Don’t hesitate to physically restrain anybody who triggers your Spidey-sense. Restraints don’t have to be painful or even uncomfortable. When you use them, incorporate all the cot’s safety straps. Photo Thom Dick
When was the last time you attended a talk on psychological transfers? How about the last time you ever even heard of such a talk? I can’t even guess how many hundreds of times I’ve personally transferred people with behavioral issues between facilities in the middle of the night. There was a raging value conflict in those days between people who had fought for their lives in World War II and their children, who were being forced to fight for something much more nebulous in a faraway place called Vietnam. It was also a time of widespread use of amphetamines, barbiturates, narcotics, cocaine and a whole array of psychogenic substances. When we transferred those folks, it was standard practice for the discharging facility to seal the transcript before they gave it to us. And, standard practice for us not to open it—or else.
You’ve probably heard there’s a recession, Life-Saver. I don’t know if you’re seeing what we’re seeing, but we’re seeing a lot of angry, scared and disoriented people, beset by circumstances they didn’t necessarily create. Our little town’s behavioral emergencies have increased 100% since 2008, while our community hospital’s ED has one psych bed. One. So once more, our crews are transferring lots of psych patients. Behavioral emergencies can be simple, or they can be immensely complex. You don’t have to be a genius to understand that scared people can be very dangerous just because they’re scared. They can suffer from the effects of external factors that have nothing to do with medicine, like the loss of a job, a home and a car. Throw in a divorce, all in the span of a year, and you can expect them to be devastated. They’re the ones who need your kindness as much as anything. Others suffer from internal factors, such as imbalanced chemicals in their brains. In the span of a one-hour transfer, you likely don’t have the wherewithall to assess or alleviate those kinds of problems.
I think you deserve to know everything the discharging facility knows about any patient for whom you accept responsibility. You should definitely read the transcript before you even meet the patient. It should describe circumstances, suicidal risk, flight risk, medications and behavioral history prior to and during their stay in the ED. (If it doesn’t, you should ask and expect a straight answer.) You also deserve to know whether they’ve been treated with physical or chemical restraints prior to your arrival.
One of the best things about being with JEMS for some 30 years is I’ve met a lot of wonderful people. Aside from having a fine name and spelling it properly, Dr. Thom Dunn is one of them. Thom is not only a seasoned medic, but he’s also a licensed clinical psychologist. A couple of years ago, he gave the only talk I’ve ever heard on psych transfers (and behavioral emergencies in general). You may not have ready access to Thom’s work, but you can access a great article he published on the subject in 2008.1 It’s full of practical suggestions that could only have come from someone who has handled his share of these potentially high-risk calls.
Thom’s suggestions include the following and numerous others:
1. Dispatchers and supervisors should choose experienced crews, not neophytes, to transfer patients with behavioral issues;
2. A patient who presents in physical restraints should stay in physical restraints;
3. Ask every patient in advance: Are you planning to harm us or try to escape?
4. Warn every patient in advance: Touching the buckles will be perceived as an ominous behavior;
5. A physically restrained patient’s hands and feet should be kept visible during transport;
6. Get into the habit of turning your strap buckles upside down on the cot. It gives you a few seconds’ extra warning if a patient acts to unbuckle them;
7. Watch the patient’s eyes. If you notice them sizing up your location in the patient compartment, consider the possibility they’re considering an attack or an escape;
8. If you’re wondering whether or not to physically restrain, restrain;
9. Incorporate the cot’s buckle straps—all of them—into every application of physical restraints;
10. Beware of physically restrained patients who attempt to negotiate their way out of restraints; and
11. Exercise special caution any time an ED staff seems especially anxious to discharge a patient with a behavioral issue.
1. Dunn TM. Handle with Care: The challenges of transporting suicidal patients. JEMS. 2008;33(10):86–92.