YOU, THE VIOLENT PSYCH, AND THE RESTRAINTS.......

[JPINFV]

Protocols:

restraints PRN on patients on holds or who obviously lack the ability to refuse treatments (implied consent). Restraints should be 4 point, non-locking and have the ability to quickly release them. No handcuffs unless the police are either transporting with the patient or (acceptable, but not suggested) following behind the ambulance in the squad car. Leather restraints or nylon restraints are fine. No hog tie, restraining prone, or sandwich allowed (positional asphyxia. Hey, if it didn't happen then it there wouldn't be death, lawsuits, or rules against it). Paramedics do have the option of chemical restraints, as well I've transported many a psychiatric patient who was given a sedative immediately prior to transport. The county I worked in had zero rules requiring restraints, unlike a county next door (there, any patient on a hold was supposed to be given 2 point restraints as a preventative measure). Continuing assessment should include extremity checks for PMS q 15 minutes in addition to immediately after application of restraints.

Personally, I do my best to not need restraints in the first place. If that means that I can catch a trigger (had a patient where any discussion eventually led to him becoming more agitated. That was a very quiet transport) and keep from hitting it, then I make sure not to hit the trigger. If that means that my patient gets an extra pillow, then he gets an extra pillow. A happy psychiatric patient is a quiet and calm psychiatric patient (you can't make all patients happy though). This also means that if the patient wants to go to a different hospital (for example, one 5 minutes further down the road) and the facility has no real objections, then I have zero problem honoring the patient's request.

On the other hand, if I pick up a patient that is currently being physically restrained (say, hand cuffed), then I will continue restraints. This alone is the only automatic restraints situation that I can think of. Otherwise it comes down to the patient's actions/activity/state of mind, the report I receive from the staff/on-scene personnel (has this patient been violent? agitated? etc.) and how my partner and I feel about it. I'd rather not restrain if I don't have to, but I have no problem restraining if need be. Furthermore, restraints should be done properly. Best setup is 9 people (person to hold each limb, person for the head, and a person to apply the restraints), but this can obviously be cut down [significantly] depending on the situation, patient status/size, and who exactly is on scene.

:steps onto soap box:

To be honest, anyone who thinks that all psychiatric patients need restraints is an idiot. Similarly, anyone who thinks that all psychiatric patients need to go by police is also an idiot. There is a time and a place for restraints and a time and a place for police. Psychiatry is a medical field (medical, as in the second word in Emergency Medical Service), and there are psychiatric emergencies (emergency, as in the first word in Emergency Medical Service), therefor EMS is the proper place for these patients (proper place, as in primary service. Not to be confused with "don't draw upon available resources such as police). Law enforcement. Notice the lack of the terms "medical" in the name.

:steps off soap box:

[Richard B the EMT]

With going home in more or less the same condition I started the shift as priority one, if I feel threatened by the patient, I unapologetically will back out, and await the restraining of the patient by the LEOs.

If the LEOs (reference here is the NYPD) cannot handle it, under their policies, they call in the Emergency Services Unit. Using their training and specialized equipment, they eventually will put the patient into a restraining body sized "bag", which then goes onto our (FDNY EMS) stretcher, and we all go to the Psych ER. After the facility doctors get the patient on tranquilizers, "chemical restraints", or whatever, we take the patient out of the bag, leaving them in the "rubber room", for the hospital's further evaluation and whatever treatment decided on.

I have been on only 2 of those calls from 1973, and was frightened by the patient's violence, or exhibited potential violence, on both of them.

[Eydawn]

Think about how the respiratory process actually works... when you breathe, your ribcage expands outward and upward. Now think about being restrained forcibly in a prone position and how that might affect expansion.

It's not just about airway. It's about positional asphyxia. That's why we never do prone now.

And there are so many factors that go into whether a prone position results in harm... why take the risk? There's a reason I'm no longer allowed to restrain clients on the floor in my job... period. I can put them in a seated upright position if I have no other option... but I have to defend it afterwards.

Wendy

CO EMT-B

[ERDoc]

Food for thought:

http://www.ncbi.nlm.nih.gov/pubmed/9200808...Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/9360565...ogdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/1532245...ogdbfrom=pubmed

[Don1977]

Police matter.........

[jsadin]

In regards to the medical patient that is also an uncontrollable psych: the PD is simply there to assist in getting them restrained. Once I have them restrained then I can start treating properly.

