Patient restraint: Protect yourself from the predictable fallout of public misperception

Justifiable and properly executed patient restraint, within protocol guidelines, never looks good to the lay public

Restraining a combative patient is a necessary part of the job for EMS providers. Properly executed on the appropriate patient, restraints serve to protect both the patient and the provider – and in many cases, the public. Unfortunately, in the wake of numerous patient-restraint-related "incidents," it’s essential that providers be reminded about certain realities.

No matter how properly one applies restraint techniques, it will always look bad to the untrained, inexperienced eye. It will look even worse on YouTube or Facebook with an inappropriate caption and no context.

Nevertheless, EMS providers cannot be dissuaded from doing the right thing simply out of fear of misperception. Instead, EMS providers must follow EMS rule #2: "Quod vos postulo facere" which is Latin for "do what you need to do." (The first rule, of course is: "Primum non nocere;" first do no harm)

Following these three steps, I believe, can best protect the provider from the predictable fallout of public misperception associated with patient restraints.

1. Know and follow your policies

Every EMS agency has policies and procedures directly addressing the issue of patient restraints. If your agency does not have a written patient restraint policy, it’s time to start writing one.

The policies controlling when and how to apply restraints to a patient should be clear; each provider must know them, understand them, and follow them in every situation. Of course, nothing in EMS is always black and white, especially when it comes to restraining a patient, EMS is the original 50 shades of gray.

In those instances that are not clearly addressed in the policies and procedures manual, the standard for behavior is "reasonableness." Generally speaking, a provider may act – in all situations – as would a reasonable, prudent, sober EMS provider with the same level of training and experience, in the same locale, under similar circumstances. There is no one right answer.

Typically, a provider is permitted to apply only the amount of force reasonably necessary to subdue and secure a patient in order to protect the patient and the provider(s) from harm. Likewise, a provider is generally permitted only to apply approved techniques and devices when restraining a combative patient.

In most areas, hogties, for example, have been banned because of the incidences of secondary complications. Soft restraints, on the other hand, are still widely used and can be effective.

Lastly, in my humble opinion, the first and best restraint tool – when the situation allows – is de-escalation. It seems that so many providers prefer to jump quickly to the more aggressive modalities, but if we can talk a patient down to a calm and non-combative state, everyone wins. If de-escalation doesn't work, "Quod vos postulo facere (do what you need to do)."

2. Document, document, document

After you have acted reasonably and in compliance with established protocols, policies, and procedures, you must thoroughly document EVERYTHING!

In addition to the documentation already associated with assessment and treatment, documenting patient restraint is essential and cannot be overemphasized.

Unfortunately, as much as we hate the idea of it, EMS providers, like every other professional, must consider the legal ramifications of our actions. Providers must be prepared to justify everything they do with facts and reason, not speculation and opinion.

When documenting patient restraint, capture what you did; how you did it; when you did it. These are all vital pieces of information necessary to protect yourself from unfounded complaints or actions.

The most important question to answer, though, is WHY you restrained the patient. Your documentation should include objective information on why it was necessary to restrain the patient; including the potential harm of not doing so – and that explanation must be reasonable.

Lastly, be prepared to testify to everything you did, whether you documented it or not, which is true of every call.

3. You are being videoed

There are more cameras monitoring the everyday movements of citizens than George Orwell could have ever imagined. The human surveillance of the dystopian future he predicted has progressed well beyond Big Brother.

Video recording devices are everywhere and YouTube (along with the myriad other outlets) has proven that they are all pointed at us. It is well within the realm of possibility that your conduct on any given scene will be recorded, uploaded, and viewed by hundreds or thousands of people before you arrive at the hospital with the patient.

By the end of your shift millions of people might have viewed whatever the video uploader wanted the world to see; context be damned. Worse yet, the content of the video (read: your conduct) is analyzed, dissected, and judged long before all of the facts are known.

For some, this reality is frightening; for others it’s motivating. For me, this reality is just that, reality. And reality is the ever-changing barrage of circumstances that make life interesting. It’s not to be feared – it’s just to be lived.

If every provider simply operates under the assumption that a live feed to the internet is capturing their every movement, then it should be pretty easy to do the right thing. And if you have to restrain a patient, then restrain a patient – as if you are restraining a patient on live TV.

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