10. Chemical Restraint

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

10. Chemical Restraint

I pride myself on my ability to talk to psychs. I saw a movie once about a hostage negotiator called “The Voice.” I would flatter myself that I, too, was “The Voice.” I could talk anyone down, make any madman set down his hammer, sword and WWF delusions, and come peacefully. Once I was trying to talk down a kid on angel dust. I am very patient, but other responders there were not so much so. While I was talking this guy down and making what I thought was steady progress, a medic from another division, who was up helping us handle a particular rowdy concert, had had enough and jumped the guy wrestled him to the stretcher and with his partner roughly four-pointed the boy, who fought and spit and screamed all the way to the hospital. I was torqued. It seemed there was a certain class of responder who got into restraining/beating up people. I’m not saying I was always able to talk them down, but most of the time I could. If I couldn’t, sure I’d end up using the physical restraints, but I have never liked that part of the job.

Then we got Ativan and Haldol. Things are different. No more driving to the hospital with four people fighting a patient all the way to the ED. If I can’t talk them down, sure we may have to hold them down for five minutes, but I load’em up and they sleep baby dreams to the hospital.

***

This is my favorite Ativan/Haldol story – Sleepy Boy or Fetch My Dart Gun:

We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.

A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal’s office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.

When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.

I am not.

Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.

Six people, I think, right. Talk about overkill.

I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.

“You’re just one crew?” the cop asks. “You have restraints?”

***

Now when I first took my EMT class many years ago, I wasn’t too keen on the section of the course where we practiced restraining patients. I mean I wasn’t certain I wasn’t going to vomit at the first sight of gore, and I wasn’t certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.

I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouldn’t get called for the big guy who wanted to kick my ass.

I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn’t work on. That’s why we have cops, but cops don’t like to get worked up any more than paramedics.

In recent years, restraining patients has also gone somewhat out of favor due to some tragedies — patients dying of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title “Chemical Restraint.”

***

“We’re going to sedate him,” I say. (If this was movie, I would have said to my partner, “Fetch my dart gun.”)

2 mg Ativan and 5 mg Haldol IM.

He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.

Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.

Ten minutes go by. He is still angry and yelling.

I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. “By all means,” he says.

Andy nearly throws everyone off him when I hit him in the other thigh.

I sit back down in a chair and wait.

A staffer asks what the plan is now.

“I’m going to sit here until he’s asleep,” I say.

Five minutes later, he starts to snore.

One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.

He snores all the way to the ER.

***

Here is our restraint guideline:

North Central EMS Behavioral Emergency Guidelines

EMS providers may use physical and/or chemical restraints on patients who pose a danger to themselves or others.

Providers should make every effort to ensure that law enforcement and adequate assistance are present when attempting to restrain a violent or combative patient.

Only the minimum amount of restraint necessary to protect providers and the patient should be used.

Providers should first attempt to verbally calm the patient down. If the patient does not comply, physical restraint may be attempted.

Providers should assess the patient for medical conditions that could be contributing to the patient’s behavior. If an assessment cannot be performed prior to physical restraint, it should occur as soon as possible after restraint is applied when it is safe and feasible.

Physical restraints must be soft in nature and pose no threat to the patient’s safety.

Only the extremities shall be restrained and these restraints must be assessed every five minutes.

Patients must never be hog-tied, restrained in a prone position with hands tied behind their backs or placed between backboards or mattresses. No restraint shall ever be tied around the head, neck or chest. A surgical mask, spit shield, or an oxygen mask may be placed loosely on the patient to prevent spitting.

Handcuffs may only be used by law enforcement or correction officials on patients in their custody. If the law enforcement officer insists that the patient remain handcuffed during transport, they must either accompany the patient or provide a key to EMS personnel.

Chemical restraint may be used per guideline following unsuccessful attempts at verbal and/or physical restraint or when a patient continues to forcibly struggle against physical restraints.

All restrained patients must have continual reassessment of vital signs and neurovascular status of distal extremities. In chemically restrained patients (safety permitting) this should include ECG, pulse oximetry, and capnography if the patient is no longer alert.

Documentation must include justification for restraint, type of restraint used, restraint procedure, results of continual reassessment, medications administered, the indications for the administration, and any other care rendered.

Do not hesitate to involve medical direction in any call involving restraint.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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