Loose in the Caboose: Restraining for Keeps

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. Send ideas c/o Nancy.Perry@cygnusb2b.com.

You could swear there was no way he could have done it, but the patient on the cot calmly smiles at you and, telling you to "watch this," he frees one wrist and then the other from the leather cuffs that bind his upper extremities to the cot's upper frame. It's like his wrists were greased or something. You're all by yourself with him in the back of the ambulance, so now you have a true emergency on your hands.

You encountered this guy standing on the roof of a car in the local mall's parking lot, where the police department summoned you for an incident involving an angry male. There he was, shouting at passers-by about being the Lord, commanding them to come to him and rebuking them furiously when they did not. After a good 20 minutes of pleading with him to come down, the police Tased him. He went down like a box of bricks, and put a big dent in the hood of that shiny new Honda.

His smile comes as a complete surprise to you because he has been extremely angry and agitated throughout your 40-minute encounter with him. It was like somebody flipped a switch and presto!—his whole affect changed right there in front of you. Your partner gets the ambulance out of traffic and advises the communications center what's going on. He and the officer who has been following the ambulance enter the compartment and help you reapply the restraints. Fortunately, the patient remains calm and cooperative and seems amused.

"I told you," he says. "I am the Lord thy God. I can do anything I want to."

Q. How much of a threat is this guy to you?
A. If he is who he says he is, chances are he likes EMTs. But chances are he's not who he says he is, and people who get out of their restraints in moving ambulances should scare us. Also, verbal expressions of anger should always get our attention. But he has had 40 minutes to do something violent. If he's not escalating, that's worth considering.

Q. How could he have slipped out of those cuffs?
A. Every piece of patient-handling equipment you can name was designed to accommodate the anatomy and physiology of most people. There are bound to be some folks who don't fit the mold, so to speak. But when people do get out of their restraints, the most common reasons are the simplest ones: loose application and clothing under the equipment; both of those circumstances are preventable.

Q. Is there anything we could have done to absolutely protect this guy and us?
A. Actually, you did several things very well. You got the ambulance out of traffic as soon as you perceived a threat. You advised dispatch there was a problem (your exact location is most important, so you can be found). And you had an officer follow you in case something went wrong.

Additional precautions could include asking the officer to handcuff at least one of the patient's extremities to the cot. The handcuff should be applied distal to a padded wrist restraint to make sure its inside diameter is small enough to prevent it from slipping over a hand. If you have not done so already, ask the officer to help you with a thorough weapons search. If you do not have access to pharmacologic restraints and are not close to a receiving facility, consider an ALS intercept. And finally, ask the officer to consider accompanying you in the ambulance the rest of the way. (That's logistically difficult for most cops, so the answer may be no.)

Q. How reliable is "spider sense" as an indicator of whether or not a patient is dangerous?
A. If it's warning you, trust it -- every time. If it's not warning you, that's never a good enough reason to get comfy. Lack of a protective hunch in any situation can result from inexperience or inadequate training.

Or both.