Psych pts

iExposeDeformities said:
I’ve heard being on 15 LPM on NRB is like sticking your head out the window of a moving car. That’s definitely gonna worsen a lot of patients conditions where they don’t need it whereas not putting a restraint on some psychs won’t necessarily make a lot of difference so it’s really not analogically the same
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I think you should try one day on yourself. Seriously. it's nothing like as you describe, which would be more on the level of a N/C at 15 LPM. You won't suffer any ill will. There are issues with 15 LPM (free radicals, etc), but it's more along the lines of "why are you doing something that won't actually help the patient?"

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

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

Bullets said:
my medical director i guess trusts me any my staff to, as you said, "Not shotgun everything". We view restraints as a treatment, with clinical criteria for such. Just making a statement that activates a hold isnt criteria for such, just as saying "i have chest pain" isnt automatically getting 15LPM NRB O2.
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the shotgun approach, overly broad policies and knee jerk responses show, in my opinion, that the medial director doesn't trust the people under them to use their clinical judgement as to when they should or should not apply or utilize a particular treatment.

Thankfully, I have never had to work in a system with that type of medical director.
DesertMedic66 said:
It is poorly written however it is implied as “these are the conditions when it is necessary: danger to themselves/others, 5150 hold, in PD custody”. Company policy backs it up.
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Anyone who has worked in this field long enough knows that company policy is looking out for the interests of the company first, not the provider and not the patient (unless they happen to line up with the company's interests, which isn't always the case)
 
DrParasite said:
Anyone who has worked in this field long enough knows that company policy is looking out for the interests of the company first, not the provider and not the patient (unless they happen to line up with the company's interests, which isn't always the case)
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I completely agree. However there are a lot of instances where the company policy protects the company, employee, and patient (i’m not saying our policy on 5150 holds is an example of this).
 
It only takes 1 (one) error in judgement from a provider who chose to disregard the policies, because they thought they know better. That’s when a seemingly cooperative involuntary psych is either left unrestrained, or loosely restrained; then there are psychs jumping out of the rig on a freeway, crew members being punched in the face etc. pt’s advocacy is good and dandy, but there’s also the matter of clinician’s safety. I know for a fact that I am not there to diagnose or decide how to fix them, because it is way above my pay grade. What I can do, however, is make sure I, my partner & them get from point A to point B safe and unharmed. Building a rapport and making every possible accommodation is an added bonus.
 
I get there are definitely ones that slip through, but for the most part psych calls either run A. calm and voluntary or B. involuntary and/or violent for whatever reason. Usually it is category A and I see no reason to use physical restraints "just in case". I am more than happy to just sit and ******** with them for a few minutes to try to make that experience slightly better for them. If they are category B, they are most likely getting both chemical and physical restraints.
 
StCEMT said:
I get there are definitely ones that slip through, but for the most part psych calls either run A. calm and voluntary or B. involuntary and/or violent for whatever reason. Usually it is category A and I see no reason to use physical restraints "just in case". I am more than happy to just sit and ******** with them for a few minutes to try to make that experience slightly better for them. If they are category B, they are most likely getting both chemical and physical restraints.
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Mandatory restraints apply ONLY towards involuntary psychs. Why on earth would I restrain a voluntary one , if they’re calm and cooperative ??
 
Qulevrius said:
Mandatory restraints apply ONLY towards involuntary psychs. Why on earth would I restrain a voluntary one , if they’re calm and cooperative ??
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Guess I misunderstood parts of the Cali rules. Even then, I've had a very small percentage of folks who weren't voluntary as well that I didn't restrain. They weren't threatening me, they just didn't want me there to begin with and we're given an A or B option by PD. They were cool with me and I gave them the space they wanted.
 
StCEMT said:
Guess I misunderstood parts of the Cali rules. Even then, I've had a very small percentage of folks who weren't voluntary as well that I didn't restrain. They weren't threatening me, they just didn't want me there to begin with and we're given an A or B option by PD. They were cool with me and I gave them the space they wanted.
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We’ve been beating the same dead animal for 5 pages now, and I explained the policy in post #35.
 
Qulevrius said:
It only takes 1 (one) error in judgement from a provider who chose to disregard the policies, because they thought they know better. That’s when a seemingly cooperative involuntary psych is either left unrestrained, or loosely restrained; then there are psychs jumping out of the rig on a freeway, crew members being punched in the face etc. pt’s advocacy is good and dandy, but there’s also the matter of clinician’s safety. I know for a fact that I am not there to diagnose or decide how to fix them, because it is way above my pay grade. What I can do, however, is make sure I, my partner & them get from point A to point B safe and unharmed. Building a rapport and making every possible accommodation is an added bonus.
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Meanwhile, the rest of us don't seem to be having an issue. Cannot remember the last time I physically restrained someone. I medicate lots of people, but tie em up? No thanks. This sort of defensive medicine is asinine and providers should be ashamed of themselves if they can't identify who needs restraint and who doesn't.
 
The way I read the policy, it's a three part policy. Part 1 is for patients that do not fall into either part 2 or part 3 (most patients). Part 1 allows the crew to restrain patients as necessary to prevent harm to the patient themselves or to anyone else. This would include dementia patients that grab at everything and try to pull everything off or the drunk/high patients that are combative. Part 2 applies only to 5150 patients. By definition these are involuntary psych patients so they may or may not be willing to go along with the program. Some have been known to act calm/cooperative only to suddenly flip, assault the attendant, and fly out the back doors at freeway speed. (I was very late to work one day because this happened...) Part 3 applies only to patients that are in custody (under arrest OR already in inmate status). Notice that the wording used states either "restrained" or "handcuffed." This implies strongly that a patient that is in custody also must be restrained in some manner and conditions are placed according to which method is used.

