# 5150 transport



## SD EMT OPS (Apr 27, 2011)

a 5150 is a patient has been deemed a danger to self or danger to others. should this patient HAVE to be in some level of restraints during transport?


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## DesertMedic66 (Apr 27, 2011)

SD EMT OPS said:


> a 5150 is a patient has been deemed a danger to self or danger to others. should this patient HAVE to be in some level of restraints during transport?



Yes. My protocol/ company policy says arm and leg restraints at all times.


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## Amycus (Apr 27, 2011)

Depends on the PT.

I'm assuming a 5150 is like a Section 12 in Mass or such. The only PTs that get restrained are the combative ones. If someone is transported for SI or whatnot, I won't restrain them unless it's necessary.

Most of them I've found, if you're civil to them, they'll be civil back. Unfortunately, most people don't treat them that way. That's my experience anyways


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## SD EMT OPS (Apr 27, 2011)

my company policy is the same... all 5150 pts are to be restrained in some way. does anyone know if there is a rule, law, protocol or standard of care that dictates the required minimum level of care an SI or psyc pt must be transported with?


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## DesertMedic66 (Apr 27, 2011)

SD EMT OPS said:


> my company policy is the same... all 5150 pts are to be restrained in some way. does anyone know if there is a rule, law, protocol or standard of care that dictates the required minimum level of care an SI or psyc pt must be transported with?



I've seen them get transported on BLS rigs and ALS rigs. So I'm guessing it just depends on how stable they are.


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## nonsense (Apr 27, 2011)

It depends on you're company's policy, and your county protocol.  Most private ambulance companies will require any 5150 pt to be restrained and this is mostly for the safety of you as the transporting attendant, as well as the fact that the 5150 hold does not allow the patient to refuse transport on their own free will. That being said, I don't see a lot of 5150 patients being restrained.


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## Sasha (Apr 27, 2011)

I think it's stupid and unnecessarily traumatic to restrain all psych patients. Use a little common sense, watch your patient so they don't get a chance to unbuckle themselves. If they're combative, absolutely, restrain them. If they're the scared little teenager who just wanted attention or a calm, quiet schizo, then don't restrain them.

It's silly.

Amazingly a majority of the patients who are "problem" patients for the hospitals are not for me. Why? Because I treat them with kindness and respect. Approaching a patient going "I know you're being good, but because you're a little nuts I'm going to restrain you anyway" just sets the tone for a bad transport.


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## DesertMedic66 (Apr 27, 2011)

Sasha said:


> I think it's stupid and unnecessarily traumatic to restrain all psych patients. Use a little common sense, watch your patient so they don't get a chance to unbuckle themselves. If they're combative, absolutely, restrain them. If they're the scared little teenager who just wanted attention or a calm, quiet schizo, then don't restrain them.
> 
> It's silly.
> 
> Amazingly a majority of the patients who are "problem" patients for the hospitals are not for me. Why? Because I treat them with kindness and respect. Approaching a patient going "I know you're being good, but because you're a little nuts I'm going to restrain you anyway" just sets the tone for a bad transport.



If it's a 911 transport from the public into a hospital then we will normally watch them. If it's a 5150 transport then we don't have a choice. It could be a 5 year old or 105 year old. They have to have 4 restraints on at all times.


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## Sasha (Apr 27, 2011)

It's a stupid policy and probably causes more problems than they fix.


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## medicdan (Apr 27, 2011)

How about doing a bit more of a detailed assessment (the part where you actually have to talk to the patient... however traumatic that may sound). If they have suicidal iteration, do they have a plan? What methods? Timing? 
Do they have the means? motive? while in your care? Are they combative? Are they calm? 

Within the scope of your training and protocols, select the treatment that is appropriate to your assessment of the patient's condition. Do you slap an NRB on everyone who has had chest pain, nausea, or difficulty breathing in the last 3 months? (Oh wait...P?)


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## DesertMedic66 (Apr 27, 2011)

emt.dan said:


> How about doing a bit more of a detailed assessment (the part where you actually have to talk to the patient... however traumatic that may sound). If they have suicidal iteration, do they have a plan? What methods? Timing?
> Do they have the means? motive? while in your care? Are they combative? Are they calm?
> 
> Within the scope of your training and protocols, select the treatment that is appropriate to your assessment of the patient's condition. Do you slap an NRB on everyone who has had chest pain, nausea, or difficulty breathing in the last 3 months? (Oh wait...P?)



If my protocol and company policy say that is what your supposed to do then I am going to do it. I'm don't plan on getting fired for not following policy


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## MMiz (Apr 27, 2011)

*All patients should be restrained, *even if it's just wearing a seatbelt or stretcher starps. You're going to have to follow your local protocol for any restraints beyond that.  

At my service, where we did a lot of psych. transports, we didn't carry restraints and most patients were only restrained by the three stretcher belts.  If a patient was to be restrained beyond that we'd get disposable restraints from the facility, or use their leather ones and return them.

A big private service in the area they required all psch. patients to be in four point restraints.

I don't think there is any best solution, but I tend to believe in giving the provider the opportunity to pick the best restraint method.  Whether that be a MD or EMT, I think we can make the judgment call.


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## JPINFV (Apr 27, 2011)

SD EMT OPS said:


> does anyone know if there is a rule, law, protocol or standard of care that dictates the required minimum level of care an SI or psyc pt must be transported with?



San Diego EMSA protocol for application of restraints only says the following in regards to when to use restraints, "C. Restraints are to be used only for patients who are violent or potentially violent, or who may harm self or
others."
http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/EMS-PolicyProtocolManual_2010online.pdf
Starts on page 326.

It essentially leaves the decision up to the transport crew. I think that applying it to everyone who has suicidal, or even homicidal, ideations is overkill. Conduct an assessment, and then make the decision based on the assessment. To give a good example for homicidal ideation, I once transported a patient (sans restraints, completely cooperative) who had a lengthy psychiatric history who was being seen in an outpatient clinic because he wanted to kill his wife. However, he recognized that that want was bad, hence why he was seeking treatment. Does someone who is having bad thoughts, and recognizes those bad thoughts as bad and symptoms of their illness, really need restraints beyond seat belts? Does the slightly inebriated woman who just broke up with a long time boy friend and who's BFF called police based on how the patient was venting her emotions over the phone really need restraints? 

There is no simple or protocol answer to this, nor should there be. Patients present differently, and just being under a legal hold should never enough of a reason to be placed under physical restraints.


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## JPINFV (Apr 27, 2011)

SD EMT OPS said:


> a 5150 is a patient has been deemed a danger to self or danger to others. should this patient HAVE to be in some level of restraints during transport?


 
Sure. Actually, all patients should be restrained... with seat belts.


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## JPINFV (Apr 27, 2011)

nonsense said:


> It depends on you're company's policy, and your county protocol.  Most private ambulance companies will require any 5150 pt to be restrained and this is mostly for the safety of you as the transporting attendant, as well as the fact that the 5150 hold does not allow the patient to refuse transport on their own free will. That being said, I don't see a lot of 5150 patients being restrained.




