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

[Laura Anne]

Doing 911, if I had a patient that was going to cause me or my partner harm, I'd remove my partner and I from harms way. If this cannot be achieved (in the back of the rig), remove the harmful component, AKA, remove them from the truck. If it ever got to this point, Pd would immediately be required to collect the patient. Once restrained, have Pd assist in transport to ER.

I never heard of restraining a person face down on a LBB. Different, I must admit. :?

As far as VS go, you can obtain a set by assessing your patient:

screaming/talking= airway, breathing

once a patient is restrained, check the radial... presence= BP, rate= well...rate!

In doing these simple things, you obtain the basics for maintaining the patient. You don't need a Pulsox or EKG in a case like this because it's not going to give accurate information, which in turn can be more detrimental to a patients well being. Starting an IV is probably just as dangerous, so as long as the patient's basic VS is being maintained, then if meds needed, IM will suffice or just transport to ER. I live in a local where we have 2 ER within 5 mins of any call,so transporting w/o further care is normal because by the time the above are completed, you're at the ER doors.

[Doczilla]

For spitters, the non-rebreather oxygen mask can always be medically justified, and would never be called into question as being appropriate. Surgical mask is not really medically justified, but is harmless as an intervention (it's DESIGNED for people to breathe through it), and may be just as feasible. Pillowcase is probably a bad idea. A full pillow with both hands over it: don't go there, though we've all thought of it.

Agitation and combativeness are signs of a medical emergency, whether induced by substances (EtOH, cocaine, meth...) or by a medical problem (hypoxia, hypoglycemia, metabolic derangement, head trauma) or by psychiatric disease. Agitated delirium is closely associated with in-custody death. Agitation and combativeness are in themselves a medical emergency, and I am a believer in liberal use of medication (benzos, particularly) to treat the condition. I believe the risks associated with the agitation, increased HR and BP, accidental or purposeful self-injury, and sustained physical activity outweigh the risks of the medication. Settling them down with some versed or valium may also permit a more complete medical evaluation and continuous monitoring. Of course, getting a blood glucose level and oxygen saturation and neurological exam are absolutely necessary.

I have also paralyzed and intubated a number of folks in the ER to gain control and allow a medical exam. Refer to local protocols before trying this.

'zilla

[firedoc5]

Since it didn't happen to you, it's never going to, is that it? You think we're making this shit up?

Here, I'll even give you the first few Google hits:

Never said it never happened or that it could not ever happen. And no, I don't think any of this crap is made up.

But if someone is yelling and screaming, you pretty much know that they have a good airway. If they stop yelling and screaming then you can ascertain whether or not their airway is compromised or not. I've never seen someone that has respirations of 12 and shallow being able to screech at the top of their lungs. Have you, CB? And if they are not getting enough air, then they are not going to be able to use up a lot of energy for very long fighting you. It's when they do stop fighting then, like I said, evaluate their resp. status.

Any questions? I'm sure there are. :homework:

[Doczilla]

I have had highly combative, initially thought to be psychiatric patients, with the following final diagnoses:

Spontaneous intracranial hemorrhage

Occult head trauma

Meningitis/encephalitis

Pulmonary embolism

Acute ST elevation MI

Hypoglycemia

Pneumonia

Hyponatremia

Uremia

Sepsis

That doesn't count the folks with known issues (GSW, stab wounds, hemorrhagic shock, pneumonia, CVA) whom I have seen highly combative and required restraint.

Always let these things go through your mind as you are applying the restraints and the meds. Again, it is still medically appropriate to use medication to treat their behavioral emergency (and to allow a complete exam), but never chalk it up to behavior alone without a very thorough eval.

'zilla

[fireflymedic]

+2 Doc - couldn't agree with ya more. When I worked in ER I got to see my fair share of 'em come through that were "socially intubated" due to their mental status. Many had serious medical issues which may not have been detected otherwise (their violence would have prohibited any reasonable exam), others were just *ssholes. On my truck, I don't tolerate violence be it for a medical reason or not. I'm 5'2 and don't weigh enough to fight with someone 6'6 and 350 lbs tanked on meth - that's what the troopers are paid for and I have no problem using them for that. They are there to make sure my butt comes home every night ! I've been in that situation before, and it's no fun. Had the entire cabinet side of my ambulance destroyed. Guy was hurt, I was hurt, and just not a good situation all around. If you can't respect me, or if you have medical/psychological issues to where I can't adequately assess and treat your condition you're winning a round of meds. If I max out what I have available to me to use, and I've got a long transport (ie transfers sometimes 2 hours plus to trauma/specialty centers) then good night, sleep tight. The truck is too small for me to be thrown around and you are compromising my safety as well as your own. Enough said, be safe.

[CBEMT]

If they stop yelling and screaming then you can ascertain whether or not their airway is compromised or not.

:roll:

By the time they're quiet, it's usually too late.

Positional asphyxia isn't about the airway. Their airway is probably fine, it's their breathing that stops.

[firedoc5]

Closed head injury is probably what I saw most with being combative due to trauma. There are a few MVA's I had that really stand out in my mind that we knew it was not behavioral. Those can be difficult because you can't lay them prone.

I never said that all combative patients need to be prone, like I think a few has assumed. If you do have them prone and they stop breathing, it's no big effort to turn them back over.

[letmesleep]

Another question about this topic......Why is it so easy to say never? This is EMS, do any absolutes truly exist? I guess my point of asking the inital question is: If you do have to transport a Pt in prone position, what steps would you take to monitor? Why is it an absolute NO NO? I will concede (for obvious reasons), and I think most of you feel the same that it is not the RECOMMENDED way of transporting. As FIREDOC just stated, not all combative Pts get transported this way, but is it never going to happen? what if it does, how are you going to handle it?

[firedoc5]

Another question about this topic......Why is it so easy to say never? This is EMS, do any absolutes truly exist? I guess my point of asking the inital question is: If you do have to transport a Pt in prone position, what steps would you take to monitor? Why is it an absolute NO NO? I will concede (for obvious reasons), and I think most of you feel the same that it is not the RECOMMENDED way of transporting. As FIREDOC just stated, not all combative Pts get transported this way, but is it never going to happen? what if it does, how are you going to handle it?

You're right, Sleepy, there are no absolutes. You can never say never, and you can't always say always. Each situation is different. Sometimes you have to go with the flow, over come, adapt, compromise. Common sense comes into play. What worked one time may not work all the time. Use experience and training together. That's what I try to emphasize when I'm teaching.

[AnthonyM83]

We have 4 FFs, 2FF/Paramedics, and 2 EMTs to each call automatically, so if we can do it easily, we'll take care of it. If there's any doubt, PD is called.

Depending on how violent or simply resistive patient is, PD might help hold them down, and allow us to work the soft restraints (to the mainframe of the gurney). Or PD will wrestle/taser/handcuff a very violent subject, then place them on gurney, and assist us in switching to soft restraints one limb at a time. Or if patient is really bad and is being charged, they'll just handcuff to mainframe of our gurney.