Swingers and Spitters

     Attack One responds to a local bar for a "man down." The man fell off a barstool after a self-reported "long night of drinking." He staggered outside the bar, where he fell again onto the sidewalk. In one of the falls, he had an impact on his forehead and scalp area, with moderate blood loss onto the sidewalk and his clothing. No one, including the patient, was aware of any loss of consciousness.

     A bystander activated EMS, and Attack One and a police officer arrive on scene about the same time. The man is uncooperative from the beginning, sitting on the ground, still oozing a little blood from the cut on his forehead. He refuses evaluation, and will only let the paramedics offer him some bandages to hold on his laceration. He wants to walk home, he says, but can't stand up. No friends are present.

     Two more attempts to befriend the man and complete an evaluation meet no success. Paramedics can identify no injury other than the forehead, and the man will only let them palpate a pulse and blood pressure. They help him to his feet as a method of assessing his neurologic function and, hopefully, convincing him he can't walk home. The man is very unstable, but still refuses offers to complete his evaluation, transport him to the hospital to have the laceration closed, and check for other injuries in a warm, dry emergency department.

     When the police officer suggests the man is too intoxicated to walk home, the man swings at the officer, misses him and lands on the ground again. The officer now places handcuffs on the man. This results in increased struggling, kicking, bleeding, spitting and cursing, and the Attack One crew places a surgical mask on the man to prevent the spitting. The crew consults medical control by phone and is asked to restrain the patient safely and transport him to the hospital.

     A medic asks the officer if he's placing the man under arrest. After consulting with his superior, the officer says no, and he's then asked to assist the crew in securing the man for transport. He assists with the crew's restraint procedure:

• They secure soft medical restraints to each of the patient's extremities.
• They place the patient supine on a long backboard and secure his lower extremities to the backboard's lower portion.
• They secure his arms to the stretcher beside his body.
• They secure his torso to the board with straps.
• The patient persists in trying to spit, so the surgical mask is maintained loosely over his face.

     Once the patient is restrained, the crew can finally perform a complete assessment, including pulse oximetry. The patient's pulses and capillary refill and movement are reassessed in each extremity every five minutes on the trip to the hospital.

     The patient remains combative. His condition is assessed continually by the paramedic in the patient care area, and his respiratory status is unimpaired. His hands remain pink, his pulses intact, and he complains of no pain.

Hospital Course
     Emergency department staff perform their evaluation on arrival, the restraints and surgical mask left in place. The man's blood alcohol level is high. A CT scan of his head reveals a large bleed, and he is taken to surgery. He recovers slowly but completely, returning to his baseline function, and is ultimately discharged to his family.

Case Discussion
     There are many reasons why a patient may be combative: hypoxia, mental illness, drug/alcohol ingestion, post-seizure effects, head injury or some combination of the above. The priority when caring for medical patients who present with combative behavior is to identify and treat the underlying cause. "Talking someone down" is an option in a few cases. If verbal communication is not effective, restraints can be utilized. They may include chemical restraint with certain medications, physical restraint using a variety of devices applied to the extremities and torso, or physical restraint using law enforcement techniques and procedures. Every EMS organization needs a restraint policy in writing, approved by medical direction and understood by every EMT.

     When faced with a patient who poses potential violence, the first duty of the crew is to protect themselves and bystanders. Transportation and/or treatment can be denied by EMS for any violent or suspected violent person if he/she cannot be adequately restrained. Even a restrained patient may be deemed unsafe to transport without law enforcement presence, should law enforcement decline to escort.

     Many departments have developed joint policies with local law enforcement agencies. This collaboration is particularly important for violent or suspected violent persons in custody of law enforcement officials. Handcuffs or other "hard" restraints are not to be applied by prehospital providers unless they are dual-role, certified and in possession of the keys to release the patient. Typically, if a patient is under arrest at the time of transport, the law enforcement agency will be asked to escort the patient aboard the ambulance or follow the ambulance to the hospital, at the discretion of the EMS transport crew.

     Learning Point: Restraining a patient puts that patient at high risk of medical problems, regardless of the method chosen. Hospitals and law enforcement must have detailed procedures regarding the use of restraints in all areas. EMS services should similarly have restraint policies that protect both treating personnel and their patients. Restraint requires more careful monitoring of the patient, restraint-specific documentation and an explanation to bystanders and family, if they are present.

     The process of restraint must be performed with patient safety continuously considered. Restraint removes patient freedom, and often the ability to protect the airway. EMS providers have no doubt heard of positional asphyxia, which is a particular risk when a patient is restrained in a prone position with extremities behind them. A properly maintained airway and adequate breathing is the responsibility of the EMTs. Once a patient is restrained, an EMT must remain with the patient at all times. The patient must have constant supervision en route to and at the hospital, until properly turned over to hospital personnel. Even there, remove restraints only with sufficient manpower.

     Some departments have developed chemical restraint procedures, which are beyond the scope of this column. If chemical restraint is utilized, personnel should undergo extensive training to prevent a patient and system tragedy.

     There is a priority to appropriately documenting a restraint procedure. Some departments have developed a checklist to assist EMTs in proper execution of the process and documentation of a safe operation. Documentation should include:

• Why the restraint was necessary.
• A description of assessment findings obtained through observation (injuries, behavior, mental status, etc.) and statements made ("I am going to hurt all of you for taking me to the hospital!") that justified restraint.
• That the EMTs did not overlook a medical cause for combativeness, e.g., head trauma, hypoxia, hypoglycemia, alcohol/drug ingestion.
• Names of all law enforcement and first responder personnel who observed the patient's behavior or assisted in the restraint decision and process.
• The type of restraints used, a brief description of actions taken to restrain the patient, and the time the patient was restrained.
• A description of the position in which the patient was restrained, and of adequate assessment being done. Pulse oximetry readings are particularly important.
• Data showing the patient was monitored continually to prevent complications until turned over to hospital personnel.
• A description of any changes in patient condition during transport and on arrival at the hospital.
• Documentation of safe patient turnover at the hospital, and repeat vital signs and assessment of restrained extremities.

     There is an opportunity for good customer service even in these stressful patient encounters. Restraint may require an explanation to bystanders and family, if they are present. Done in a professional and nonjudgmental fashion, it can show the crew as patient-focused and caring for all involved.

James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He serves as deputy chief-assistant medical director for Washington, DC Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at James.Augustine@dc.gov.