Why should some one who is gravely disabled due to a psychiatric disorder be restrained? Are you regularly picking up patients from psychatric facilities or emergency departments restrained?


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## JPINFV (Apr 27, 2011)

emt.dan said:


> Do you slap an NRB on everyone who has had chest pain, nausea, or difficulty breathing in the last 3 months? (Oh wait...P?)



I've seen protocols (a few years ago, when someone posted a link based on a request from me) that require all patients, regardless of complaint, to receive a NRB.


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## Epi-do (Apr 27, 2011)

We are allowed to make the decision, based upon how the patient presents.  If they are being cooperative, and not acting as if they are going to be a threat or cause any problems, we do not have to restrain them (outside of the cot straps or seat belts that every patient must use).  We also have the discretion to determine when physical restraints are appropriate, and when chemical restraints are a better option.

Typically, if a psych patient is going voluntarily, they aren't going to be restrained.  It is the ones that are being forced to go that may end up getting restrained.  With those patients, it is also policy to have a police officer follow us to the ER since they are the ones responsible for completing the paperwork for the hold.  If we have a patient that we opted to not restrain suddenly require restraints for some reason, all we have to do is stop and the officer will assist us in doing so.


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## Aidey (Apr 27, 2011)

JP - *snicker*

I'm with Sasha and JP on this one. 

Honestly the majority of people I restrain are intoxicated in some manner, usually alcohol, meth or cocaine (or some combination thereof). After that it is probably unmedicated schizophrenics, but with them it isn't usually because they are violent towards me, it is to keep them on the gurney.


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## AnthonyM83 (Apr 28, 2011)

It's my opinion that there should be a level of restraint above seatbelts, but below wrist restraints.

If a patient decides to suddenly unbuckle both seatbelts (standard around here is 1 lap belt and one leg belt) and leap forward toward the doors, he has a high probability...especially if he's been in and out of psych hospitals and used to the ambulance operations. The taller ones can do it more easily . . . if you're on the freeway, by the time you unbuckle your belt to reach them, it's going to be pretty dangerous try to struggle to keep them from jumping out if you're on the freeway (which has happened a NUMBER of times locally).

All you really need is something to slow down the process of unbuckling to give time for your partner to stop the ambulance (usually).

I do feel bad putting 4-point restraints on the 110 lb 16 year-old  girl who is on a psych hold from the night before because she was cutting at her wrists when her boyfriend broke up with her. She's embarrassed and terrified enough.

But in the end it's all weighing pros/cons.


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## Monkey (Apr 28, 2011)

We normally transport a TON of SI/Psych patients.  We are told in the dispatch the reported mood of the patient and given the notice "restraints prn" on the MDC.

If a pt is calm and collected, just the belts, (SD protocol is a minimum of 3 belts but we use the shoulder as well.) and no restraints. If the pt is hostile and poses even the slightest of a "threat" then the prn comes into play, 

But to answer your question, no.. there is nothing I've ever read on a county or even city level that mandates 5150, 5250, or even a voluntary psych patient MUST be restrained.

-S-


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## Veneficus (Apr 28, 2011)

JPINFV said:


> I've seen protocols (a few years ago, when someone posted a link based on a request from me) that require all patients, regardless of complaint, to receive a NRB.



That is awesome.


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## SD EMT OPS (Apr 28, 2011)

I Have implemented a simple minimum level of restraint policy at my BLS company for all 5150 transports...  I have added a 3rd seat belt to our stretchers that goes around the Pt's chest and secures on the back side of the stretcher. Its non-invasive or confrontational, the only people that know the Pt is restrained are my EMTs. its very effective and will allow enough time for the attendant to signal to the driver to pull over and assist in the Pt compartment and prevent the Pt from jumping off the stretcher in route. Obviously the minimum level would be based off of Pt history and crew assessment. we should always consider Pt and crew safety first.


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## Sasha (Apr 28, 2011)

I didn't know that stretchers came with less than three seat belts...


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## SD EMT OPS (Apr 28, 2011)

our strykers come with 2


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## Veneficus (Apr 28, 2011)

*Run Forest! Run!*

I have transported my fair share of psych patients. 

Some have tried to run. Some have succeeded.

Towards the end of my street time I wrestled with a patient trying to escape. After she reached for my trauma shears and it became a battle over them, my opinion is to let them jump out the back if they are so hell bent on it. We'll just change the destination to the trauma center.

If their goal is to hurt me, my solution is opening the door and pressing the cot release.

I have never worked for any organization that had less than 3 cot straps. 99% of them had shoulder straps as well.

In 2 countries I have provided care in, physical restraint is not permitted or only as a very last resort in extreme circumstances.

Given that psych disorders are considered biochemical in nature, I agree with the philosophy that chemical restraint should be the first treatment. But I understand the US systems make that difficult or impossible in some cases.

System fail...

To physically restrain every psych diagnosis regardless of presentation seems to me like a human rights violation. Akin to locking up or handcuffing psych patients because they are.
(Not to mention it is more trouble than it is worth)

No patients should be riding on a cot without the proper seat restraints in place.


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## JPINFV (Apr 28, 2011)

Sasha said:


> I didn't know that stretchers came with less than three seat belts...



When I worked in So Cal, everyone used just a chest belt (no shoulder loops) and a leg belt. However in Massachusetts, it was a waste, chest, legs, as well as shoulder belts.


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## Veneficus (Apr 28, 2011)

JPINFV said:


> When I worked in So Cal, everyone used just a chest belt (no shoulder loops) and a leg belt. However in Massachusetts, it was a waste, chest, legs, as well as shoulder belts.



CA is so broke they can't afford 3 straps?


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## DesertMedic66 (Apr 28, 2011)

Veneficus said:


> CA is so broke they can't afford 3 straps?



policy for my company is 5 straps at all times.... and we are in cali. we have feet, waist, chest, 2 shoulder (supervisor) straps.

those straps go on all patients. ifs its a 5150 then all those straps plus 2 ankle and 2 wrist straps.


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## SD EMT OPS (Apr 28, 2011)

your pt look like this?


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## DesertMedic66 (Apr 28, 2011)

SD EMT OPS said:


> View attachment 786
> 
> 
> your pt look like this?



nooooo. our straps are more colorful


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## Frozennoodle (Apr 28, 2011)

I read a thread earlier about 201/302 patients and now 5150 patients.  I could quote LRS:14 all day long and no one would have a clue what I was referring to unless you happened to be a LEO in Louisiana.  Why use local codes on an international forum?


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## DesertMedic66 (Apr 28, 2011)

Frozennoodle said:


> I read a thread earlier about 201/302 patients and now 5150 patients.  I could quote LRS:14 all day long and no one would have a clue what I was referring to unless you happened to be a LEO in Louisiana.  Why use local codes on an international forum?



