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To Restrain or Not To Restrain

121508-Wesley

Review of: Campbell M, Weiss S, Froman P: "Impact of a restraint training module on paramedic students' likelihood to use restraint techniques," Prehospital Emergency Care. 12:388-392, 2008.

The Science

In this study, 34 paramedic students at the University of Pittsburgh were provided a one-hour module by an emergency medicine physician on specific issues related to restraint of the physically agitated, combative or violent patient. They completed a pre- and post-test quiz and then watched five video scenarios to determine whether they would utilize various restraint techniques on the patient.

The areas covered in the module included:

  1. Definitions of delirium, agitation, and violence;
  2. Scope of violence faced by EMS personnel;
  3. Behaviors strongly associated with assaults on EMS personnel;
  4. Intervening with the agitated patient;
  5. Determining mental capacity;
  6. Methods of talking down agitated patients;
  7. When to restrain and when not to restrain;
  8. Do s and don ts of restraint techniques;
  9. The agitated delirium;
  10. Common medical, traumatic, and pharmacologic root causes of agitation;
  11. Proper restraint techniques;
  12. Methods to avoiding death in custody and positional asphyxia;
  13. Appropriate means of assessing the degree of agitation, and
  14. Proper documentation of restraint use.

Post-test scores showed significant increased knowledge and awareness of the issues related to restraint use. However, half of the class was more likely to use restraint on the video scenario patients while the other half were not. Therefore, the authors concluded that the module didn't result in a behavior modification.

The Street

Violent patients represent a major risk to you and are a potential of great liability to EMS and law enforcement. This study is, I hope, just the first in what should be a multiphase, multi-center trial. The authors readily recognize its limitations. The module was presented by an emergency medicine physician. How much more credible would it have been had it come from an experienced veteran street medic? Additionally, this module was provided to paramedics in initial training. We know nothing of their previous street experience. It would be very interesting to repeat this study in a large urban system and correlate the results with years of experience of the medics as well as the possible impact of any violence that any one of them may have encountered during their career.

The worst thing that can happen is for educators and curriculum writers to read the conclusion and dismiss the value of including such a module into both initial and refresher education merely because it showed no change in behavior in this one small group of students. With the mantra of "Is the scene safe, BSI" forever emblazoned in our mine, I believe it's the violent patient for whom we are unprepared that is more likely to harm us than any germ, virus or downed power line.

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