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

Where I used to work, we also required (by company policy) 100% restraint of 5150 patients. Whether we did 2 point or 4 point was up to the discretion of the crew and the behavior of the patient. Patients that had to be restrained for their own safety usually were only 2 point restrained. Only a couple times did I have to transport patients in 4 point and required mitts. Those patients scratched at everything... including themselves.
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My point exactly. I had to restrain a non-5150 only once, because the pt flipped 180 on us. The 5150s, on the other hand, are always restrained (per company’s policy), but how and how many, I leave to my discretion. The company requires 4-points, but if a pt doesn’t pose any immediate threat, I usually do diagonal 2-point. They don’t feel completely degraded, can scratch their arse if needed, it’s impossible for them to break free before I have to intervene & I’m *mostly* compliant with the policies. There was a _single_ instance where I chose to forego the restraints altogether, because the 5150 hadn’t had any psych issues. She was just a silly 25 y.o. who had too much to drink, and was dared by her friends to take 100 Advils.
 
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Qulevrius said:
My point exactly. I had to restrain a non-5150 only once, because the pt flipped 180 on us. The 5150s, on the other hand, are always restrained (per company’s policy), but how and how many, I leave to my discretion. The company requires 4-points, but if a pt doesn’t pose any immediate threat, I usually do diagonal 2-point. They don’t feel completely degraded, can scratch their arse if needed, it’s impossible for them to break free before I have to intervene & I’m *mostly* compliant with the policies. There was a _single_ instance where I chose to forego the restraints altogether, because the 5150 hadn’t had any psych issues. She was just a silly 25 y.o. who had too much to drink, and was dared by her friends to take 100 Advils.
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“Dared by her friends to take 100 Advil’s” sounds like someone needs new friends
 
I am a little surprised restraints are treated so lightly in EMS, I guess for the most part patient's arent in them for very long. Behavioral restraints in the hospital require a Physician evaluation with thin one hour of application and every 4 hours after. Then its 1:1 supervision, Q15min charting, and Q2hr release and re-position. And if a patient deteriorates or codes while restrained it is a huge deal. Behavioral restraints are very serious legally and medico-ethically.
 
Chase said:
I am a little surprised restraints are treated so lightly in EMS, I guess for the most part patient's arent in them for very long. Behavioral restraints in the hospital require a Physician evaluation with thin one hour of application and every 4 hours after. Then its 1:1 supervision, Q15min charting, and Q2hr release and re-position. And if a patient deteriorates or codes while restrained it is a huge deal. Behavioral restraints are very serious legally and medico-ethically.
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I don't think it's necessarily that restraints are "lightly treate" in EMS, it's that EMS recognizes that restrained patients are already on 1:1 supervision and aren't in restraints for long enough (usually) to cause an issue. At least in my experience, EMS doesn't do locking restraints but rather just very secure soft non-locking. Field restraint use is aimed at patient and provider safety due to (usually) slow availability of backup. In hospital, we have the luxury of having lots of hands at our call and if a patient in my ED needs to be restrained, within seconds of asking, I have backup. Also any restrained patients are seen immediately (at least in my county) by a physician and they determine if further restraint use is necessary.

And may the almighty God have mercy on the soul of the crew that had a restrained patient die during transport. It has happened before and it's why sandwiching is never to be done and why we keep a very close watch on our excited delirium patients.
 
Correct, these are soft restraints. And, per protocols, PMS is reassessed every 15 min. Even if the transport is longer than an hr (due to external factors such as distance/traffic), it’s not long enough to cause any physical damage. And once on a wall in a facility, there’s usually no issues with supervision and the restraints can be released.
 
Qulevrius said:
Not every psych is a 5150, but all 5150’s are involuntary psychs. If it’s a voluntary psych, the county’s guidelines are ‘restrain if/as needed’. Bit if it’s a 5150 who is, by definition, an involuntary psych and danger to himself and/or others, the only difference between counties is how many restraints they should have. REMSA and OCEMSA require 4-points, LACo and VEMSA require 2-points etc. As I said, I’ve yet to hear about any county in CA that does not have mandatory restraints for involuntary psychs in their protocols.
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This isn't an attack on you, but that's a ridiculous policy. If an involuntary patient is trying to escape or actively trying to cause harm, by all means restrain them. But if they're not, than that restraint is inappropriate and, very possibly, unlawful.
 
medichopeful said:
This isn't an attack on you, but that's a ridiculous policy. If an involuntary patient is trying to escape or actively trying to cause harm, by all means restrain them. But if they're not, than that restraint is inappropriate and, very possibly, unlawful.
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There’s a lot of things that I personally find ridiculous, but my only options are a) abide by the policies (and have a job), b) quit the job, c) become an MD (as in, Making Decisions). Everything else is tilting at windmills.
 
Qulevrius said:
There’s a lot of things that I personally find ridiculous, but my only options are a) abide by the policies (and have a job), b) quit the job, c) become an MD (as in, Making Decisions). Everything else is tilting at windmills.
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Option d) practice EMS in a place that trusts its providers.
 
medichopeful said:
But if they're not, than that restraint is inappropriate and, very possibly, unlawful.
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psttt. what do you know? you aren't from the EMS mecca that is SoCal....

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