Question about possible restraints on a psychiatric call.

[SC Bird]

During my second internship on Friday, we had a relatively slow day. Three calls until about a half hour before I was scheduled to get off shift. Call goes out for an Alpha Response for Psych. - Threatening Suicide. Police on scene. We respond to the location to find two officers already talking to the 20 y.o. pt. inside his house with family present but located in different part of the house. Per family, pt. had been severely agitated earlier in the evening including "tearing up his room, swinging the dog into a wall and threatening us (family) and himself up until the police arrived." Also per family, pt. has history of autism, bipolar disorder, and paranoid schizophrenia.

Pt. admitted to responding officers that he had not taken his medications in three weeks and knew he needed help. (I know from class that admission is key in dealing with behavorial pts.) However, upon our arrival, pt. refused to talk.

Crew chief goes with family member to retrieve medications while myself, another EMT, and two officers try to persuade pt. to go to get checked out at hospital.

Crew chief comes back down and informs myself and the other EMT that pt. has completely destroyed his room and is a first degree black belt and has multiple Jujitsu certificates. Basically he tells me, just be alert and on my toes.

Well pt. finally decides to stand up and begin walking to the truck accompanied by EMS personnel and police. Police perform a quick search to make sure he doesn't have any weapons on him. We get him secured on the stretcher, and transport without any problems. No restraints were used throughout the call...and especially looking back on it, I don't feel as though they were necessary.


This was my first psychiatric call, and I was really glad that I got to observe a patient who presented with more than a girl who just broke up with their boyfriend of two weeks.

While I felt completely safe throughout the entire call, there is still the little part of the back of your brain that sees something like him clenching his fist as he's walking to the truck as a possible sign that this guy might be ready to snap.....or he could have been cold....

So now for my questions....
Are restraints only used when a patient presents aggression while on scene?? Or to EMS personnel/police/etc?? My textbook says that "you may use restraints only to protect yourself or others or to prevent a patient from causing injury to himself/herself."

Could someone offer some insight on when you might see fit to use restraints?? I know some of it is probably shades of gray...

-Matt

 

[Epi-do]

I don't think I would have restrained your particular patient either. Speaking in very broad generalizations, if a ppshcy patient goes willingly, I don't think I have ever restrained one. If a patient has been ID'ed, then it really depends upon the actions of the patient and how much of a rapport I have been able to establish with the patient. Patients that are physically acting out, are being abusive to those around them, etc, most definately get restrained. Granted, part of my protocols state that restraints are for the safety of the patient, but for me, alot of times it is for my protection. In fact, I can't say that I recall ever restraining a patient "simply" for their safety. Psych runs can be complicated, and there are defiantely countless shade of grey involved. I have found that the best thing to do is to just trust your gut/follow your instinct.

 

[SC Bird]

During the whole time we were on scene, he was almost tranquil. Complete opposite of how his family had described his actions pre-EMS/LEO arrival. However, since he had hx of psych disorders, restraining orders against him, and evidence of some martial arts training I was cautiously aware around him. Wanted to give him his personal space (as well as protect my own) both on scene and while in the back of the truck.

Thanks for the reply...

-Matt

 

[MMiz]

It is my policy that:

- If we arrive and a patient is in restraints or being restrained, the patient stays in restraints.
- If we arrive for a BLS transport and the patient is in restraints, the patient stays in restraints.
- Otherwise it's really up to me and my partner. If I'm responding to a location and putting a patient in restraints, I always have PD present. There have been some times when PD has had to step in.

 

[bstone]

When I get to an ER or facility or meeting the cops and a patient is being restrained, I'll take that into consideration but I often will establish a rapport and explain to my patient I have no desire to restain him/her but will if they are violent.

I then take a few minutes to interview them, determine what's going on and assure them I am there to help them. That is usually enough to enable an incident and restraint-free transport.

On my old BLS service we'd get 2-3 psychs per SHIFT. So yeah....I've done a lot of them. The old ladies usually need to be restrained more often than the big, huge men.

 

[skyemt]

after RMA's, restraints are the second leading reason for lawsuits in EMS...
they are to be used (at least in our district) if the pt presents an IMMEDIATE
danger to himself or others... there is no mention of "potential dangers".

if something were to go wrong with the restrained pt, and you could not prove than an immediate threat to your safety existed, it will be an expensive day in court, and the end of your EMS career.

if we feel insecure about a pt such as the one you described, we typically have PD ride in the rig for that very reason.

 

[Ridryder911]

http://www.merginet.com/index.cfm?searched=/clinical/psychiatric/PatientRestraint.cfm

http://www.merginet.com/index.cfm?searched=/operations/field/RestraintIssue.cfm

 

[BossyCow]

I've only had to use restraints twice. Once was an itty bitty little gal who was suicidal. The other was a recreational chemical user.

 

[Ridryder911]

I use restraints at least daily to weekly either in the field, CCU or ER setting. It must be weighed heavily upon the reason, the type and course of the restraint.

