Of all the topics in EMS education, patient restraint is probably the most important and least stressed topic for all levels of providers. Encountering a patient who requires restraint is one of the rare situations that increases risk for both providers and the patient. Beyond the physical risk of injury, an improperly handled patient-restraint situation puts the provider and organization at risk legally and in the court of public opinion.
EMS education, however, doesn’t adequately address this controversial topic. The National Association of Emergency Medical Physicians (NAEMSP) has developed a position paper on the topic of patient restraint.(1) The paper does an excellent job of identifying the scope of the issue and pointing out steps EMS systems should take in regard to protocols and procedures. Although the position paper states medical directors should “provide training,” it doesn’t define what that training should be. It’s up to the EMS educator to tackle this difficult, multifaceted educational issue.
When you look at the topic of patient restraint, you initially think of the psychomotor skills involved in properly applying and assessing appropriate restraint to a combative patient. However, when you break it down to its component parts, you realize the process covers nearly every topic of EMS education:
- Medical and legal issues;
- Medical ethics;
- Ambulance Scene safety and assessment;
- Patient assessment;
- Psychological causes of combative patients;
- Proper team patient-restraining techniques;
- Chemical-restraint pharmacology (for ALS providers);
- Airway control;
- Reassessment; and
These topics teach the student about the complex issues involved in patient restraint and ensure the students’ safety and allow for them to properly assess and comprehend the situation. Without a proper assessment of the scene, the situation and the patient, an appropriate treatment can’t be developed.
This is also where the two most important points are delivered to the student. The first is that this is a patient they’re treating, not a criminal, and the combative issues are a symptom of their illness or injury.
The second is that alternative treatment modalities exist, which may avoid the use of patient restraint or make it safer.
When I teach rapid sequence intubation (RSI), I tell my students to make the patient convince them of a need for RSI. The same tactic could be applied to the use of patient restraint. By correcting a treatable metabolic condition or using verbal defusing techniques, the provider can lessen the use of restraints. A verbal defusing technique may cause the patient to not turn anger to physical violence. A simple phrase like, “I’ll listen to you,” may allow the patient to vent his anger through his words and not his body.
The last four topics are the most risky for the patient–and the provider. The proper use of restraint, the safety of the patient and the follow-up documentation will protect patients and providers from harm. The challenge for the educator is to develop a program that encompasses all these objectives.
Build your presentation around your agency’s policy or protocol. If you’re teaching for a general body of EMS students, seek out a policy that fits the requirements laid out in the NAEMSP position paper.
Begin your presentation by discussing a background of the legal issues surrounding patient restraint. Case studies that illustrate patient injury or treatable causes that are missed are great discussion generators.
Responder safety should be stressed, and the prevention of injury is paramount. But our ultimate goal should be to avoid or minimize physical contact and restraint of the patient. And when restraint is indicated, use a team effort to overwhelm and quickly control the patient.
Instructors should teach patient restraint with a team approach, which means educating our partners in law enforcement and other health-care professions. This is important because most policies and protocols for patient restraint involve interaction with law enforcement.(2) Police training techniques can be applied to EMS provider training. However, EMS providers shouldn’t use such law enforcement tools as handcuffs or Tasers. If law enforcement officers use those devices, they should ride to the hospital in the transport unit with the patient or at least maintain contact in case their assistance is needed during transport.(3)
Another useful resource is hospital personnel who are involved in patient restraint situations. Staff members who work on psychological care units offer unique abilities in verbal patient control. This de-escalation technique may avoid the use of restraints or make the effort easier and safer for all involved.
This is the start of what has been called the “control continuum,” which is an escalating cascade to control your patient and protect the responder. However, instructors should ensure their students know that immediate restraint may be needed to gain control of some situations. For example, a combative hypoglycemic patient must be restrained to protect them from hurting themselves and allow you to correct their metabolic state.
The first step is to teach the student to take a commanding presence in the situation. Identifying who they are and why they’re there may defuse the situation and start a dialogue with the patient. Using verbal commands and suggestions is also useful in gaining control. Asking or directing them to sit on the stretcher or put their hands at their side are just a few techniques a provider can use to subdue a patient.
Tone and voice inflection also come into play here. Some patients may respond to a soft, firm voice, and others may prefer a commanding voice. How we use our voices when we talk to the agitated patient can mean the difference between a peaceful ride to the hospital and a fully restrained, combative patient.
Before teaching the proper techniques of physical restraint, instructors should teach their students what isn’t acceptable. The use of soft restraints, spine boards, scoop stretchers, Reeves stretchers and straps are all useful in patient restraint. The “sandwiching” of a patient between two devices or wrapping the patient up like a mummy isn’t acceptable. Tell your students about positional asphyxia and why “hog tying” the patient could have lethal results. Teach them to keep the patient supine, so their airway and circulation can be assessed.
Gaining physical control of the patient is truly a team effort, which is why you should practice with drills before attempting restraint. Most prehospital and hospital restraint procedures call for a team of four to five people. A five-person team is ideal–four designated to take control of the patient and one to direct and assist as needed. This team should develop key phrases that are directions for action. These phrases should be easy to remember, but they shouldn’t tip off the patient as to their intended action.
An example may be using a phrase like “ball four” as the term to direct the two team members who will restrain the arms to move in. Another phrase (e.g., “blue jeans”) could direct the two providers assigned to control the legs to move in. A third phrase could be the command for the team to take the patient to the floor. As the restraint is occurring, the student should continue to talk to the patient to calm them and gain control. Teach the actual techniques of taking a standing patient to the ground in a safe environment (e.g., a gym with mats).
Demonstrate application of the restraints and ask students to repeat. The goal is to firmly apply the restraints so they hold but don’t disrupt circulation.
Instructors should stress that once a patient is restrained, the providers have also taken full responsibility for the patient’s welfare. This includes frequent reassessment of the airway and ventilatory status, as well as distal movement, sensation and circulation in the restrained extremities. This assessment should be performed and documented at least every five minutes after restraints are applied. Don’t forget to stress that care can’t stop with the restraint. Any care you would attempt to do for a non-restrained patient, you should also do for the restrained patient.
For the ALS provider, discuss chemical restraint as an option that can help reduce injury. One of the best tools is intranasal administration of medication. This is an ideal tool because of the rapid onset and the fact that you don’t have an open needle around a combative patient. Emphasize to your students that the use of chemical restraint means that reassessment of the breathing and airway must be followed as in any sedated patient. Students should use pulse oximetry and cardiac monitor post-sedation.
Documentation is the final and most important step. Include a detailed description of the situation and what steps were taken to avoid the use of physical restraint. It must also include why the provider was left with no option but to restrain the patient, how the patient was restrained and all assessments done after the restraint was complete.
Patient restraint situations tax the skill and patience of even the most experienced provider. They also risk injury to the patient and providers involved. As educators, we can develop programs to teach methods that protect our providers from physical and legal threats these calls can cause, and we provide our patients with better care when it may be the most difficult to provide. JEMS
1. Kupas D, Wydro G. National Association of EMS Physicians. Position Paper: Patient restraint in emergency medical services systems. www.naemsp.org/pdf/restraint.pdf.
2. Boston EMS Standard Operating Procedure on Patient Restraint. www.iaemsc.org/members/docs/Boston%20Patient%20Restraint%20SOP.pdf.
3. Delaware State Paramedic Protocols 2010. www.dhss.delaware.gov/dhss/dph/ems/files/paramedicstandingorders2010.pdf
This article originally appeared in February 2011 JEMS as “Teaching “˜Restraint’: Improper technique risks injury and lawsuits.”