Restraining The Combative Patient

Recent events around the country continue to place firefighter/paramedics in positions of having to defend themselves in criminal or civil courts after restraining combative patients. In one terrible predicament for firefighters, they found the local district attorney considering indicting them on murder charges after a patient in their care died after becoming combative and was restrained.

An unfortunate side of performing EMS in the streets is that restraining patients is sometimes necessary and essential for the safety of the firefighters, bystanders and even the patient. Although we all have been trained from the same textbooks and there is a standard of care that is followed in the development of those textbooks, the bottom line is that those textbooks cannot educate you on every situation you are going to encounter. This is especially true when encountering combative patients and there becomes a need for restraining them.

When performing emergency medicine in the streets, firefighters sometimes have limited resources, encounter more scene hazards, and are not as well-equipped as a hospital with diagnostic equipment to rule out non-life threatening causes of abnormal behavior. Restraining a patient takes into account that you have a duty to act and you are doing so legally because the patient has implied consent for treatment with abnormal behavior. Usually, we must restrain patients because there is a need to protect them from physically harming themselves deliberately or not deliberately, such as self-extubation. We also need to restrain a patient when you are protecting yourself, other firefighters, the patient's family and sometimes bystanders from violence brought on by the patient. Sometimes, there is a need to restrain disoriented or uncooperative patients so that they may be assessed, or to facilitate medically necessary procedures.

Many times when patients are combative, they are known to be in an agitated state known as agitated delirium or excited delirium. Usually, these states are associated with a metabolic cause such as low blood sugar, chemical imbalance, or the use of a stimulant such as cocaine, methamphetamines or PCP. These patients usually have increased exertion and an increase in oxygen demand.

Patients who are in an excited or agitated delirium are usually restrained, and it is during that restraint when death can occur. This has led to the lawsuits and potential criminal charges against firefighters around the United States. The lawsuits and criminal charges against the firefighters allege improper restraint leading to positional asphyxia. "Positional asphyxia" is a phrase coined by Dr. Donald Reay, chief medical examiner for King County, WA, several years ago to describe patients who died in custody while being restrained. Reay conducted studies showing oxygen recovery rates in the body when influenced by extreme exertion. He also conducted experiments to determine what body position, specifically weight on the chest and stomach, has on one's ability to recover to normal heart rate and blood oxygen level. Finally, he studied whether the way in which one is restrained and the position of the body can impair the mechanical respiratory process in inhaling and exhaling. Since then, studies have identified weaknesses in the methodology of Reay's studies and concluded that his results were invalid.

A subset of positional asphyxia is restraint asphyxia. Essentially, restraint asphyxia is positional asphyxia caused by improper restraint techniques. There are four primary methods of restraining a patient: verbal, non-verbal, physical and chemical.

Verbal and non-verbal restraint should be the first methods used, but sometimes they are not feasible. Sometimes, you can speak with patients and convince them to cooperate by being firm, forceful and fair. Other times, non-verbal communication is a tool that can de-escalate a situation by using your body language and just showing firefighters who outnumber the patient.

When verbal and non-verbal communication do not work, physical restraint is usually the next means for restraining a patient. The national standard of care for restraining patients includes:

• Making sure that police are present and that you have adequate help
• Planning your activities
• Estimating the range of motion of the patient's arms and legs, and stay beyond that range until ready

Once the decision to restrain the patient has been reached, act quickly:

• Have one rescuer talk to and reassure the patient throughout the restraining procedure
• Approach with four persons, one assigned to each limb, all to act at the same time
• Secure all four limbs with restraints approved by medical direction
• Position the patient face up (note: the patient may be place faced down initially to gain control of the person)
• Use multiple straps or other restraints to ensure that the patient is adequately secured
• If the patient is spitting on rescuers, place a surgical mask on the person
• Reassess the patient's distal circulation frequently and adjust restraints as safe and necessary if distal circulation is diminished
• Use sufficient force, but avoid unnecessary force
• Document the reasons why the patient was restrained and the technique of restraint used

It is important to note that universal precautions should be used at all times when restraining patients. If possible, do not restrain patients by sandwiching them between backboards, hobbling or hog-tying them, placing them in body bags or securing them to papoose boards. Avoid using handcuffs, if possible; soft restraints are available.

Chemical restraint is another method of restraining a patient, but mainly is used as an addition to physical restraint. Chemical restraint should not be considered in every case of restraint. It should be considered only when physical restraint by itself increases risk to the patient and/or others.

There are risks when using chemical restraint. Patients may experience respiratory depression, increasing the effects of other central nervous system depressants such as alcohol, and they will have a limited mental status, which can make neurological assessment difficult.

Pharmaceutical agents that can be used in chemical restraint include any drugs in the benzodiazepines family, such as Valium, Versed and Ativan. Other pharmaceutical agents that can be used include tranquilizers and neuroleptic agents such as Haldol, Thorazine and Phenergan.

Remembering important goals during physically restraining a patient will lead to your patient being delivered to the emergency room safely. These include not letting the patient reach you, IV lines or other medical devices. Oxygen and pulse oximeters should be in place and your patient should be on an EKG monitor, if possible. Never leave the patient unattended and the patient's ABCs should be continuously reassessed.

Restraining patients presents difficult and challenging decisions for firefighters. Even though it may be difficult at times, following basic principles during the restraint of patients usually will lead to a successful outcome. Remember - do no further harm!