A Report (Synopsis) of Winnie Maggiore's
2001 JEMS EMS Today Conference Presentation
March 13-17, 2001; Baltimore, Maryland.
By Elizabeth A. Criss, RN, Med
Probably not a day goes by that EMS personnel don't face a potentially dangerous patient. How successful they are in subduing and managing the patient as well as protecting themselves reflects their restraint protocol. According to Winnie Maggiore, JD, EMT-P, clinical instructor at the University of New Mexico School of Medicine, the problem is: "Most EMS systems don't have a well-defined restraint protocol that provides a practical, legally defensible means of managing a violent patient."
At the 2001 EMS Today Conference in Baltimore, Maggiore introduced participants to the medical-legal questions and answers surrounding patient restraint. Following a brief review of recent litigation involving out-of-hospital restraint and death, she presented the issues related to patient restraint, including the frequency of encountering violent patients and some causes of patient violence.
Most EMS personnel understand the overall mechanics of physical restraints: "It takes more of us than there is of them to be effective." However, patient restraint, according to Maggiore, is not properly taught during EMS training. Very little time is spent on proper approach techniques or restraint methods. Documentation and legal issues are also often poorly emphasized, and providers fail to realize the legal significance of restricting a patient's freedom through restraints.
Maggiore also pointed out that many EMS agencies rely solely on local law enforcement for patient restraint. Although this sounds like a good idea, it may be one of the least effective methods. Not only does it put EMS at risk while waiting for law enforcement response, in some communities law enforcement won't act as willing partners to subdue a patient who hasn't committed a criminal offense.
Many EMS agencies don't fully realize that using medications to slow or gain control of an individual also serves as a method of restraint. According to Maggiore, the use of chemical restraints is an area of significant legal risk for EMS systems that function without a restraint protocol. Maggiore recommends all EMS agencies and systems implement proper restraint training and protocols to protect themselves and their patients.
According to Maggiore, the best restraint protocol provides a wide range of options to EMS providers. It should include non-physical as well as physical restraint methodologies. It's important the protocol be fluid, not a rigid algorithm that requires completion of each step before moving on. That fluidity allows EMS providers to protect themselves should the patient's mental and/or emotional condition suddenly change. For example, the protocol may begin with verbal de-escalation, but should the patient suddenly demonstrate violence, providers need the flexibility to move directly to a physical or chemical means of restraint, abandoning further verbal techniques.
The other area Maggiore emphasized to the participants was the need for proper documentation. To protect themselves and their agency from litigation, EMS providers must fully document subjective information related to the patient encounter. This includes documenting attempts at verbal de-escalation prior to use of physical or chemical restraint.
Documentation should include a patient assessment, when possible. Special emphasis should be placed on documenting cardiovascular and airway status at the initiation of the restraint and at predetermined intervals during the restraint. All of this must be supported by the medical director and a local or regional protocol.
So what should the ideal protocol contain? Maggiore recommends the following:
Above all else, Maggiore advises EMS providers to understand that restraints are a serious violation of patient rights unless applied with appropriate discretion and under a physician's direction. It's imperative that physicians become actively involved in the development of and training on new restraint protocols.
Maggiore reminds all EMS providers and agencies to remember safety first. Learn proper restraint techniques, including physical and chemical methods. Work closely with your medical director and legal counsel to develop a restraint protocol and documentation requirements to protect yourself and your agency.
You can purchase a copy of this presentation on audiocassette by visiting the Audio Visual Education Network at www.aven.com and clicking on the 19th Annual EMS Today 2001 link. Also look for an article on the topic in a coming issue of JEMS.
W. Ann Maggiore, EMT-P, JD, practices as a medical negligence defense attorney with Atwood & Malone, Albuquerque, N.M., and has been active in EMS since 1973, practicing as a full-time paramedic in both Albuquerque and the small mountain village Placitas, N.M. She holds a clinical faculty appointment at the University of New Mexico School of Medicine, where she teaches legal issues to paramedics and emergency medicine residents.
Elizabeth Criss, RN, Med, is a senior research associate at the University of Arizona and clinical educator for the emergency department at University Medical Center in Tucson. A member of the Board of Advisors of the Prehospital Care Research Forum, she has been involved in prehospital care and research for more than 10 years.