CHAS' Review of a 2-Part "Tricks of the Trade" Column

By Thom Dick, EMT-P

Review of "Tie-Downs"; Use of Restraints, PART 1 December 2002 • Volume 27 • Number 12

Review of "Straight Shot"; Use of Restraints, PART 2 January 2003 • Volume 28 • Number 1

I really hate writing a "negative" review of stuff written by folkz I know! And, it doesn't "help" that Thom Dick and I are only "somewhat acquainted." We met somewhere ... sometime (likely at a JEMS EMS Today conference, years ago) – certainly, we've "heard of" each other down through the years. And, I'm reasonably confident that Thom Dick is a caring, and responsible, EMS provider and educator. But, when I read Part 2 of his JEMS "Tricks of the Trade" column about restraints, and saw the pix that accompany it, I was ... AGHAST!!!

"aghast: adj. struck with overwhelming shock or amazement;
filled with sudden fright or horror"

Still, I'll start my review by identifying some POSITIVE aspects of Thom's Restraint Tricks columns. After a strongly positive beginning, I'll segue into identification of the many NEGATIVE aspects of Thom's Restraint Tricks columns.

EXCERPTS from Thom's column are in dark blue text.

Review of "Tie-Downs"
Use of Restraints, PART 1

If you've never had a thorough class on how to restrain someone, you need – and deserve – one. Do yourself and your whole agency a favor: Ask for one today. And if it hasn't happened a month from now, insist on it – and insist on it again – until you become the EMT from hell. (EMTs from hell get things changed.)

Right ON, Thom!
Be a "squeaky wheel!" Yeah, it's a "risk." But, if YOU don't do it, who will? And, if no one does it, NO ONE will get the training they "need – and deserve!"
Since money is often an issue when it comes to getting the best possible training, pool your resources. Encourage your service's Education Officer to contact the individuals who organize your State (or Regional) EMS Conference. Request that they visit my Web Site, and hire me to provide restraint training at your conference(s).
In the mean time: USE MY WEB SITE! Learn all you can from my "All Tied Up And No Place To Go" and "Restraint Asphyxia – Silent Killer" articles. Encourage your coworkers to learn from my web site! Empower yourself and your coworkers by becoming educated, safe and effective, restraint providers.

3. When somebody calls 9-1-1, either they can describe their emergency (SOB, chest pain, stabbing, etc.) or they are clearly impaired. When you respond, you deserve to know what you're responding for. Insist on that much from your dispatchers, or ask for the PD to respond and evaluate the situation prior to your arrival.

Right ON, Thom!
I'll be quoting Thom in April, 2003, when I address an EMS Dispatchers conference. Dispatchers are the "first link" in any emergency response. Well-educated dispatchers certainly would KNOW to pass along information about the calling party speaking as though they had an "altered level of consciousness." But, if we don't educate Dispatchers as to what information is important to responding providers, they won't know to pass it along. Consequently, even though they don't "perform" patient restraint, Dispatchers need to – at least – be educated as to the WHYs of patient restraint. In that way, they'll be much better able to identify calls with a potential need for restraint ... much more likely to pass that information along!

4. Take a critical look at every scene before you go waltzing in like a dumb***. Things are supposed to make sense. If they don't, they're dangerous until proven otherwise.

I wish Thom had expanded upon this point, just a bit: If, after a "critical look," the scene still doesn't "make sense" ... doesn't seem "right" to you ... DON'T GO IN!!! Summon law enforcement and wait at a safe distance, until you are ASSURED that it is SAFE for you to go "waltzing in." There is no way in **** that you can help ANYone if YOU become a patient!

5. Don't run, no matter what you see and no matter how frantic people seem to be when you arrive. Walking gives you more time to analyze what's going on and keeps your catecholamines under control so you can think and communicate more clearly. (It also prevents the jitters.)