We have the policy they are only to be placed upon a patient that may endanger themselves or others. This interpretation as includes "endangerment to themselves" as pulling at tubes, IV's, etc.

With this there becomes proper documentation. Type restraint, length of time, good circulation and sensation distally, as well as no-injuries related to the patient. In hospital, the documentation is MUCH greater as most has to be ordered by a physician (within a reasonable time) and re prescribed (usually it has to be reordered within 12 -24 hrs) to justify restraining. Exceptional charting of the padding of the restraint, ability of circulation, again movement and sensation and offering of toilet. Many might find humorous, but as well most facilities, one must offer secondary choices prior to restraining. Such as discussion of why restraints is needed, etc. May appear silly, but the courts do not think so.

The point I am offering is to be sure you have a policy in place, that each member is properly trained and have demonstrated in training, safe techniques, and then exceptional documentation afterwards.

R/r 911

 

[SC Bird]

I use restraints at least daily to weekly either in the field, CCU or ER setting. It must be weighed heavily upon the reason, the type and course of the restraint.

We have the policy they are only to be placed upon a patient that may endanger themselves or others. This interpretation as includes "endangerment to themselves" as pulling at tubes, IV's, etc.

With this there becomes proper documentation. Type restraint, length of time, good circulation and sensation distally, as well as no-injuries related to the patient. In hospital, the documentation is MUCH greater as most has to be ordered by a physician (within a reasonable time) and re prescribed (usually it has to be reordered within 12 -24 hrs) to justify restraining. Exceptional charting of the padding of the restraint, ability of circulation, again movement and sensation and offering of toilet. Many might find humorous, but as well most facilities, one must offer secondary choices prior to restraining. Such as discussion of why restraints is needed, etc. May appear silly, but the courts do not think so.

The point I am offering is to be sure you have a policy in place, that each member is properly trained and have demonstrated in training, safe techniques, and then exceptional documentation afterwards.

R/r 911

Thanks for the advice on just how precise documentation should be (particularly in this instance) noted.

I appreciate all of the responses.....

-Matt

 

[havok965]

i work in a psych ward, and have dealt with all kinds of combative patients. You wouldn't use restraints until he got out of hand, or at least started to get out of hand. Once verbalizing the intent to harm, then have the right personel to take down the patient, but restraining them should be the last resort. You are taking away their rights as a person, but for the safety of them and others. And i know what you mean by 'being on your toes'.

 

[Onceamedic]

What do you think about the easy, very little documentation required, easy to justify form of restraints - the c-collar/spine board ?

 

[triemal04]

What do you think about the easy, very little documentation required, easy to justify form of restraints - the c-collar/spine board ?

Have you ever tried to take someone who is sitting on the gurney in the back of the ambulance, throwing punches, kicking and screaming, and between you and your partner put them on a longboard?

Just wondering.

 

[Onceamedic]

its as least as easy as 4 points..... gotta control them for a little while.. get some stuff tied down and it gets easy...

 

[triemal04]

its as least as easy as 4 points..... gotta control them for a little while.. get some stuff tied down and it gets easy...

So you've never tried it.

 

[Onceamedic]

nope - thats why i was asking

 

[triemal04]

nope - thats why i was asking

Ok. Sorry. It's not a bad way, but not the best either. To do it will take more than two people...getting the person flat on the ground...onto a board...holding them down long enough for 4-6 straps to be put on...not fun, or easy. But, if you've got the manpower and the room to work (cramped quarters aren't fun for this) then go for it. Toss a couple of soft restraints around the wrists, and you're golden.

When you don't have the manpower, or are stuck in the back of the car with them, use soft restraints, or even flexcuffs if you carry them. Tie the hands to the gurney, then move on to the feet as neccasary. If possible get one arm above their head to limit body movement.

Or just flip them face down, tie the hands behind their back and smile. Course, there's a lot of explaining to do with that way.

 

[Onceamedic]

thanks... appreciate it.

BTW.. we had one patient with BS OD - bunch of her roommate's beta blockers as well as a lot of ETOH. Stong little gal. She pulled her hand out of the leather and messed up her IV. The security guys (this was in the ED) tied her arm up as you suggested. She was on the monitors and her cuff was on the arm that was over her head - needless to say, the BP reading on that arm got a little unrealiable....

 

[firetender]

Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney.

Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...

...and never undersetimate the temporary power of duct tape.

 

[ffemt8978]

Forgive me if this has been mentioned already, I may have missed it, but (and I'd imagine they're still in use), the Ferno-Washington Scoop Stretcher is a great "sandwich board" to lay over the combatative patient once you manage to get him/her on the gurney.

Start by holding the combatative one to the gurney as best you can, then laying the scoop over him/her and strapping it to the gurney, immobilizing the person...

...and never undersetimate the temporary power of duct tape.

And a lot of protocols have been written to specifically preclude you from using a "sandwich" method of restraining a patient due the bad press about it. I have always wondered though, if I would get in trouble for "sandwiching" a patient using two Stokes Baskets and some zip ties. h34r: