Patient Restraint for Responder Safety
Editor's Note: At the annual Wyoming Trauma Conference in August, Sharon Fluty, of the Poudre Valley, Colo., Health System, and Thom Dick, quality care coordinator for Platte Valley Ambulance Service, hosted a pre-conference session on "Best Practices on EMS." The afternoon session was dedicated to dealing with and restraining violent patients, focusing on the current restraint guidelines being used by Thom's agency, which he developed during his time at Pridemark Paramedic Services in Colorado. In the following article, Sharon highlights some of the key points of the presentation.
By Sharon Fluty
Frequently in the news we read about an EMS worker being assaulted by a patient and it makes us wonder if there are any ways to improve our safety while at work. Obviously restraining someone should be done in order of verbal, physical and/or chemical, with the least amount of force that's deemed necessary to keep the patient and care givers out of harm's way. Restraints, whether physical or chemical, are only used in certain circumstances so that the patient can be transported to the hospital safely, and never as punishment to the patient. Physically restraining a person can be very dangerous and if a takedown of a patient is needed, it should be done by law enforcement.
The times that restraints might be considered are the following:
1. If the patient has a medical or mental condition, is needing transport to a facility and is exhibiting behaviors that may endanger themselves or others.
2. The patient is under a Hold: Mental, Police or Security.
3. If the patient has a life threat and needs immediate treatment and consent is not available or the patient is unable to give informed consent due to injury or illness
When restraining someone, it is best practice to have at least five people to do the procedure, keeping in mind to always treat the patient with respect. Make sure you have your equipment ready (and which should have been checked at the start of your shift to ensure it was all in working order. Always explain what you are doing and why, even is the patient in unable to understand. Platte Valley uses a Level I Physical Restraint and a Level II Physical Restraint system, and the following information is taken from their restraint guidelines.
The restraint guidelines are followed after the patient's medical or mental condition warrants ambulance transport to the hospital and when the patient lacks decision-making capacity, OR there is basis for police custody or a Mental Health Hold to be instituted.
The Level I system is used on patients who are cooperative and not likely to become violent. The patient has been informed and agreed to being restrained for their transport. The crew applies the Posey Velcro ankle restraints and the Morrison wrist restraints making sure that the patient is comfortable. Finally they apply a buckle strap across the patients lower thighs at a point just above the knees and tighten the belt, making sure that the female end of the buckle is face-down to its latch and is not easily accessible to the patient.
The Level II system is used on patients who are uncooperative and/or likely to become violent. The crew gathers a minimum of five people to apply the restraints or they do not attempt the restraining. As before, they gather their equipment and have the pram close, in its lowest position, and with the handrails lowered. They follow the principles of Verbal Judo and ask the following question, "Is there anything we can do or say that will convince you to lie down on this cot and go with us to (the facility)?" If they refuse, then they are told, "We seem to have no choice but to ask the police to force you to go."
Once the patient is under control, four team members should each grasp a distal extremity. The fifth member of the team puts on leather gloves and stabilizes the patient’s head throughout the restraint process. This is done to prevent the patient from biting. Once the patient is on the pram, one of the members on the ankles can straddle the patient’s knees and sit on them, facing toward the foot end, and raise both handrails.
By holding the handrails, the team member can control how much pressure is put on the patient's knees and also frees up the other ankle member so they can start applying the restraints. The members holding the arms should then exchange arms and horizontally cross them across the chest. The member who was at the ankle should now apply restraints — first to the wrists and then to the ankles, one at a time.
The wrists should be restrained using Posey synthetic leather cuffs and straps, and the straps should be fastened with moderate slack to the upper frame rails of the pram, not the part that can be tilted. If the patient struggles, this allows the upper body to be tightened instantly by raising the head end of the pram but it does not restrict the patient’s ability to breathe. Once all four extremities are secured, then the pram strap is placed just above the knees as in the Level I system.
The member at the head should grasp the head with both hands and brace their forearms against the end of the pram. This member needs to constantly be assessing the patient's airway and mentation, while talking to them in a calm voice and reassuring them that the team means them no harm. Don't let go of the head until all four extremities are secured firmly.
Chemical restraints can be considered if the patient continues to be aggressive or even before medical restraints as a way to sedate the patient. Aspiration can occur and constant monitoring and protection of the airway if paramount. Always consider all the possibilities of why a patient might be combative and treat those underlying causes as needed.
Once the patient has been successfully restrained, then the caregiver(s) need to constantly remain with them and reassess them. If they spit, then try and apply a NRB mask or a spit shield. Watch for any changes in mentation, skin color, or any evidence or complaints of difficulty breathing. Any problems need prompt attention. Accurate and complete documentation of the facts justifying the use of the restraints, what type(s) were used, the steps taken and how the patient did after being restrained is absolutely necessary.
We, as caregivers, are always looking for better and more effective ways of protecting ourselves and our patients. As we investigate what other services are doing, we can implement their ideas, whether all or in part, into what our own service is doing and constantly improve our medicine. I have taken what I learned that day from Thom and turned it into my agency for review because I think there is a lot to learn from this restraint system that will foster a safer environment for providers and patients alike.
Sharon Fluty has been in EMS for 25 years and is currently a paramedic at the Poudre Valley, Colo., Health System. She was previously the Saratoga Encampment Ambulance Director in Wyoming.