Right ON, Thom!
Just being dispatched to an emergency stimulates "Fight/Flight" system adrenalin ("catecholamine") release. Running stimulates an even greater adrenalin release! Adrenalin-tweaked responders are impatient and make poor decisions (like entering scenes they shouldn't). Adrenalin-tweaked responders incompletely assess patients ("miss" vital clues, signs and symptoms) ... misdiagnose injuries and illnesses ... and – because of all that stuff – provide inadequate treatment. The only time you should ever run, is when you're in danger. Then, RUN AWAY ... drop all equipment and GET OUT!!!
(Worrying about being considered a "whimp" can kill you. Just GET OUT!!!)

8. Most violent situations in EMS result from our own disrespect. Remember your role as a caregiver, and treat patients and their families with dignity and respect – even if they're cranky (on what may be the worst day of their lives).

I wholeheartedly agree that responder "disrespect" (something that happens because we get impatient, or because we harbor prejudices against certain patients) often results in "violent situations." I wholeheartedly agree that treating ALL patients with respect will significantly minimize the likelihood of responder-escalated "violent situations."
(Here comes the "BUT..."!)
BUT! "Violent situations" are the LEAST-often-encountered reasons for restraining an emergency patient! Plz see the "REASONS For EMERGENCY PATIENT RESTRAINT" section of the INTRODUCTION to my (currently under construction) DEFINITIVE PATIENT RESTRAINT PROTOCOLS.
And, by focusing only upon "violent situations" when addressing "restraint," Thom is promoting the continued MISINTERPRETATION of the REASONS for patient restraint. Misinterpretation of patient restraint reasons promotes INAPPROPRIATE (and dangerous!) restraint performances.
For example; In Part 2 of his Restraint Tricks of the Trade column, Thom Dick promotes INCREDIBLY DANGEROUS RESTRAINT TECHNIQUES ... techniques inconsistent with patient "care" provision ... techniques that even interfere with patient care provision.
I don't want to believe that Thom did this "on purpose." I want to believe that he did it only because he's never been adequately educated about restraints. I want to assume that Thom has simply forgotten the fact that MANY causes of an altered level of consciousness are productive of violent behavior, and require MEDICAL ASSESSMENT AND TREATMENT.
Unfortunately, all providers who follow the directives offered in Part 2 of Dick's Restraint Tricks, will be entirely unable to provide definitive MEDICAL ASSESSMENT AND TREATMENT to the individuals they restrain – no matter WHAT caused their altered level of consciousness.

Review of "Straight Shot"
Use of Restraints, PART 2

Thom begins this column with many wonderful tips!!!:

• Have a "plan" (a "protocol") for patient restraint situations ...
  
• Five people are the preferred MINIMUM for safely initiating the restraint of a violently resistive patient (both for patient and provider safety!) ...
  
• PRACTICE is vitally important to performance of safe restraint ...
  
• Predesignated "audible signals" (verbal cues) are incredibly helpful ...

And, thank goodness Thom promotes SUPINE restraint!
NO OTHER RESTRAINT POSITION is appropriate to EMERGENCY CARE provision.

UNFORTUNATELY, the bulk of Thom Dick's Restraint Tricks of the Trade Part 2 column, promotes INCREDIBLY DANGEROUS RESTRAINT TECHNIQUES ... techniques inconsistent with patient "care" provision ... techniques that even interfere with patient care provision.
I don't want to believe that Thom did this "on purpose." I want to believe that he did it only because he's never been adequately educated about restraints.

But, I'm appalled that Thom Dick has apparently forgotten the fact that MANY medical or traumatic causes of an Altered Level of Consciousness ["AEIOU-TIPS"] are productive of violent behavior – and that they ALL require thorough MEDICAL ASSESSMENT AND TREATMENT. Certainly, all providers who follow the directives offered in Part 2 of Dick's Restraint Tricks, will be entirely unable to provide definitive MEDICAL ASSESSMENT AND TREATMENT to the individuals they restrain – no matter WHAT caused their altered level of consciousness.