Thats just what we are used to using.


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## RESQGUY (May 1, 2011)

I definitely do not believe that restraints are necessary for all 5150 holds. I agree with what some others have posted, just assess the pt.Use your head and grow from there. If s*** goes south during TX. Then its time to get down.


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## HotelCo (May 1, 2011)

Frozennoodle said:


> I read a thread earlier about 201/302 patients and now 5150 patients.  I could quote LRS:14 all day long and no one would have a clue what I was referring to unless you happened to be a LEO in Louisiana.  Why use local codes on an international forum?



+100


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## kevin1988 (May 10, 2011)

My company requires four point restraints on all 5150 transports as well.

I tell patients up front, before they touch my gurney,what is going to happen and why. The cooperative ones get them put on loosely and with most range of motion. Basically just enough to cover my a** if my manager decides to drop by.

This is mostly only on IFT's as the cops are usually to lazy to write up the paperwork on 911's


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## Veneficus (May 10, 2011)

kevin1988 said:


> My company requires four point restraints on all 5150 transports as well.
> 
> I tell patients up front, before they touch my gurney,what is going to happen and why. The cooperative ones get them put on loosely and with most range of motion. Basically just enough to cover my a** if my manager decides to drop by.
> 
> This is mostly only on IFT's as the cops are usually to lazy to write up the paperwork on 911's



I am starting to wonder if this is really for safety or used as a technicality to get medicare or medicade to pay for the transport. 

I think it is time to give the good folks over there an email and find out if this is simply a form of fraud and abuse.


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## Veneficus (May 10, 2011)

Could I ask all of those who have a company policy to place psych patients in physical restraint if they could just PM me what county they are in so I may send an email to the appropriate medical director to clarify the medical position on this?


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## slb862 (May 10, 2011)

I use the:  "we can do it my way or your way".  

Most of our psych. (chapter 51, here in Wisconsin).  The police are the *only* ones that can Chapter someone.  When in the hospital, a "Crisis Worker" is called to determine the needs of the pt. and then the pt. alot of times will be transported by the Police. 
Most of my psych calls, come with a police officer on scene.  The service I work for, protocol allow us to use a chemical restraint (Ativan), if needed.  I have used it twice.  No additional restraints were needed after each case.  But, for most psych cases, all that was needed was a soft and reassuring voice.  And the explaination as to what is going to be done, prior and during transport to the hospital.  With the police either in the back of my rig or following behind.
You can also try the swaddling with a blanket, then the straps from the cot.  Works good for the elderly.


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## systemet (May 10, 2011)

I think that this is highly dependent on the situation.  If you have a patient who's voluntarily coming with EMS to a medical facility, who has shown no signs of violence, and does not appear to be agitated, hallucinating, delirious, intoxicated, etc. then you may feel comfortable transporting without restraints.

On the other hand, if they've tried to fight the cops, are acting irrationally, aggressively, and you're concerned for your safety, then both chemical and physical restraint should probably be liberally applied.

I don't think this is the sort of situation where someone should try to plan for all contingencies in a rigid protocol.  The paramedics / EMTs on the call should be allowed to use their best judgment.  But they also have to be ready to be responsible for it.

The decision to use chemical restraint has to be balanced between the risks of a sedation procedure, and the potential benefit of facilitating transport, and preventing harm to caregivers, law enforcement, or the patient.  Both leaving an agitated patients screaming and thrashing in restraints and snowing them into hypercapnia and near-apnea are irresponsible, and poor care.  There has to be a balance in between.

Personally, I've found few people I haven't like more after they've had a little SL ativan.


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## Veneficus (May 10, 2011)

My perception of the issue.

The physical or chemical restraining of psych patients is not medically indicated in all cases.

I think it is an absolute betrayal of the priviledge, esteem, and trust placed in medical professions in order to globally apply such interventions masquerading in the name of safety.

Especially when considering that a restrained patient is a medically acceptable criteria for the use and payment of ambulance transport.

It speaks ill of providers and the ambulance driver labor pool when people aspiring to be esteemed healthcare providers will tie down a patient or chemically snow them in order to make a few dollars. 

Probably good that these technicians (aka laborers) aren't taught how to harvest organs or any other common surgical procedure.

What is especially troubling is the effort to hide behind SOP as an excuse in perpetrating this overt malpractice and releive oneself of personal responsibility for the act.

These ambulance drivers and owners are an embaressment to the medical community.


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## sir.shocksalot (May 10, 2011)

I agree with Vene and the others that have said it's situationally dependent. There is 0% reason to physically restrain someone who is just sad that their GF or BF or whatever left them. In fact to do so is completely inhuman, you have basically said that this person is so F*cked in the head that they must be strapped down to a stretcher so they may not move at all. These individuals have already felt like they lost everything, now they have lost their rights by being placed on a mental health hold, now you have made this view worse by strapping people down to a bed.

Do you guys also restrain all diabetics and people with a history of seizures because "If your sugar gets low or you have a seizure and become post-ictal you might become combative"? It's completely ridiculous.

I encourage all of you who have such protocols that basically constitute some kind of human rights violation to urge their employers to look into the purchase of bucklegarde. It's what we use for those that tend to the uncooperative side of things, it simply goes over the buckle and prevents anyone without something small and pointy from opening the seatbelt.

As someone with a mental illness, I think the way some providers treat the mentally ill is completely inhuman. If I ever see anyone restraining someone because they are on a mental health hold I will correct you on the spot.


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## Veneficus (May 10, 2011)

sir.shocksalot said:


> I agree with Vene and the others that have said it's situationally dependent. There is 0% reason to physically restrain someone who is just sad that their GF or BF or whatever left them. In fact to do so is completely inhuman, you have basically said that this person is so F*cked in the head that they must be strapped down to a stretcher so they may not move at all. These individuals have already felt like they lost everything, now they have lost their rights by being placed on a mental health hold, now you have made this view worse by strapping people down to a bed.
> 
> Do you guys also restrain all diabetics and people with a history of seizures because "If your sugar gets low or you have a seizure and become post-ictal you might become combative"? It's completely ridiculous.
> 
> ...



I am thinking it is not so much a medical SOP as an operational mandate so the patient will meet the criteria for ambulance transport for billing purposes.

Let's face it, when basically ignoring human rights, what's a little fraud?


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## DesertMedic66 (May 10, 2011)

sir.shocksalot said:


> I agree with Vene and the others that have said it's situationally dependent. There is 0% reason to physically restrain someone who is just sad that their GF or BF or whatever left them. In fact to do so is completely inhuman, you have basically said that this person is so F*cked in the head that they must be strapped down to a stretcher so they may not move at all. These individuals have already felt like they lost everything, now they have lost their rights by being placed on a mental health hold, now you have made this view worse by strapping people down to a bed.
> 
> Do you guys also restrain all diabetics and people with a history of seizures because "If your sugar gets low or you have a seizure and become post-ictal you might become combative"? It's completely ridiculous.
> 
> ...



