Restraints- Houston we have a problem....

[DT4EMS]

Houston.....we have a problem!
I have spent about 14 years speaking on restraints and the pitfalls of restraining a patient. I have recently discovered that the problems facing EMS/Fire and the healthcare community is more widespread than I initially thought.

When it comes to placing a patient in restraints, the mechanical/physical application of the restraints is an issue all unto itself. The problem I want each of you to look at in your area is protocols.

Many protocols list the reasons for the application of medical restraints. These issues are supposed to be due to a condition requiring medical attention i.e. head injury, post intubation etc. The basis is to protect the "patient".

Many protocols have gone a step further and added the "protect the provider". I am no attorney, but I am a subject matter expert in the EMS use of force. The application of restraints to a person, to protect a "provider" now enters that provider into an area of "custody" of a person, not "care".

Let's take a look at Missouri's' "Law", particularly the portion, that covers the use of force to restrain a patient:

Missouri R.S.M.O. ( 563.061)
Use of force by persons with responsibility for care, discipline or safety of others.

4. The use of physical force by an actor upon another person is justified when the actor is a physician or a person assisting at his direction; and

(1) The force is used for the purpose of administering a medically acceptable form of treatment which the actor reasonably believes to be adapted to promoting the physical or mental health of the patient; and

(2) The treatment is administered with the consent of the patient or, if the patient is a minor or an incompetent person, with the consent of the parent, guardian, or other person legally competent to consent on his behalf, or the treatment is administered in an emergency when the actor reasonably believes that no one competent to consent can be consulted and that a reasonable person, wishing to safeguard the welfare of the patient, would consent.

5. The use of physical force by an actor upon another person is justifiable when the actor acts under the reasonable belief that

(1) Such other person is about to commit suicide or to inflict serious physical injury upon himself; and

(2) The force used is necessary to thwart such result.

6. The defendant shall have the burden of injecting the issue of justification under this section.

Source:
http://www.moga.mo.gov/statutes/c500-599/5630000061.htm

Some important things to ponder:

· Notice the need for CONSENT?

· Where is "protection of the provider portion?
I have contacted several agencies both EMS and Fire regarding this very issue. I have also consulted the Missouri Bureau of EMS. The Bureau responded with recognizing the conflict between "protocols" and the law.

I would strongly consider you to think about this:

If you have a person who you are trying to restrain because you believe they are trying to hurt you...... leave the scene. Let the police or trained security handle the restraints. The possibility of a person suing you and your agency for felonious restraint is a very real possibility. As a healthcare provider, you do not have legal authority to restrict a person's freedom of movement. That is custody, not care.

If you would like to do some research on the "protocols" in your area and find out how they match up in your area with the law please tell us about it.

What kind of issues have you come across in your area regarding restraints?

 

[JPINFV]

The first thing we need to do in qualify what type of violence and why the patient is violent. There's a huge difference between a patient in delirium randomly swinging their fists around and a patient with paranoid schizophrenia who's in full control of his body (even if not his mind) who's standing in a fighting stance issuing threats. I'd say that both need restraints, but one is a patient that a medical team providing restraints shouldn't need police/security assistance (assuming no problems with manpower) and the other does.

In terms of custody vs care, you can argue that any patient who is not competent due to either age or disease who is in the care of a medical team is also in the custody of the medical care team. When I transport a patient on a pyschiatric hold, that patient is both in my care AND custody since either a police officer, a physician, or a member of a mobile psychiatric assessment team has deemed that patient unable to make their own decisions, including the ability to refuse medical care.


As far as consent, the state law covered that one.

or the treatment is administered in an emergency when the actor reasonably believes that no one competent to consent can be consulted and that a reasonable person, wishing to safeguard the welfare of the patient, would consent.

Finally, the safety of the patient and the safety of the medical team is one and the same. If the patient is a threat to the medical team (but not directly a threat to himself), then he is impeding the ability of the medical team to provide care. By impeding the ability of the team to provide care (including care that might reverse the delirium), the patient is ultimately being a danger to his own welfare.

 

[LondonMedic]

In terms of custody vs care, you can argue that any patient who is not competent due to either age or disease who is in the care of a medical team is also in the custody of the medical care team.

Wait, what?

 

[JPINFV]

How many 12 year olds do you know with, say, Alzheimer's or other progressive neurological disorders? I could have probably been a little clearer, but I wanted to differentiate between progressive and acute diseases.

 

[lightsandsirens5]

How many 12 year olds do you know with, say, Alzheimer's or other progressive neurological disorders?

Errmmmmmmm.......ummmmmmm......I.....wellllllllllllllll.

Excellent point.

I totaly agree with your post. I have almost been bitten by that. Not calling in a LEO whin I probably should have. Someone like the second person you described has simply lost touch with reality. Their unconscious mind is still fully operational with respect to defending themselves and/or attacking you. While their perception of the situation is way off, their response to that situation may not be too far from what they would do if their imaginary situation was real and they were thinking rationally.

 

[DrParasite]

I have NEVER restrained ANYONE by myself. if law enforcement is there, they are the ones who do the restraining.

I have, however secured patients to the cot. this usually involves the three seatbelts, but it can often mean securing their arms and legs, so they don't fall off the cot while they are flailing their arms. Sometimes their extremities get secured to a backboard for the same reason.

Restraints are only put on by law enforcement

actually, I lied, I have restrained one patient. it was a psych transfer, not really a crazy, but more of a PITA. he wanted it known that he was going against his will. he was calm, respectable actually. we called the doc, he said to restrain him for the transfer. pt hopped onto the cot, we tied his legs down, had an uneventful transfer. he wasn't violent, just very insubordinate, and wanted to make sure everyone knew that he was not consenting to this. and we transported with a copy of the doc's written order.

So I guess those are the two exceptions, when a doc writes a written order for restraints, and when LEO deem them necessary.

 

[JPINFV]

So if you're on in IFT psych transport and determine that the patient on a psych hold needs to be restrained, you're going to call the police to the facility? What if you're doing a transfer with a patient wearing a 'posey' style vest restraint?

 

[DrParasite]

if the person is in a psych facility, generally they have security or their own law enforcement agency. and if a doctor says to restrain the person, usually it's the job or security and/or the facility PD to handle restraining people. And if during a transport it is determined that a patient is becoming a threat to others, then either LEOs are called to restrain people, or the patient is secured more securely to the cot until assistance can arrive. and yes, that is how my documentation is written.

and I have never transported anyone in a posey vest, so I can't comment.

 

[Shishkabob]

I transported a psych patient yesterday who was under court order containment, where it didn't matter where he wanted to go or do, the court said it was up to the healthcare providers.


I could have done the physical restraints had I wanted to, or gone a step further and done chemical restraints to make him go nighty-night during the 40 min transport, but I opted to not do either of those, just talked him down to a calm level, and transported.


I had a talk with the patient before we left (who was fully AOx4, and with it) stating I could restrain him if I wanted, but I didn't want to, and as long as he was calm during transport I'd treat him like a human (obviously in much more tactful language...). We ended up chatting the whole time (turns out he was raised 15 minutes from where I was)

Granted if he jumped from the rig I would have been screwed come court time, but I used clinical judgment not to, as I spoke with the nurse and she said he's never been violent, just loud. I had Haldol and Valium ready in my pocket if needed.





So YES, I do have the right to physically and chemically restraint patients in the state of Texas against their will for my protection. You can't always leave the scene, and you can't always forget about the patient, and it's silly whenever I hear someone say that, be it with psychs or just combative patients in general.