Restraints for combative patients

Qulevrius

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Since we all have to deal with psych pts on a regular basis, seeing pts on a 5150 is fairly common and in itself warrants soft restraints. But what about someone who's on a voluntary hold and suddenly flips ? Can the restraints still be used and, more importantly, when ?

Here's a specific example: I left a pt @ a sending facility a few days ago, because he was very agitated, verbally abusive and borderline combative. The facility in question is a BHU and the pt needed to be transported Code 2 to a hospital for med clearance; AOS to find the pt in the above stated condition and refusing to cooperate with EMS personnel (ripped off the BP cuff & threw it @ my partner, to name a few). Urging the pt to calm down did not bear fruit, the facility personnel had to step in but to no avail. I informed the facility that they can either call the PD and let them restrain the pt or produce a 5150 so I can do it myself, but that I am not putting a combative pt, in my ambulance, without restraints. Tl; dr he had to stay, we cleared it w/ dispatch and left.

Followed the outlined above, had a discussion with a few coworkers who claimed that it was my right & duty to apply the restraints without a 5150 because 'safety comes 1st'. My question is, did I miss something in school and applying the restraints without a involuntary psych hold isn't considered a false imprisonment anymore, or my coworkers clearly want to get me in trouble for violating pt rights ?
 

NomadicMedic

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If you don't have protocols for restraints, you may not apply them. If you do, you may.

Seems pretty simple to me.

I'm not familiar with California protocols, I'm assuming that's where you are because you referred to a psychiatric/combative patient as a 5150.

However, I have never seen any instance of a lack of protocol that states a combative patient may not be restrained for the safety of the provider. Of course, there are instances where medical control must be contacted, documentation must be very precise and the patient must be monitored frequently. (And I'm using several states as my experience. Washington, Connecticut, Delaware and Georgia.)

I've also transported more than my share of IFT psychiatric patients, and have never, ever had difficulty in receiving assistance with restraining a combative patient or receiving orders for sedation en route if needed. Even those that were on a "voluntary hold" and were being transported to a medical facility for clearance. The fact that they were aggressive, combative or otherwise needed restraint usually was a decent clue as to why they were visiting a mental health facility in the first placeand further illustrated that they needed additional assessment.

I suggest contacting your supervisor, medical control or your local regulatory agency to determine what you may and may not do. Or, you know… Read your protocols.
 

luke_31

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If it's Los Angeles county only on a 5150 hold can you restrain a patient, otherwise it's let PD deal with it.
 

Jim37F

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LA County EMS Policy 838 Application of Patient Restraints
http://file.lacounty.gov/dhs/cms1_206355.pdf

A quick review says the policy only really talks about HOW to restrain a patient (I.e. soft non locking restraints, don't sandwich them between two backboards, make sure they can take full deep breaths and you can still monitor vitals, if PD restrains with handcuffs or whatever, they should either ride in the back with you or at the very least follow the ambulance in their squad car, documentation requirements and re asses CMS immediately after and every 15 minutes, and so on).

I did not see anything in the County Policy about who to restrain beyond the very first paragraph "Purpose: To provide guidelines for emergency procedures and use of restraints in the field or during transport of patients who are violent or potentially violent, or who may harm self or others." (emphasis mine)

When I worked for Gerber Ambulance (2-2 1/2 years ago, they are since out of business) we had a company policy that mandated ALL 5150 patients, regardless if they were voluntary holds or not, whether they were calm and cooperative or not (and inevitably they always were with this company mandate) they all got at least two point restraints. Failure to restrain a 5150 patient was a fire-able offense. Why? Because one time years and years ago a psych patient being transported by a completely different company managed to jump out the back of the ambulance while they were on the freeway. If the sending facility didn't have restraints we would simply apply them ourselves (after all application of patient restraints IS in the LA Co BLS Scope of Practice) without needing to bother the FD or other ALS. So considering they had that policy, oh probably around a decade or so, anecdotally at least it seems that practice of you simply restraining someone who isn't an involuntary 5150 is rather legal.

I think I'm gonna go dig up my notes from my EMT recert class since they had a decent section on restraints, however I also strongly suggest if you have any questions regarding the legality of restraining a specific patient (or group of patients) you would be better served by contacting your on duty supervisor (that's kind of what s/he's there for lol) who can give you specific guidance that's also within your company SOPs if they mandate something above and beyond what the County says like mine did.
 
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Qulevrius

Nationally Certified Wannabe
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If it's Los Angeles county only on a 5150 hold can you restrain a patient, otherwise it's let PD deal with it.

