Question about possible restraints on a psychiatric call.

[Gbro]

We used to transfer psychiatric's often to the main regional Cuckoo bin(80miles) and i had a few that constantly companied about the 4-points, always wanting them loosened, etc.
I would have the ER staff lock the 4-points to our cot and I would check everything and then the staff would, as prearranged, put the key in their pocket. I already had one in my pocket, but the Pt. doesn't need to know i have a key. The question came up often, how are you going to get me out of here in an emergency?, My EMT sheers. They will cut a penny in two.
It made for less hassle.

One of my more memorable psychiatric calls;
dispatched to a rural residence, report of a 70YOM chasing the chickens with a butcher knife, In the nude!, all kinds of mental pictures popping into the head enroute. Once on scene, it only took about 5 minuets to determine the 70YOM was the most lucid member of the whole family.(he found his bib's by the time we arrived)

 

[firetender]

And a lot of protocols have been written to specifically preclude you from using a "sandwich" method of restraining a patient due the bad press about it. I have always wondered though, if I would get in trouble for "sandwiching" a patient using two Stokes Baskets and some zip ties. h34r:

When the safety of you and the people around you is compromised, asking for forgiveness makes more sense than waiting for permission.

 

[Arkymedic]

During my second internship on Friday, we had a relatively slow day. Three calls until about a half hour before I was scheduled to get off shift. Call goes out for an Alpha Response for Psych. - Threatening Suicide. Police on scene. We respond to the location to find two officers already talking to the 20 y.o. pt. inside his house with family present but located in different part of the house. Per family, pt. had been severely agitated earlier in the evening including "tearing up his room, swinging the dog into a wall and threatening us (family) and himself up until the police arrived." Also per family, pt. has history of autism, bipolar disorder, and paranoid schizophrenia.

Pt. admitted to responding officers that he had not taken his medications in three weeks and knew he needed help. (I know from class that admission is key in dealing with behavorial pts.) However, upon our arrival, pt. refused to talk.

Crew chief goes with family member to retrieve medications while myself, another EMT, and two officers try to persuade pt. to go to get checked out at hospital.

Crew chief comes back down and informs myself and the other EMT that pt. has completely destroyed his room and is a first degree black belt and has multiple Jujitsu certificates. Basically he tells me, just be alert and on my toes.

Well pt. finally decides to stand up and begin walking to the truck accompanied by EMS personnel and police. Police perform a quick search to make sure he doesn't have any weapons on him. We get him secured on the stretcher, and transport without any problems. No restraints were used throughout the call...and especially looking back on it, I don't feel as though they were necessary.


This was my first psychiatric call, and I was really glad that I got to observe a patient who presented with more than a girl who just broke up with their boyfriend of two weeks.

While I felt completely safe throughout the entire call, there is still the little part of the back of your brain that sees something like him clenching his fist as he's walking to the truck as a possible sign that this guy might be ready to snap.....or he could have been cold....

So now for my questions....
Are restraints only used when a patient presents aggression while on scene?? Or to EMS personnel/police/etc?? My textbook says that "you may use restraints only to protect yourself or others or to prevent a patient from causing injury to himself/herself."

Could someone offer some insight on when you might see fit to use restraints?? I know some of it is probably shades of gray...

-Matt

It is our policy that we have to have medical control's permission to apply ONLY soft restraints and have very good reasoning. If the pt wants to fight so hard as to hurt someone then the hell with it they can go to hospital by PD. It's not worth my partner nor my career or our health. Skyemt was exactly right when he posted of the legal ramifications of using restraints, especially unapproved restraints. Though it may have been the only way using a spineboard and scoop to sandwich, using kerlix, c-collars turned backwards, flexicuffs, duct tape, face down with hands tied together, etc
all appear barbaric in court and compromise pt safety. Yes I work in the field and deal with psychs and have used some of those methods too before coming to the present service I work for however it's just something to thank about. Your safety is first, your partner second, and then the pt and bystanders.

 

[BossyCow]

Great timing on this one! At 0'Dark thirty this morning I was standing a safe distance from the gurney watching 5 LEO's deal with a combative pt. This guy bucked so hard handcuffed to the gurney that we were all waiting to see the gurney go over with him on it.

We ended up getting the soft restraints on him but he was so combative they couldn't get enough halodal into him to get him transferred to the ER bed. 5mg im x2, still thrashing, 8 mg iv, still thrashing. Turns out he had a skull fracture from the butt end of a 'buddy's' shotgun, a blood alcohol level of .356 and quite a healthy libido based on the comments he made about me on the 35 minute transport to the ED. We were gonna go out for drinks after, but they admitted him. (Just kidding, the bars weren't open)

 

[Gbro]

Bossy,
That is where the KED shines.

