5150 transport

[cherpy66]

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.

 

[JPINFV]

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

 

[DesertMedic66]

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

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.

 

[JPINFV]

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.

 

[JPINFV]

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.

 

[DesertMedic66]

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.

 

[JPINFV]

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?

 

[DrParasite]

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.

 

[DesertMedic66]

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.

 

[JPINFV]

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?

 

[JPINFV]

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.

 

[DesertMedic66]

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".

 

[DrParasite]

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.

 

[flightmed256]

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.

 

[flightmed256]

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.