Tie Them Up or Run?

I was recently asked about restraining the combative or disoriented patient. The practice of patient restraint is one of the more dangerous things a Medic can be called upon to perform. It should always be very carefully considered, and even more carefully monitored. Here is what we know. About a half dozen patients every year die while restrained. Tying people up can be very dangerous to their health. Even the use of Chemical Restraints is dangerous and except for in a helicopter, usually unwarranted.

There was a day; I thought “playing with drunks” had an entertainment value. Forget the “cowboy” mentality, and view patient restraint as a dangerous practice with potentially fatal complications. EMT’s get hurt every day trying to do it. Patients get killed. Medics get sued, and lawyers get fat. Walk away. Yep, that’s right, I said walk away. Run, if you have to.

If you are confronted with a situation where you are considering the restraint of a combative patient ask yourself first why. Who is really at risk here? Is the patient really at risk of hurting himself or herself? Look for signs of self-damaging behavior, cuts, bad scrapes, and fresh bruises. If there are none, then ask yourself again, are they in immediate risk of hurting themselves? If not, they are not your responsibility.

Next ask yourself, are they about to hurt someone else? Is there a reasonable risk someone is at immediate risk of bodily harm? If yes, this means it’s time to get the guys with pretty badges and guns. Anyone who poses a danger to the public is also not your job. Police Officers have years of training in the appropriate use of force. They and only they, have the tools and training to SAFELY restrain someone who poses a danger to others.

Let’s assume for some reason patient restraint is unavoidable. How should you perform patient restraint? Always restrain the patient on their back. Never, ever restrain a patient face down. Never ever place anything on top of them. The myth about putting them face down with a scoop stretcher on top is a dangerous one. The primary reason people die while being restrained is suffocation. Always be able to continuously monitor the patient’s airway and breathing status. Always use enough people to effect restraint safely. If you do not have at least four people available (one for each extremity), call for help and wait until you do. When in doubt, see paragraph two.

I developed a well thought out restraint system for EMS use some years ago. I wanted one that worked on an ambulance cot, and kept the patient secure during the transfer to the hospital bed. It needed to lock fast, without a key – and it needed to be easy to clean. I developed the EMS Restraint System with a company called Human Restraints. They have been in this business for many years, and they did a great job on the product. But not many EMS services bought them, so I don’t know if they are even still available.

I can’t advise any common device or technique, because they are all bad. Handcuffs and Nylon Ties create some nasty injuries that I hate having to explain. Kerlix and Cravats are entirely dependant on your knot-tying skill, and usually a mess. Most hospital/extended care restraints were intended for a demented granny, not a 6 foot wacko on Steroids and Meth. Typical leathers are painfully slow, and the straps are way too long for a cot.

Unfortunately, this issue is still pretty low on the national radar. I doubt any serious efforts to improve pre-hospital restraint devices will be undertaken until a few more patients die needlessly. Until then use plenty of people, or use the Police. It is not your job to secure the unruly. Instead, I suggest you run away. Once you are safe radio for help.

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About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I write about EMS Technology on the Paramedic Blog, the Insights on Innovation column for EMS1.com, on AmbulanceWorld.com and Multibriefs.com. I work for Intersurgical, Inc. managing EMS sales and distribution. I can be reached directly at 573-240-0002. Follow me @Paradan on Twitter
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4 Responses to Tie Them Up or Run?

  1. Nae says:

    Dan ~
     
    Thank you for the GREAT explanation.  Run away.  I can do that.  Leave the doped up people in the ambulance and let the police take them to the hospital in their vehicle.  I can do that too. 
     
    I have been off the radar finishing up my schoolwork and starting another grant project.  Still trying to decide whether or not to go up for EMT II.  I don\’t feel like I have enough experience with EMT I, and so am not sure whether or not it would be a good idea to take on more responsibilities when I\’ve only been responsible for one (very minor) patient\’s care in the back of the ambulance by myself.  Generally, I don\’t think for myself.  The ALS tell me what to do and I do it.  SO … I\’m not sure that I would actually do what I\’m supposed to if a EMT I were looking to me for guidance. 
     
    Thanks for the great blog!  I appreciate the lessons!
     
