moments notice, a trained restraint expert is in the ambulance, and no firearms are in the back of the ambulance.

yes, I know this doesn't work where you have one cop patrolling an entire county or middle of nowhere, but in the urban and suburban areas I have worked, it works just fine.


----------



## dmc2007 (Feb 7, 2010)

46Young said:


> The cruiser rides right behind the bus. It takes less than 30 seconds to pull over and have the LEO jump in back if there's an issue. Anyway, how far is the pt going with an arm cuffed to the cot? No liability there regarding airway, since they're sitting fowler's/semi-fowlers or whatever. It works well for us, and is acceptable under our SOP's.
> 
> If the perp grabs the gun, where are you going to hide? I'll accept a 30 second delay in LEO assistance with a pt that is already restrained, should I need to remove the cuff for some reason vs getting shot.



I have confidence in an officer's ability to retain his/her weapon.  I don't, however, have confidence in my ability to quickly remove restraints which I am not trained to use nor in having an officer in a cruiser behind the ambulance having the ability to respond quickly enough if needed.  

Not to mention, if my patient is such a danger that he/she needs to be restrained, I certainly would like to have an extra pair of hands present, especially one that is trained in defensive tactics and the use of force.


----------