I don't think I've seen anyone saying that all psych patients get a PD response....only the ones that want to harm/kill us. I've only had one of these that posed a real threat (maybe two) and he wasn't restrained. He only became agitated when we were close to our destination. He also outweighed me by about 75lbs and spent most of the ride regaling me with stories of how he had dreams of killing the staff at the psych facility we're heading to. :shock: That was the longest transport of my life....

[fireflymedic]

As far as psychs and deaths due to positional asphyxia it's not just due to being placed prone. It's the position their head is in. Also, some succumb to cardiac arrest due to the combination of drugs in their system in addition to the struggle they present to EMS/PD. Best approach with this situation is to administer some form of chemical restraint with the least amount neccessary to do the job effectively. Then apply appropriate restraint (I'm a fan of spider straps and tying the hands as if I were gonna fly 'em) maintains good IV access, appropriate restraint, and much more difficult to get out of as well as providing restraint to key areas preventing bending of knees and arms and raising of head, neck, and chest. An alternative if you don't have spider straps is to apply cravats across the chest, knees, ankles, stomach and tape head down. Take one arm and secure to head of stretcher behind patient's head and the other to the side rail. Prevents them from using both major muscle groups. Both work quite nicely and are considered appropriate restraint.

[Mateo_1387]

:takes JPINFV's place on the soap box:

:steps onto soap box:

Psychiatry is a medical field (medical, as in the second word in Emergency Medical Service), and there are psychiatric emergencies (emergency, as in the first word in Emergency Medical Service), therefore EMS is the proper place for these patients (proper place, as in primary service. Not to be confused with "don't draw upon available resources such as police). Law enforcement. Notice the lack of the terms "medical" in the name.

:steps off soap box:

I would say generally what you stated above is true.

I am not trying to nit pick, but your logic of psychiatry being medical, there are psychiatric emergencies, therefore emergency being in EMS automatically makes them our patient. I do not see where keeping peace and order is in the job description of Paramedic, so if a patient is violent (threatens my life, physically Fighting me, no combative due to a medical problem (there are some exceptions)) then they can go with the police department. Again, the goal is to go home every night.

I hope this does offend you, it is just something I felt should be said.

:steps off the soapbox, then slips and falls: :shock:

[EMT347744]

When we run on psych patients, and not all psych pts are combative or wanting to harm anyone...actually let me rephrase; When we run on any pt that has the outward propensity to become or is already combative or threatening, they will be "assisted" to a backboard already placed on the stretcher with 4 point soft restraints waiting close by. At that point, the 4 straps on the backboard, additional 5 straps to secure them to the stretcher (we have 4 point shoulder straps on our stretcher as well), head blocks and then the 4 point soft restraints attached TO THE BACKBOARD so as not to hae to fight with them a 2nd time around to transfer them to the hospital bed, this pt isn't going to do much. And if that all does not work, we will have fire ride in as a "restraint" and pd to follow. we generally don't bust out the chemical restraints. In our system we have to call for orders from our doc, and since we have 12 hospitals in our county chances are we will be in the ambulance bay before the meds are drawn up. Thats how we roll...lol

[JPINFV]

:takes JPINFV's place on the soap box:

I would say generally what you stated above is true.

I am not trying to nit pick, but your logic of psychiatry being medical, there are psychiatric emergencies, therefore emergency being in EMS automatically makes them our patient. I do not see where keeping peace and order is in the job description of Paramedic, so if a patient is violent (threatens my life, physically Fighting me, no combative due to a medical problem (there are some exceptions)) then they can go with the police department. Again, the goal is to go home every night.

I hope this does offend you, it is just something I felt should be said.

:steps off the soapbox, then slips and falls: :shock:

It takes a lot to offend me and the first time I get offended simply because someone disagreed with me will be when I stop posting on internet forums.

The biggest part of my argument wasn't the "emergency" part (that was more of a counter to people who say that psych patients don't count as an emergency), but that pysch patients are a type of medical patient. While I do agree that the number one priority is to go home at the end of a shift, there are risks of the job that are tacitly acknowledged by simply showing up. I'll go out on a limb here and say that police and fire fighters all want to go home at night as well, but that their jobs also are dangerous to a point that no preparation, planning, or training will fully eliminate all danger and risk.

Now if a person is being violent not due to any medical condition (including, but not limited to, psychiatric issues), then I agree that the proper service is law enforcement. On the other hand, if a person is being violent due to a medical condition (again, including, but not limited to, psychiatric problems), then the primary service should be EMS with law enforcement assisting as needed.