 

[triemal04]

Bossy,
That is where the KED shines.

That's the second time you've shown that picture. Why I don't know. For anyone who's looked at it, remember: do not, repeat DO NOT restrain your pt's face down. Ever. And especially if they have been fighting, are whacked on drugs, or a combo of both. Doing so is asking for them to become hypoxic and/or stop breathing and potentially code.

 

[BossyCow]

Bossy,
That is where the KED shines.

I'm not sure how a KED would have been easier to apply than the 4 point restraints we used. Personally I didn't want to get close enough to have to do up all those buckles. We ended up duct taping a towel to the guy's head to stop him from spackling the inside of the rig with his blood, covering it with a pillowcase and duct taping that to the gurney. Between the soft restraints and the gurney straps, he was pretty tied down.

Turns out he had a blood alcohol of .356, and according to the deputy I talked to afterwards, his pal had broken three different shotguns while beating the guy with the stocks.

As an addendum, the third guy in the room when this happened wrapped his car around a tree and died the very next night.

 

[OreoThief]

Generally speaking, if I have a PT that needs to be restrained due to risk of violence, our protocols dictate to call the police, and have them available and on hand just in case. If things are still too risky, they are usually more than happy to take a ride with you in the truck. Scene safety.... scene safety..... scene safety.

 

[Ridryder911]

Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney.

Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...

...and never undersetimate the temporary power of duct tape.

....Patients should never be transported while hobbled, hog-tied, or restrained in a prone position with hands and feet behind the back, and never be transported while sandwiched between backboards or mattresses


Sandwiching is a guaranteed litigation deal. It has been proven to be dangerous and harmful, Be sure that any restraint device must be able to be removed in a hurry and be safe to the patient.

R/r 911

 

[OreoThief]

Wow... never even heard of "sandwiching" before..... maybe I'm just too new to this.

 

[eggshen]

The scoop sandwich is, without a doubt, the best way to restrain a pt. That is unless you don't wish to keep your job and livelihood intact. Years ago they were great. That was prior to the whole postitional asphyxia thing becoming apparent. Nevermind if your pt. is some kind of sympathomimetic OD. In fact, if you have never seen it, forget you ever heard about it.

Egg

Also, the way that KED pt. is sorted? We try NOT to kill people.

 

[BossyCow]

So it used to be okay to kill pts?

 

[Gbro]

I'm not sure how a KED would have been easier to apply than the 4 point restraints we used. Personally I didn't want to get close enough to have to do up all those buckles.

No KED straps need to be used. I just lay the KED on the Pt. and it is held in place by the cot straps, just snug enough to keep in place.
Now for anyone who thinks this is a dangerous method is just being "PIG HEADED".
The Pt. in the Pic was delivered, and the ER staff each took their turn trying to control this one and had No problem with the restraint in use. The Cuffs are much more likely to do damage.
BTW, the local ALS service is the one that showed me this technique.

 

[Comedic]

If I feel that if the pt is going to hurt myself, my partner or be a problem. I am going to restrain them before transfer. No questions ask. Haldol sucks it's to slow and if PD is there use them.

It's a judgment call. Your the one in back and the one that has to deal with them during transport.



A scoop and backboard sandwich funny stuff. I head about it and also heard how Pt's had died. So maybe not so funny, but still funny.

We all get tired of the combative drunks and the suicidal Pt's. That hates the world and wants to fight.
But it's our job to take care of them in there time of need.
Don't get me wrong I make jokes about them all the time and cuss them at 2am when I have to get up cause Frank is trashing his house again and wants to fight. Who doesn't like a good fight.

 

[triemal04]

No KED straps need to be used. I just lay the KED on the Pt. and it is held in place by the cot straps, just snug enough to keep in place.
Now for anyone who thinks this is a dangerous method is just being "PIG HEADED".
The Pt. in the Pic was delivered, and the ER staff each took their turn trying to control this one and had No problem with the restraint in use. The Cuffs are much more likely to do damage.
BTW, the local ALS service is the one that showed me this technique.

So what was the point of the KED again? And while you're at it can you explain what positional hypoxia is and why it's a problem? I'd really appreciate it. I guess all the evidence is wrong...and everyone who says it's right is wrong...and it doesn't matter if the pt dies...after all, we're just pig headed.

 

[jmaccauley]

How many of you are required to transport a violent pt. to the mental health facility if there is no injury? Just curious, because generally if the police are on scene and can establish that the pt. is or has been violent, they transport, and apply restraints for everyone's safety. Whether he is suffering excited delirium or is off their meds, they can flip in a heartbeat, so why would you take their word that they will be calm for the ride? Just asking.

 

[jmaccauley]

So what was the point of the KED again? And while you're at it can you explain what positional hypoxia is and why it's a problem? I'd really appreciate it. I guess all the evidence is wrong...and everyone who says it's right is wrong...and it doesn't matter if the pt dies...after all, we're just pig headed.

Just to add to the debate and confusion over positional asphyxia/hypoxia. That has always been a major concern and many medical authorities warned of the danger. However, the debate has recently challenged that postion. For example there have been studies done (admittedly with low numbers of volunteers) to question how long a person would need to have their upper thorax region constricted before it became critical. The original tests often involved healthy young adults, but have now included various other age groups. Anyway, the weight being on the chest was usually blamed for sudden death syndrome, but now it has been more widely accepted that other factors probably contribute as much or more to the breathing complications. It's still a good idea to at least not appear to have contributed to the patients death.

 

[Ridryder911]

The main point is to have a plan, the right equipment, and to safely use it. I question why EMS would have to transfer any seriously "violent" patient and for what medical reason?

Enough personal and planned delivery of application of approved restraint devices, should be implemented after the decision of "restraining" devices.

This is one of the highest litigation areas in EMS and medicine itself. Not assuring patient safety after recognizing that the patient has a recognized or known psychiatric disorder is going to be reviewed and scrutinized if any unfortunate event occurs. Remember, almost each state has special considerations for those with known emotional and psychiatric medical problems. Undue roughness, hostile treatment, etc. should NEVER be placed onto those individuals, that is if one would like to continue to work in any medical profession.

Yes, it may appear unfair, but patients with known or those presenting emotional behavioral problems are protected that they are not aware of what they are doing. That is why it is VERY important to have documented special training in restraining and restraint training. As well a very thourough protocol on how and when should be implemented.

Any indication of "sandwiching" patient for restraints is opening the door for litigation. It has been documented and proven to be harmful and anyone wanting to continually use it does not value their career.

If my service area has a high percentage of emotionally distraught or pyschiatric patients, then I would recommend to discuss programs that teach proper restraining patients, and self defense against those that possess known disorders (yes, again those with known history have special rights), as well as to invest in approved restraint devices. Those patients that definitely demonstrate severe violent behavior should be restrained and transported by other means than EMS, again justifying why EMS should even be considered?

R/r 911

 

[jmaccauley]

A violent patient is generally treated as a medical emergency by law enforcement. We may have to restrain them in order to get them the help that they need. We are also very aware of Sudden Custody Death Syndrome and will probably have a restrained, violent person transported to the nearest ER by ambulance. I would expect most crews to request an officer ride with them, but it doesn't always happen. From LE's perspective, we logically assume that there is a high probablility that a patient suffering from drug psychosis or excited delirium is in the downward leg of living. Given a choice of having them die on the ground with our restraints in place, or in the ambulance, guess what the choice will be? Our paramedics face the same decision and feel that the patient should die on the operating table rather than in their rig. It's all about perception and recognizing that bizarre and violent behavior is something that can blow up instantly, taking reputations, careers and lives along with them.

 

[BossyCow]

The main point is to have a plan, the right equipment, and to safely use it. I question why EMS would have to transfer any seriously "violent" patient and for what medical reason?

R/r 911

We transported one just the other day. He had a fractured skull and is still in a medically induced coma at the nearest trauma center. He was the victim of an assault and was in serious need of medical treatment. He also is a well known instant a:censored:e.. just add alcohol and presto.. a:censored:e!

In this case, Law enforcement was on scene and cleared us for entrance. The guy had bouts of combativeness and violence followed by periods of well behaved compliance. There was generally no warning prior to the outbursts so we had him restrained to the gurney with 4 point restraints. To use a KED would have required a whole lot more cleaning than I wanted to do. The deputies cuffed him to the gurney and stood over him while I ducked in around them and secured the restraints. The soft restraints allowed me to restrain one limb at a time instead of offering myself as a target to his outbursts. I can't imagine using a KED for this! But I'm funny that way, I prefer to use tools for their designed use. KED for spinal immobilization prior to extrication, restraints for restraining pts.