Physical restraint techniques and procedures are a subject of debate and controversy in EMS. Few agencies have taken the time and energy to research and develop a comprehensive restraint guideline for field providers to follow.
When violent or aggressive patients show up (and they always do) EMT’s are left to fend for themselves. In these situations we take on a great deal of risk, both personal and legal, to bring the patient safely to the hospital.
I’ve had my share of both good and bad take-downs. When things go well the call transitions smoothly from the street to the hospital. The patient stays protected, the prehospital personnel stay safe and everyone goes back in service happy.
When things go badly people get hurt, patient care gets compromised and everyone ends up writing a lot of paperwork. In the worst cases you may end up sitting across from your patient in a courtroom explaining why you made the decisions that you made.
Here are some tips to help make your next patient restraint scenario go smoothly. Follow these guidelines and you’ll reduce the possibility of ever having to explain your actions. If you do end up needing to justify your decisions, you can take comfort in the fact that these gudeliness give you a rock solid foundation of compassionate, patient centered care.
1.) Wait until you have enough resources present that nobody is going to get hurt. (Including the patient.)
EMS tends to be a ready, fire, aim type of industry. We manage emergencies, so we put a premium on speed. Physical restraint scenarios area one of those times when it can really pay off to wait a few extra minutes and get the right amount of resources on scene before you charge in with your Kerlex and nylon.
How many resources do you need? That entirely depends on the size of the patient and the size of the resources (That means you and your buddies.) If the patient looks like Lindsy Lohan you’ve probably got it covered. If he looks like Tim Silvia you’re going to need to make some phone calls and request some people by name.
Don’t do all this while you’re standing next to the patient. Back off and gather your crew. Once you have all the resource to overpower the patient with a shock and awe strategy make sure you …
2.) Have a plan.
Once everyone is there, huddle up and decide exactly what your going to do and when you’re going to do it. Who’s going to lay hands on the patient first? Who’s second?
A whole bunch of people won’t do you much good if nobody knows what they’re doing. I assign people to limbs. You grab his left arm, you control his right leg, I’ll control his head. If were talking about someone big, assign two people to each limb. Don’t forget to assign a floater to hold the pram and fasten the straps.
This should go without saying but, once you have a job, do your job. Trust the other folks on the team to do their job. If you let go of your arm, it’s probably the poor sap still holding on to the other arm who’s going to get punched. Don’t let that happen.
3.) Assign a team leader.
Once the ball is in play, the game is bound to change. Decide who the leader is going to be so everyone doesn’t have to yell and shout when that happens. Assign the leader to the head or a non-wrestling role so she can keep an eye on everything that’s happening. Stick with the plan until the leader changes the plan.
4.) Have a plan B and a bail out plan. (Know your exit.)
If plan A doesn’t work, what is the next best option? How will we know if plan A isn’t working? It’s good to put as many options on the table as possible before the physical stuff starts. It seems like overkill until plan A goes really bad. Then you look brilliant for having thought out plan B.
Any time you have an opportunity to look brilliant take it. There will always be opportunities to look bad later.
Once you’ve established your backup plan, you also need a bailout plan. What are you going to say if you need to cut and run? How will everyone exit? Important point here, everyone needs an exit and you need to make sure the patient doesn’t ever get between you and your exit. Consider this while you’re developing your plan.
5.) Protect the patients airway.
Speaking of looking bad, if you take a patient down and don’t protect their airway, you’re bound to look really bad when they vomit, choke or become hypoxic. Protecting their airway does includes putting them on oxygen as soon as possible, securing them in a way that allows good airway access and unrestricted breathing and making sure you can roll them if they vomit.
It also means never using a choke hold and always opting for supine restraint. Also take care not to place straps where they can work their way across the patients neck. Chest straps need to go under the arms, not over.
6.) Consider sedation if the patient is still fighting after restraint.
Some folks calm down once they become aware that they are completely restrained. Some folks keep fighting. The individuals who keep fighting are burning through a tremendous amount of energy and oxygen. This isn’t a time for high fives and war stories. Pay close attention to fighting patients.
You need to continue to manage their increased oxygen demands, monitor their vital signs and attempt sedation if it’s available.
7.) Pay close attention to any patient who suddenly becomes quiet and compliant.
Patients who are fighting for their lives and then suddenly become quiet and sedate are of particular concern to EMS. Your patient may be worn out and ready to comply or they may be transitioning into respiratory or cardiac arrest.
Whether you believe the controversial concept of excited delirium or not, there is a known pattern of individuals fighting aggressively against physical restraint and then lapsing into cardiac arrest. It has happened enough times to warrant real concern when violent patients become quiet and relaxed. Pay attention and don’t let your guard down.
Here are a few restraint errors to avoid:
Don’t scream “calm down”
I’m not sure why there always seems to be one guy (yes it’s usually a guy) who thinks it will be helpful to scream, “Calm Down!” at the patient. This never, never, never works. Really. resist the urge to be the calm down guy.
It’s usually the guy screaming calm down who needs to calm down the most. Instead of doing this just speak in a clam voice to the patient, even during a take-down. Find the person who’s the coolest cucumber in your group and place him or her near the head to just keep a dialogue going. “Were trying to help you. We don’t want to hurt you. Just relax for us. It’s OK. We’re not going to hurt you. We just need to secure you down.”
This ongoing narrative will also sound much more professional if a bystander starts rolling cell phone video in the middle of your wrestling match. Let everyone hear a friendly, calm narrative instead of a shouting match.
Paramedic Jarbsunthie does a great job of talking calmly to this dude. I would have opted for face up restraint and I think she should have put the chest strap under his arms. (Watch the way it rides up by his neck when he rolls.) But she gives a very nice example of the power of a calm, compassionate voice. Screaming “calm down” would never help this guy.
Don’t give the patient ideas
I’m amazed by people who warn other team members of things the patient might do. Like, “Look out, he might spit.” or “Careful, don’t let him bite you.” or even, “That left wrist strap looks loose.” All of those things can be considered coaching for the patient.
It never seems to fail, as soon as someone warns about spitting, the patient starts spiting. Don’t give them ideas. If you’re worried they might do something, watch out for it and try to mitigate the possibility, but don’t shout it out.
Don’t use arm locks, leg locks, face down restraint, hog tie or sandwich restraint techniques
We already discussed protecting the airway. I’m also not real fond of techniques that are designed to force the patient to comply through pain. Even for police officers who are trained in pain compliance moves, these techniques require skill and ongoing training. Even then, they still tend to be hit and miss.
If you cause the patient pain they are likely to fight harder. Then you apply more pain and they fight harder and then they get injured and you have to explain it to the doc at the ER, or worse. Also, keep people face up. For a whole bunch of good reasons, just keep em face up.
With those guidelines in mind, go get it done. If you meet the take-down challenge with plenty of resources, a good plan and a calm team, everything should go just fine.