This is exactly what I was taught. On the other hand, what Jim said is yet another shade of gray. I'll clear this with the OP manager next week & update the thread. Thanks for all the input, chaps !
 

Fleury14

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LOL @ "Urging the pt to calm down did not bear fruit."
I don't think telling someone to calm down ever works but it's always funny seeing people trying it.
 

FiremanMike

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LOL @ "Urging the pt to calm down did not bear fruit."
I don't think telling someone to calm down ever works but it's always funny seeing people trying it.

Your words as a provider and and will escalate or de-escalate a situation, and you need to firmly understand that. You will certainly not reach everyone and some folks will need to be restrained (chemically or physically) but you need to at least attempt verbal techniques first.
 

NomadicMedic

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Agreed, however most EMTs verbal de-escalation techniques involve such gems as "hey! You need to calm down right now or you're going to go to jail!" and "hey dude. Calm down or I'm going to have to tie you down to my stretcher!"

Yeah. Verbal judo/de-escalation should probably be a required module in the national curriculum.
 

Flying

Mostly Ignorant
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Don't forget gems such as:
"You can go with them or come with us."
"Calm down or else the cops will have to come."
"MA'AM IF YOU CONTINUE TO BREATHE FAST, THE HOSPITAL WILL HAVE TO PUT A TUBE DOWN YOUR THROAT"

Has nobody read Aesop, and when did the police become our battering rams?
 
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Qulevrius

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LOL @ "Urging the pt to calm down did not bear fruit."
I don't think telling someone to calm down ever works but it's always funny seeing people trying it.

You never know. And you never will til you try. You'd be surprised how strong and effective word-fu can be.
 

gotbeerz001

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Agreed, however most EMTs verbal de-escalation techniques involve such gems as "hey! You need to calm down right now or you're going to go to jail!" and "hey dude. Calm down or I'm going to have to tie you down to my stretcher!"

Yeah. Verbal judo/de-escalation should probably be a required module in the national curriculum.
I reinforce to paramedic students who gripe about having to do 20 hours in PES that they are not simply there to take vital signs; they should be watching the staff and learning techniques for how to talk to those with mental illness.
 

teedubbyaw

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Serious question...

do you guys think the patient would have been able to bear fruit if he calmed down?
 

gotbeerz001

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I'll use one soft restraint on a grabby stroke pt to keep them from trying to pull the IVs; justified as "to prevent pt from hurting themselves".
 

DesertMedic66

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Patients on 5150 hold, patients who pose a danger to themselves or others, patients who are in police custody, combative altered patients, drunk patients who are know to get combative with EMS crews.
 

Akulahawk

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I'm pretty much in the same camp as DM. I'll restrain patients that are combative and on a 5150 hold or are altered/drunk. I do this primarily to keep the patient from hurting themselves. Patients that are in handcuffs remain in handcuffs and LE is responsible for proper use and monitoring of those restraints. They key part of me having to restrain someone is that I'm providing care under implied consent or under a 5150 hold because those folks aren't able to make their own decisions and they're combative.

If you're alert, oriented, able to make plans for self care and you're combative, I am going to consider you effectively AMA.
 
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Qulevrius

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If you're alert, oriented, able to make plans for self care and you're combative, I am going to consider you effectively AMA.

Bingo. That was exactly my reasoning in that particular case, sans the official A+Ox4 because the pt simply refused to cooperate in any possible way. But since he wasn't on a hold and had no (known) Hx of mental disorders, he stayed on the bench in the BHU. Then that discussion with the co-workers happened, where I was told that i should've restrained him regardless b/c *reasons*. Now, I know for a fact that what I did was right, but also do want to know how wrong the others are.
 

cruiseforever

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Voluntary hold? Is there such a thing? Must be a regional thing. In my area if you are placed on a hold, you are considered to be a risk to yourself or others.
 
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Qulevrius

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Yes. A voluntary hold is when a pt turns him/herself in for psych monitoring due to suicidal ideation. A very popular thing among the local homeless folks who need medical attention or simply want a warm bed and a free meal.
 

Tigger

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Are they actually on a hold though or are they just at the facility? Here you can voluntarily go to detox or a mental health crisis center and leave when you please unless the staff chose to place you on actual mental health or intoxication hold.

Also, I bet placing calm and cooperative patients in restraints really did a lot for them. I get that it's policy, but it's stupid plain and simple. Lets demean people that are already teetering on the edge, seems like a good plan. Classic California. Along with byzantine regulations for restraints. Here if I think they are needed, they go on. I don't have to a call doctor or have the police place them on a psych hold, we just do it and transport them if it's needed.
 
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