If it's a 5150 IFT then we have to restrain no matter what (company rules). If they become combative we have two choices; try to restrain them or let them jump out of the rig, then call for PD. 

If it's a 911 call then the crew gets to decide if they want restrants or not.


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## JPINFV (May 10, 2011)

Veneficus said:


> Could I ask all of those who have a company policy to place psych patients in physical restraint if they could just PM me what county they are in so I may send an email to the appropriate medical director to clarify the medical position on this?



I'll help you out publically with this one. Riverside County's protocol calls for 2 point restraints for all patients on a hold.


"Restraints are to be used when necessary in those situations where the patient is exhibiting or has exhibited behavior deemed to present danger to self or to the field personnel. Two-point restraints are presumptive for 5150 patients and escalation to 4-point restraints will be based on medical and safety issues. Refer to Policy # 5520, Restraints."

- http://www.remsa.us/policy/5510.pdf


"The minimum restraint necessary to accomplish needed patient care and  safe transportation should be utilized. 5150 patients should receive, at minimum, 2-pt extremity restraints."

- http://www.remsa.us/policy/5520.pdf


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## Monkey (May 10, 2011)

it boggles my mind why a pt that is NOT agressive, just depressed with SI, would need restrained.

I transport about 12+ psych holds a week between IFT's and 911's.  I have YET to have to restrain one.  Even the really bad schitzo effectives RARELY actually need restrained.

If a pt is not restrained by the hospital staff, why should we have to?  If like a recent call, i have a 20 something pt that is depressed over life, is somber and just mopey, wouldn't strapping his limbs down like some gitmo detainee make it worse?  

These private IFT's need to use their heads a bit more.


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## DesertMedic66 (May 10, 2011)

Monkey said:


> it boggles my mind why a pt that is NOT agressive, just depressed with SI, would need restrained.
> 
> I transport about 12+ psych holds a week between IFT's and 911's.  I have YET to have to restrain one.  Even the really bad schitzo effectives RARELY actually need restrained.
> 
> ...



It all depends on how the call comes in for my company. If it comes in as a 5150 hold or psych patient then we have to use restraints. If it comes in as something else then it's the crews choice.


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## Monkey (May 10, 2011)

so if a it's an IFT, say from a hoptial ER to a psych/BHU and the pt is just depressed but on a hold, you slap 'em in restraints?


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## DesertMedic66 (May 10, 2011)

Monkey said:


> so if a it's an IFT, say from a hoptial ER to a psych/BHU and the pt is just depressed but on a hold, you slap 'em in restraints?



Yep. It's in my county protocols for at least 2 restraints and my company protocols say 4 restraints. My company has laid off employees for not following protocols.


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## DrParasite (May 10, 2011)

not to defend a blanket policy but....


Monkey said:


> If a pt is not restrained by the hospital staff, why should we have to?


in a hospital, you have one nurse and one tech attending to the patient area, plus security/hospital PD available with a rapid response, as well as every other doctor, nurse and tech within earshot (as well as one hospital I know has the maintenance guy help out).  so in the span of (approx) 30 seconds you have have the patient restrained by lots of help.   in an ambulance, it's one person in an enclosed area, and if the person goes beserk, you better hope your partner can stop hop out and run to the back of the truck to help you, or you can dive out the side door and call for help.  much different scenario. 





Monkey said:


> If like a recent call, i have a 20 something pt that is depressed over life, is somber and just mopey, wouldn't strapping his limbs down like some gitmo detainee make it worse?


probably not.  just explain why you are doing it.  it he is mopey and depressed, being restrained for a short trip isn't going to make him worse.

again, I don't like blanket policies, but I have restrained people in the ambulance (and had two LEO's with me) and the hospital didn't want them restrained, and I have brought ambulatory psychs in that the hospital ended up putting in 4-points.  it all depends on the situation

but follow company and local protocols, because those are what you will be able to fall back on in case there is an issue.


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## Veneficus (May 10, 2011)

JPINFV said:


> I'll help you out publically with this one. Riverside County's protocol calls for 2 point restraints for all patients on a hold.
> 
> 
> "Restraints are to be used when necessary in those situations where the patient is exhibiting or has exhibited behavior deemed to present danger to self or to the field personnel. Two-point restraints are presumptive for 5150 patients and escalation to 4-point restraints will be based on medical and safety issues. Refer to Policy # 5520, Restraints."
> ...



Thanks, 

I actually wrote to the CA Psychiatric Association to solicit their input on if they found that an acceptable practice.


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## DesertMedic66 (May 10, 2011)

Veneficus said:


> Thanks,
> 
> I actually wrote to the CA Psychiatric Association to solicit their input on if they found that an acceptable practice.



If REMS does change their protocol about restraining patients I highly doubt that my company will change it's protocols about it. So if I didn't restrain a patient I wouldnt lose my EMT cert but I probably would get fired for not following company protocol. Not worth it to me


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## adamjh3 (May 10, 2011)

Vene, I am very interested in hearing their reply as I'm currently trying to fight my company's absolutely ludicrous policy of all 5150 patients being placed in 4 point restraints


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## SD EMT OPS (May 10, 2011)

A psych pt could present totally calm and cooperative while in the hospital and during your initial assessment while on scene, answer all questions appropriately and state they understand whats happening and why the requesting party is sending them to a psych facility on a 72 hold (in-order to be placed on a hold -5150 et sec- the patient must be deemed a danger to self or others by police, ER MD, or psychiatrist). the RN then tells you they have been totally calm and cooperative the entire time the pt has been in the ER and they don't need to be restrained. So you say "OK" and don't restrain the patient. during the transport the pt freaks and jumps out the back committing suicide by ambulance. (actually happens) whose fault??  the transporting crew gets the blame.. and company gets sued for wrongful death  and possibly the the Medic or EMT could be sued. I have NEVER had a pt say " i'm going to freak out and jump out the rig in 5 min."
so in-order to prevent this situation from happening our companies policy is that all patients on an involuntary hold must be retained in some way. that level of restraint is based on Pt history and your pt assessment. not all need to be placed in 4 point leathers. there are far less invasive ways to secure a patient to the stretcher to allow the driver enough time to pull over and assist the attendant in the back or prevent the pt from exiting the rig in the middle of a freeway.


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## kevin1988 (May 10, 2011)

Just because the person is in restraints doesn't mean they are strapped down tight to the gurney. Like I said earlier my company's policy is 4 point restraints on all 5150 IFT's.  I do it because I don't feel the need to be written up for violating policy.

With that being said, if the patient is cooperative and calm, I put the restraints on extremely loose and they still have full range of motion. It's basically CYA for me against my employer. 

I've had a few patients that were cool, calm and collected in the ER go apesh*t in the back of the rig during transport. It's nice to be able to just tighten up the restraints instead of fighting with the patient to get the restraints put on.