    God bless you and keep you,
     
    Nae  :o)

  2. Eric says:

    Our protocol states that if we have patient who is in handcuffs, an officer must accompany the patient, in case we have to remove the handcuffs to do any treatment.
    We use Posey soft restraints for our physical restraints, and our protocols pretty much state that they are only to be used if there is any danger to the patient or our crew.  I must disagree with your statement
    "If there are none, then ask yourself again, are they in immediate risk of hurting themselves? If not, they are not your responsibility.
    Next ask yourself, are they about to hurt someone else? Is there a reasonable risk someone is at immediate risk of bodily harm? If yes, this means it’s time to get the guys with pretty badges and guns. Anyone who poses a danger to the public is also not your job. Police Officers have years of training in the appropriate use of force. They and only they, have the tools and training to SAFELY restrain someone who poses a danger to others."
    I feel that if we are called to any scene to manage a patient with a medical problem, then that patient IS our responsibility.  It does not mean that we cowboy up and put ourselves in danger.  I also feel that just because a person is a danger to the public it is not our job.  It is our job, and we partner with other emergency services responders to get the job done appropriately.  I agree that the police have years of training, but as we have seen, it\’s not always safe for the prisoner.  With new education regarding positional asphyxia, excited delirium, and in-custody deaths, we can prevent further problems, as long as we work with the police and provide the appropriate medical care, always while staying safe.  We should always be monitoring ECG, SAo2 & EtCO2.  Have an IV in place "just in case".
    I agree that Flex Cuffs (nylon ties) are cruel.  We have been looking at different ways to restrain people, and we\’re actually thinking of going back to leather restraints.  Yes, they take a long time, but they are safe and strong. 
    This is an interesting post.  I\’m sure that there are many more opinions out there, and I\’d like to hear them.  Thanks for opening up the dialogue!
     

  3. Dan says:

    Eric,

    I really can’t disagree that much with most of your points. The driving energy
    of the post was to try to warn of the many dangers of Restraint, and to get
    folks NOT to "cowboy up and put ourselves in danger ",
    as you put it. I’ve seen & done too many stupid things myself, when it come
    to this topic. Sometimes I\’m prone to exaggeration. That\’s why I love the web.
    I do a new post, and then over time edit my more extreme embellishments :>)
    I just wanted to make a point about how freaking dangerous patient restraint
    can really be. On taking the handcuffed patient with a cop, we will have to
    Agree to Disagree. I’m pretty firm on they are my patient or your prisoner.

    When
    you say you are about to re-consider leathers, you are probably on the right
    track. Check out the Human Restraints link. They have a neat Polyurethane
    material they use on some leather style restraints. My old EMS Restraint System
    used their waist belt with integrated cuffs. The lock can be left open, and
    then quickly locked later without needing to use the key. That is a big plus.
    If you have the hands secure in front of the waist, you can monitor vitals and
    also transfer the patient safely when you get to the ED. Hobble the feet
    together the same way, and secure them to your litter on their back. This
    system was basically a two-piece leather restraint system, made from easily
    cleaned synthetics, with short nylon loop end speed-clip straps to secure the
    waist belt and feet restraint to the cot, in a small bag. Call them, they might
    remember it and still be willing to make and/or send you a set to look at.

    Nae,

    The way you are working as a "Paramedic Assistant", sometimes leaves
    one short when it comes to learning how to run things. But don\’t kid yourself,
    you are learning more & more with every new call. It has its plus sides
    too. You get to acquire clinical experience without being thrust too early into
    the role of primary caregiver. You learn without as quite as much anxiety.

    Don\’t worry about the added responsibility if you do
    elect to move up to EMT-T II. Good horse sense, some courage, and a few
    parenting skills can go a long way in EMS. I\’m sure you would be fine working
    with new EMT’s. You raised a daughter alone in Alaska right? You have probably
    done lots of stuff that would make many EMT-P’s in the Lower 48 run screaming
    for help. I’m sure you already have a lot to teach.

  4. Eric says:

    Thanks for the discussion, Dan.  I totally agree – somebody (like a lawyer) is the only one who stands to benefit from most restraint issues.  This\’s a really good way to cause harm to somebody, and end your EMS career.
    As far as the patient/prisoner issue, I\’d like to briefly discuss a case from just last night.  We were called to a car crash that followed a pursuit.  The car ended up flipping end over end, and the driver (and sole occupant) crawled out of the car and was Tased by the deputy.  When we found him, he was handcuffed and in the back of the police car, bloody.
    We transported him, and in fact, made him a discretionary trauma entry based on MOI & alcohol.  The cuffs were moved around to the front, and he got backboarded.  We transported him with a police officer in the back with us.  I think that the fight was out of him, but because he was initially Tased, I feel that there was potential for more violence.   There was an excellent article in the May 2005 issue of JEMS, and we wrote a protocol largely based on information from that article.
    So the dillema is – he\’s in custody, he\’s been in a significant car crash, and Tased.  He needs transportation and evaluation by a physician, but he\’s in custody.  Do the cops \’unarrest\’ him?  Do they transport in their patrol car?
    Oh, and exaggeration can be good too!  It\’s sometimes a way to drive home your point.  I love the web, too.  Take care.
     

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