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## JPINFV (May 10, 2011)

SD EMT OPS said:


> why the requesting party is sending them to a psych facility on a 72 hold (in-order to be placed on a hold -5150 et sec- the patient must be deemed a danger to self or others by police, ER MD, or psychiatrist).



You are missing a third indication for a 5150. A patient may be placed on a 5150 hold if they are gravely disabled due to a psychiatric disorder. Additionally, deemed a danger to self or others does not necessarily mean that they dangerous at the time of the encounter. Additionally, if they are an acute danger to self or others, the hospital isn't just going to have security sit with them, even with the additional resources that the hospital has. 


> so in-order to prevent this situation from happening our companies policy is that all patients on an involuntary hold must be retained in some way. that level of restraint is based on Pt history and your pt assessment. not all need to be placed in 4 point leathers. there are far less invasive ways to secure a patient to the stretcher to allow the driver enough time to pull over and assist the attendant in the back or prevent the pt from exiting the rig in the middle of a freeway.



So, in other words all psychiatric patients are restrained with, at minimum, seat belts? Does your company regularly condone transporting non-psychiatric patients without seat belts?


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## JPINFV (May 10, 2011)

kevin1988 said:


> Just because the person is in restraints doesn't mean they are strapped down tight to the gurney. Like I said earlier my company's policy is 4 point restraints on all 5150 IFT's.  I do it because I don't feel the need to be written up for violating policy.


The last thing I would want to do is try to justify anything with "Befehl ist Befehl." I've of the understanding that that argument doesn't work well...




> With that being said, if the patient is cooperative and calm, I put the restraints on extremely loose and they still have full range of motion. It's basically CYA for me against my employer.



How long are your straps that they allow full range of movement? Pretty much just as importantly, if the patient has full range of movement, are restraints really doing anything? Can the patient, say, wipe his nose?


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## SD EMT OPS (May 10, 2011)

JPINFV said:


> So, in other words all psychiatric patients are restrained with, at minimum, seat belts? Does your company regularly condone transporting non-psychiatric patients without seat belts?



thats why i said involuntary hold...   not all psychiatric patients


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## SD EMT OPS (May 10, 2011)

seat belts would not be considered a form of restraint when the pt can reach down and unfasten them.  and yes ALL pt's as well as any/all other occupants in the ambulance must be seat belted ..  thats state law.


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## JPINFV (May 10, 2011)

...but what sort of non-locking restraint are you equipped with that allows both a full range of movement, yet can't be reached to be unlocked?


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## Monkey (May 10, 2011)

Much of the policies sound like distrust in the EMT.  If the EMT is with the pt, not in the captains chair at the head, and is paying attention to what the pt is doing, then it'd be pretty damn hard to commit death by ambulance if they all of a sudden snapped and went from calm to crazy in my opinion.

and yes, the 5150 hold includes those that are a danger to self as well as gravely disabled, both stating in the paperwork that they cannot properly care for their daily needs and well being, not always being a danger in the sense they're maniacs.

I also agree that the ER has more staff, and usually when we arrive, they have a sitter or security watching the pt outside the room, but that is SOP around here.

I don't know, I guess it just seems overkill and sort of barbaric to have to restrain a person, just because.


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## exodus (May 10, 2011)

JPINFV said:


> ...but what sort of non-locking restraint are you equipped with that allows both a full range of movement, yet can't be reached to be unlocked?



seatbelt around the chest that locks behind the gurney... Think the way the pedi-mate  attaches to the back of the gurney.


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## DesertMedic66 (May 10, 2011)

exodus said:


> seatbelt around the chest that locks behind the gurney... Think the way the pedi-mate  attaches to the back of the gurney.



I personally could careless is they are able to move their chest. I would be more worried about their arms and legs.


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## medicstudent101 (May 10, 2011)

If you feel that the pt's a threat to self and crew, call Chuck Norris. Problem solved. B)


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## EMTswag (Jun 8, 2011)

JPINFV said:


> Sure. Actually, all patients should be restrained... with seat belts.



Exactly.


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## exodus (Jun 8, 2011)

firefite said:


> I personally could careless is they are able to move their chest. I would be more worried about their arms and legs.



That's why you out their arms under the belt!


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## DesertMedic66 (Jun 8, 2011)

exodus said:


> That's why you out their arms under the belt!



And there is no way at all to get your arms free from the seatbelt at all...... Oh wait that's really easy to do.... :lol:


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## Handsome Rob (Jun 10, 2011)

if the patient presents a threat to the crew and / or themselves (is exhibiting violent behavior), then absolutely restrain them. A lot of IFT companies in my area just use the "policy" of restraining all patients on psychiatric holds, which may be illegal (the jury is still out on this one...meaning that we have approached the county and found contradictions in the state and county laws, namely that EMT's and Paramedics have no authority under state law to hold a person against their will even if they are on a psychiatric hold, whereas the county admits that they have no clear guidelines on the matter). When in doubt, the best way to approach the matter is from a CYA perspective. As long as you can say that you did what you did in the best interest of your patient, then you should be okay. That being said, if you are indeed in California, you may want to research out the laws in your area, namely those regarding the 5150, 5585, 5250 holds etc and "officer of the state" policies and definitions.


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## DesertMedic66 (Jun 10, 2011)

Handsome Rob said:


> if the patient presents a threat to the crew and / or themselves (is exhibiting violent behavior), then absolutely restrain them. A lot of IFT companies in my area just use the "policy" of restraining all patients on psychiatric holds, which may be illegal (the jury is still out on this one...meaning that we have approached the county and found contradictions in the state and county laws, namely that EMT's and Paramedics have no authority under state law to hold a person against their will even if they are on a psychiatric hold, whereas the county admits that they have no clear guidelines on the matter). When in doubt, the best way to approach the matter is from a CYA perspective. As long as you can say that you did what you did in the best interest of your patient, then you should be okay. That being said, if you are indeed in California, you may want to research out the laws in your area, namely those regarding the 5150, 5585, 5250 holds etc and "officer of the state" policies and definitions.



For us once someone is considered on a 5150 hold they pretty much lose all their own opinions. If they don't want to be transported well too bad they are going. They aren't even allowed to sign any paperwork once on a 5150 hold at least for my area.


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## JPINFV (Jun 10, 2011)

Interesting article in the California Ambulance Association newsletter _Siren_ regarding 5150 transports and the authority to detain. It's on page 6.

http://www.the-caa.org/pdf%20docs/Winter%20Siren%202010%20web.pdf


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## exodus (Jun 10, 2011)

From what I got, is that we don't have the authority to restrain 5150 patients then if they say no....?


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## HotelCo (Jun 10, 2011)

exodus said:


> seatbelt around the chest that locks behind the gurney... Think the way the pedi-mate  attaches to the back of the gurney.



This is what we do for psych patients that aren't violent. Just tie the female end of the buckle around the piston that moves the head up and down before you go into the facility. It looks like just another seatbelt.


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## adamjh3 (Jun 10, 2011)

JPINFV said:


> Interesting article in the California Ambulance Association newsletter _Siren_ regarding 5150 transports and the authority to detain. It's on page 6.
> 
> http://www.the-caa.org/pdf%20docs/Winter%20Siren%202010%20web.pdf



I'm trying to figure out what this all means to me. 

"If an ambulance is utilized for transporting the detainee, the person writing the 72-hour hold should accompany the patient"

Many of the 5150s I transport have been on a hold for hours and the person writing the hold is often completely unavailable. 

"...There is no proper delegation of authority to the EMT transporter under the law as it is written"



> 5150.  When any person, as a result of mental disorder, is a danger
> to others, or to himself or herself, or gravely disabled, a peace
> officer, member of the attending staff, as defined by regulation, of
> an evaluation facility designated by the county, designated members
> ...



From WIC 5150-5157

There is no mention of transport by anyone other than a peace officer or jailer within the code. 

Once the patient is turned over to our care, if we can't make a determination that they're "altered" (in which care would fall under implied consent) or otherwise a danger to self or others, or unable to care for themselves they're free to go?


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## Handsome Rob (Jun 10, 2011)

This is the gap in the law. In LA County, we bypass this, more or less, by operating under the county policies which are vague at best. Ah, California. 

sent from my mobile command center. or phone. whatever.


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## Akulahawk (Jun 10, 2011)

adamjh3 said:


> I'm trying to figure out what this all means to me.
> 
> "If an ambulance is utilized for transporting the detainee, the person writing the 72-hour hold should accompany the patient"
> 
> ...


Actually... there are more folks other than Peace Officers authorized to do the 5150, take into custody (or cause it) and place the person into the appropriate facility...


> a peace
> officer, member of the attending staff, as defined by regulation, of
> an evaluation facility designated by the county, designated members
> of a mobile crisis team provided by Section 5651.7, or other
> professional person designated by the county


The problem is that transport by medical personnel (or for that matter, anyone else) is implied by "take, or cause to be taken" and is not otherwise spelled out in black letter law. Clearly a lot of non-peace officers have the authority to detain people for evaluation under 5150. That person remains detained until released by the psych facility. 

In any event, from a quick review of current protocols/policies of a couple counties, I get the impression that they would rather have LE transport the 5150 that has no medical needs...


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## Akulahawk (Jun 10, 2011)

I ran out of edit time for my post... so here is what I was going to add:

I would also like to see provision for ambulance transport of 5150  detainees specifically inserted into the law with continued detention  authority (delegated to the crew by the person who placed the hold) and immunity provisions for  the crew/company/agency transporting the 5150 patient.


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## adamjh3 (Jun 10, 2011)

> That person remains detained until released by the psych facility.



That's where my confusion sets in. Almost all of my 5150 (or 5585) transports come out of facilities that are more or less for screening purposes, they generally don't house the detainee for the full 72 hours of the hold and instead release them to a different psychiatric hospital, which is where we come in. During the time in which myself or my partner has possession of the hold, can we legally detain these individuals? 

For example, I took a gentleman out of one of these screening facilities once, he had no psych history, hell hardly any medical history at all. He was placed on a hold by a police officer after LE received a call from his girlfriend stating she received a text from him (which he apparently sent out of frustration over an argument they were having) alluding to him wanting to kill himself. He had no plan to kill himself, had no desire to follow through, he was just pissed off and said the wrong thing at the wrong time. I have no reason to believe he's a danger to himself or others nor gravely disabled. Do I have the authority to detain him if he decides he's not going to the psych hospital? 

And looking at San Diego's restraint protocol (policy number s-422) it says nothing about when to restrain, only how and what may and may not be used to restrain. But going over to psychiatric and behavioral emergencies (no s-142) it states: 



> Restrain only if necessary to prevent injury. Document distal neurovascular status q15'. Avoid unnecessary sirens.



So... I'm basically in violation of county protocol by following my company's policy of mandatory 4 point restraints on all 5150 patients, yes?


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## JPINFV (Jun 10, 2011)

Akulahawk said:


> Clearly a lot of non-peace officers have the authority to detain people for evaluation under 5150. That person remains detained until released by the psych facility.


A lot of non-LEOs can write holds, but they all basically fall under 2 groups. Physicians and specifically licensed evaluation teams. To throw an additional wrench into the works, my understanding is that 5150 holds written by physicians and psych teams are only valid in the county that they are written in. 




> In any event, from a quick review of current protocols/policies of a couple counties, I get the impression that they would rather have LE transport the 5150 that has no medical needs...


Ideally, the psych hospitals should run the teams. Technically psych patients aren't supposed to be transported in marked patrol cars, but how often is that actually possible? Also, if there's a gap in California law where ambulances can't detain 5150 patients, then in your example, what happens if the patient does need medical care and the officer refuses to ride along?



5153.  Whenever possible, officers charged with apprehension of persons pursuant to this article shall dress in plain clothes and travel in unmarked vehicles."


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## Akulahawk (Jun 10, 2011)

JPINFV said:


> A lot of non-LEOs can write holds, but they all basically fall under 2 groups. Physicians and specifically licensed evaluation teams. To throw an additional wrench into the works, my understanding is that 5150 holds written by physicians and psych teams are only valid in the county that they are written in.
> 
> 
> Ideally, the psych hospitals should run the teams. *Technically psych patients aren't supposed to be transported in marked patrol cars*, but how often is that actually possible? Also, if there's a gap in California law where ambulances can't detain 5150 patients, then in your example, what happens if the patient does need medical care and the officer refuses to ride along?
> ...


There's a convenient "out" in the law that provides for uniformed peace officers to "apprehend" and transport in marked vehicles... The law doesn't mandate plainclothes/unmarked... it just "prefers" that transport be that way. IMHO, the person that placed the hold is the one actually detaining the patient. I simply would like to see something more concrete so that ambulance crews are specifically immune to suit and charges for false imprisonment, unlawful detention and so on simply because the person placing the hold is not physically in the ambulance at the time. 

Also, whenever possible, Law Enforcement should transport these people... Ambulances should only transport if there's a medical need.


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## JPINFV (Jun 11, 2011)

Akulahawk said:


> Also, whenever possible, Law Enforcement should transport these people... Ambulances should only transport if there's a medical need.




What law did a patient with a psychatric condition break? Isn't a mental illness a medical disease?


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## Akulahawk (Jun 11, 2011)

JPINFV said:


> What law did a patient with a psychatric condition break? Isn't a mental illness a medical disease?


No law... but psych transports is hard-coded as a LE responsibility. LE also has much immunity...


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## cherpy66 (Aug 6, 2011)

*5150*

i do many 5150 transports and i restrain each one with both arm and leg 4 point soft restraints. i dont care about if its not NICE. its for me and my partners safety. i transported one the other day on a als rig that was completely normal and calm, but the at some point during the transport she tried to take my medics shears and kill herself. luckily she only got out of one restraint and wasnt able to do much. but what if she wasnt restrained?? Also, im not gonna have a death on my shoulders because someoene jumps out of my rig on the freeway. it happens. theres a reason why they give us protocols and theres things that could happen that should make us follow them and not cut corners.


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## JPINFV (Aug 6, 2011)

cherpy66 said:


> i do many 5150 transports and i restrain each one with both arm and leg 4 point soft restraints. i dont care about if its not NICE. its for me and my partners safety. i transported one the other day on a als rig that was completely normal and calm, but the at some point during the transport she tried to take my medics shears and kill herself. luckily she only got out of one restraint and wasnt able to do much. but what if she wasnt restrained?? Also, im not gonna have a death on my shoulders because someoene jumps out of my rig on the freeway. it happens. theres a reason why they give us protocols and theres things that could happen that should make us follow them and not cut corners.




1. Not all patients on a 5150 are a danger to self or others. 

2. Not all patients who have been deemed a danger to self are acutely suicidal.

3. Not all protocols calls for restraints for all 5150s. 

4. Don't preach about following protocol and then make up your own protocol. Redlands falls under the Inland Counties Emergency Medical Agency, which controls EMS for San Bernardino, Inyo, and Mono counties, and says the following about the use of restraints. 

"Restraints are to be used only when necessary in situations where the patient is potentially violent and is exhibiting behavior that is dangerous to self or others."

Do you really believe that a patient is "potentially violent *and* is exhibiting behavior that is dangerous to self or others" (emphasis added) through out the entire 72 hour period?

I almost wish that the "psych patients are always restrained crowed" has some sort of emotional event (like a break up), gets drunk, vents over a phone to a friend about how life feels worthless, have that friend call the police, who then puts the patient on a psych hold, and then have every ambulance trip (one from residence to the hospital for clearance, then from the hospital to the psych facility. Add a third if they stay at a temporary facility until a bed can be found), and put in 4 points for every leg of that journey, regardless of their mental state at the time of actual transport. 4 point restraints should never be used as an alternative to a lack of, or lack of ability to, provide a proper assessment. 

Oh, and I've transported a couple patients who were on hold based on the above scenario (drunk, "worthless" friend calls 911).

ICEMA protocol on restraints: http://www.sbcounty.gov/icema/ViewFile.aspx?DocID=163


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## DesertMedic66 (Aug 6, 2011)

JPINFV said:


> 1. Not all patients on a 5150 are a danger to self or others.
> 
> 2. Not all patients who have been deemed a danger to self are acutely suicidal.
> 
> ...



That may be the protocol for ICEMA but Cherpy falls under the REMS protocol (as he works in riverside county). And more importantly is the company protocol in which he has to follow which states that all 5150 patients are to be restrained using 4 limb restraints. 

We have to follow the more strict protocol. County protocol says at least 2 points of soft restraints where as company protocol says 4 points of soft restraints on all 5150 patients. If they have a 5150 hold then they get restraints. It's doesn't matter if they are aggressive or not.


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## JPINFV (Aug 6, 2011)

firefite said:


> And more importantly is the company protocol in which he has to follow which states that all 5150 patients are to be restrained using 4 limb restraints.



Company protocol is irrelevant when it conflicts with county protocol. If county protocol didn't call for, or leave the option for, restraining all 5150 patients then company policy doesn't get to modify that. If someone brought action against you for malpractice (which, very arguably, changing the indication for an intervention like physical restraints would be), I highly doubt (to the point of putting money on it) that your company would back your actions. Once again, "Befehl ist Befehl" ("orders are orders." Ask the Nuremburg defends how that defense went) is not a defense I'd like to use... ever. 



> We have to follow the more strict protocol. County protocol says at least 2 points of soft restraints where as company protocol says 4 points of soft restraints on all 5150 patients. If they have a 5150 hold then they get restraints. It's doesn't matter if they are aggressive or not.



Actually, just reading it, there is a bit of leeway if a provider chooses to use it.

"Restraints are to be used when necessary in those situations where the patient is exhibiting or has exhibited behavior deemed to present danger to self or to the field personnel. Two-point restraints are presumptive for 5150 patients and escalation to 4-point restraints will be based on medical and safety issues. Refer to Policy # 5520, Restraints."
http://www.remsa.us/policy/5510.pdf

Furthermore, the actual restraint protocol says, "Patient restraints are to be utilized only when necessary and in those situations where the patient is exhibiting behavior deemed to present danger to self or field personnel."

http://www.remsa.us/policy/5520.pdf

Presumptive: 1. Of the nature of a presumption; presumed in the absence of further information.
-*http://tinyurl.com/3sfg9qk

*

Key words are "when necessary" and "presumptive." If you can make an argument that, given the situation, restraints aren't necessary, then you can make a similar argument (based on your assessment) why the patient shouldn't receive presumptive restraints. 

Furthermore, under a strict, no thought, reading of the 5150 protocol and the restraint protocol, the protocol is inconsistent. How can a patient be put in restraints presumptively, yet require restraints to only when necessary and only when the patient is deemed to be a danger to self or others (completely ignoring the third situation that a patient can be placed on a 5150 for)? Even with the note about 5150 patients in the restraint protocol, there is more than enough latitude that can be argued provided a provider wants to be more than a simple technician or laborer.


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## JPINFV (Aug 6, 2011)

To add to this, if I was working in Riverside County, I'd play the following arguments.

1. Patients who are gravely disabled are neither a danger to others nor the field crew, thus the restraint protocol found under 5520 manifestly doesn't apply.

2. The 5150 policy (policy 5510) states that restraints are presumptive. Based on my experience, education, and training and in light of my assessment (including the patient's body language) and the report received from medical and nursing staff at the transferring facility, I do not think that restraints are necessary in this case (hence the term "presumptive" being used). Since I do not, based on my assessment, believe that restraints are no longer called for under policy 5510, why would I refer to policy 5520? 

3. The Intro to BLS Protocols (which an argument can be made don't apply since BLS protocols is section 6000 and the restraints/5150 protocols are in Operations, which is section 5000) includes the following lines, "These policies are intended as thought processes or decision trees, not as absolute plans to fit every circumstance. Each patient encounter is unique, and a policy could not possibly be written to cover every circumstance. However, it must be noted that basic life support treatments usually have very little variation. We expect EMT-Is and EMT-Ps to closely follow these policies in most circumstances, using their training and good judgment to determine those occasional instances when deviation from the standard of care as promulgated by them is required."

As the protocols are not written to be absolute, since the protocol recognizes every patient as being unique, and since the protocol grants me the power to use good judgement and training to deviate unilaterally from the protocol, I hereby utilize that power granted. 

Source for quote: http://www.remsa.us/policy/6000.pdf

4. The nuclear option if available. 5150 transport = base hospital contact = "Based on my assessment, I do not believe that this patient needs restraints. = at worse gumming up the works.


5. Maybe I should have gone to law school.

6. Disclaimer: IANAL and the success on the arguments above are going to be depended just as much on how the arguments are mad as what the actual arguments are.


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## DesertMedic66 (Aug 6, 2011)

I'm not going to fight a company policy because I honestly don't have a problem with putting patients in restraints. Company policy says all 5150 patients currently on a hold are to get 4 point restraints. As hard as it is to get a job as an EMT-B/EMT-1 in California I am going to follow every protocol to the letter. 

Theres no use in following county protocol if you don't have a job. The company sets more strict protocols then the county but they are not saying don't follow county protocol. If that makes sence.


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## JPINFV (Aug 6, 2011)

firefite said:


> Theres no use in following county protocol if you don't have a job. The company sets more strict protocols then the county but they are not saying don't follow county protocol.



So if company policy and county protocol are incompatible with each other, which one do you follow?


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## DrParasite (Aug 6, 2011)

JPINFV said:


> Company protocol is irrelevant when it conflicts with county protocol. If county protocol didn't call for, or leave the option for, restraining all 5150 patients then company policy doesn't get to modify that. If someone brought action against you for malpractice (which, very arguably, changing the indication for an intervention like physical restraints would be), I highly doubt (to the point of putting money on it) that your company would back your actions. Once again, "Befehl ist Befehl" ("orders are orders." Ask the Nuremburg defends how that defense went) is not a defense I'd like to use... ever.


Not true on most accounts.  Company protocol is what you need to follow to prevent from getting fired.  County protocol is what the county says.  Not only that, but if you only follow the county protocols, and not the company protocols, when something does happen, your company will hang you out to dry (and likely be successful) because you didn't follow their protocols, which could have prevented the issue in question.  very often if your company protocol exceeds the county's, it will not be considered malpractice.

Further, as long as you have the company protocols in writing, than the company might not back you, but they will be more culpable (and liable).  It's when you start deviate from the agency/company protocol, or follow verbal protocol that no one has ever put in writing, that EMS people seem to get in trouble for.

but your best bet would be to contact your local ems office or whomever sets these protocols and ask them.  tell them the situation, and you can let them give a former opinion.  even better, if what your company is doing is wrong, let the regulatory agency investigate (after an anonymous question, of course), and if what the company is doing is wrong, have them require the policy be changed.  

going against company policy can get you fired.  going against state policy can get you sued/result in the loss of your cert.  having the state policy reflect the same thing at the company policy makes your life a lot easier.


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## DesertMedic66 (Aug 6, 2011)

JPINFV said:


> So if company policy and county protocol are incompatible with each other, which one do you follow?



It all depends on what the protocol is that is incompatible. When in doubt which policy to follow we can call the supervisor. 

And so far I haven't found any protocols that are "incompatible". They are just more restrictive then county protocols.


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## JPINFV (Aug 6, 2011)

DrParasite said:


> Not true on most accounts.  Company protocol is what you need to follow to prevent from getting fired.  County protocol is what the county says.


County protocol is the medical protocols for all companies operating in that area. Break county protocol and you can lose your license. If a county says, for example, that only patients who doesn't meet a specific spinal clearance protocol gets a backboard, the company can't just say, "We don't care, c-spine everyone." If the county says, "Patients go to their home hospital unless other conditions are present," the company can't say, "All of our patients go to the nearest hospital." If anything happens medically, and I consider placing patients into restraints due to a mental illness a medical intervention, you're going to be held to what the county protocol says, not what your company policy says. 



> Not only that, but if you only follow the county protocols, and not the company protocols, when something does happen, your company will hang you out to dry (and likely be successful) because you didn't follow their protocols, which could have prevented the issue in question.  very often if your company protocol exceeds the county's, it will not be considered malpractice.



Exceeds? More isn't always better, and I reject a companies ability to change the indication for restraints as much as I would change the companies ability to change medical protocol regarding dose or indication for any other drug or intervention. The company can't just say, "We don't care what the medical protocol says, we don't give out morphine" or "every patient gets a NRB" or any other such shenanigans. Why would a company be able to change the indication for restraints any more than the indication for atropine, epinephrine, or naloxone?



> Further, as long as you have the company protocols in writing, than the company might not back you, but they will be more culpable (and liable).  It's when you start deviate from the agency/company protocol, or follow verbal protocol that no one has ever put in writing, that EMS people seem to get in trouble for.



1. These protocols are in writing.

2. Services in California do not set treatment protocol, which makes this entire line of discussion moot. It's like a company saying they get to over rule a state wide protocol. Sorry, it just doesn't happen that easily. 




> going against company policy can get you fired.  going against state policy can get you sued/result in the loss of your cert.  having the state policy reflect the same thing at the company policy makes your life a lot easier.



Ok, so you spent all of this post trying to argue about following company policy to recognize that county protocol ultimately trumps company policy when in conflict?


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## JPINFV (Aug 6, 2011)

firefite said:


> It all depends on what the protocol is that is incompatible. When in doubt which policy to follow we can call the supervisor.



Your supervisor cannot order you to ignore county medical protocol, and if you get called out for not following county medical protocol I wouldn't bet on your company or your supervisor backing your play in any meaningful way.


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## DesertMedic66 (Aug 6, 2011)

JPINFV said:


> Your supervisor cannot order you to ignore county medical protocol, and if you get called out for not following county medical protocol I wouldn't bet on your company or your supervisor backing your play in any meaningful way.



Once again I have not seen any protocols that are "incompatible".


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## DrParasite (Aug 6, 2011)

JPINFV said:


> Ok, so you spent all of this post trying to argue about following company policy to recognize that county protocol ultimately trumps company policy when in conflict?


I said nothing of the sort, so please don't put words in my mouth.  in fact, if you want to follow county policy and violate company policy, that is your choice, but don't be surprised if you get fired for doing that (violating company policy that is).

What I said was, in the event your company's protocols conflict with your county protocols, have the county solve the issue with the company.  from what I hear about Cali IFT companies, their EMTs are easily replaceable, so an EMT shouldn't stir up any trouble with their supervisors for fear of reprisal.

but if the EMT anonymously contacts the county, and requests clarification, and the county intervenes directly with the agency, well, it keeps the EMT out of trouble, and it gets someone bigger than the (replaceable) EMT to fight the battle of clarifying the "correct and acceptable" process, both in the eyes of the company and the county.


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## flightmed256 (Aug 7, 2011)

*Sop*

Our SOP states that you can only restrain a patient if they shows signs of aggression towards the crew, public, themselves or other responders but we still have to get post-radio permission to do so.


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## flightmed256 (Aug 7, 2011)

flightmed256 said:


> Our SOP states that you can only restrain a patient if they shows signs of aggression towards the crew, public, themselves or other responders but we still have to get post-radio permission to do so.



That is for Mich.


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