In the third paragraph of Part 2, Thom promotes the use of HAIR-PULLING, as the initial part of his method for "head restraint." Literally. Thom directs providers to grasp the patient "by the hair ... if they don't have hair, grab an ear." I'm not going to provide a discussion of why "hair-pulling" or "ear-grasping" is inappropriate to patient CARE. If you don't "get it" – you don't "get it."

For the second part of his "head restraint" method, Thom promotes the use of a CHOKE HOLD. He describes it as "use the crook of ... arm to cradle the front of the patient's neck."
It is still a choke hold.
Choke holds have been banned from law enforcement use since the early 80's, when they were shown to cause death, due to a variety of mechanisms.(1)

Dick warns restrainers, "Do not choke the patient! Keep the trachea aligned with the crook of your arm, and apply only enough force to keep the head under control." Dick's warning is entirely unhelpful. Called by many other names (such as "Carotid Sleeper" hold, and "Lateral Vascular Neck Restraint"), a choke hold does more than merely threaten an individual's airway. In fact, when it is applied in manner intending to avoid airway compression, bilateral carotid artery compression often occurs. This can produce carotid sinus stimulation productive of extreme bradycardia, leading to asystolic cardiac arrest.(1)

"Death From Law Enforcement Neck Holds"(1)

Dick's explanation of the "benefits" of his "head restraint": "This enables you to do two things: 1) prevent the patient from biting you or anyone else and 2) see and direct the rest of the team's activities."

There IS a Medical Head Restraint that accomplishes both of these things just as well as Dick's – but, without endangering the patient. It's called a modified jaw-thrust airway maneuver! When using it as a head restraint, keep your thumbs on the cheek bones (no need to pinch the nostrils closed), and HANG ON! YES. Sometimes, doing the "right thing" requires more effort than doing its alternative. YES, your fingers will get tired, and start to cramp. (You'll rapidly have to "trade-off" with someone.)

But, the patient won't be biting anyone. There is no risk of airway obstruction or carotid sinus stimulation when a "medical" form of head restraint – the modified jaw-thrust airway maneuver – is applied. AND, no bystanders will testify that they witnessed you "choking" the patient!

As to Thom Dick's directive that care providers "straddle the patient's knees and sit on them, facing the patient's feet": This directive clearly demonstrates why Emergency Patient Restraint protocols should never be based upon In-Hospital Patient Restraint protocols!

Since there is no medical reason for Dick's directive – nor any "kinesthetic" restraint-application-improvement reason for it – Dick's "face the patient's feet" directive was probably based upon (OLD) in-hospital protocols for restraining psychiatric or developmentally disabled patients. "Behavior Management Programs" addressing the restraint of psychiatric or developmentally disabled individuals also have to address concerns that patients' "negative-attention-seeking behaviors" may be "reinforced" by giving them "attention" during restraint. Consequently, OLD versions of such programs directed restrainers to avoid eye-contact with the restrained individual, and to face their feet during restraint.

Such directives are ENTIRELY INAPPROPRIATE
to Emergency Patient Restraint application!
In emergency medical restraint situations, ALL restrainers need to be FACING THE TEAM LEADER. Since the team leader always should be positioned at or near the AIRWAY of the patient (whether directing and/or participating in the restraint), ALL restrainers need to be FACING THE HEAD OF THE PATIENT. This is because ALL restrainers need to be aware of what is going on with the patient during the application of restraint.

(I apologize for the poor quality of this photo. It was blurry when I found it on the Internet.)

Next, we come to Thom Dick's promotion of another form of restraint entirely inappropriate to prehospital emergency medical care; the "BASKETHOLD" restraint. "the two people holding the patient's arms should criss-cross the patient's arms across their chest, ... This restrains the patient with their own upper extremities." This form of restraint also is derived from OLD restraint protocols established for psychiatric hospital staff, or for community-based care-providers of the developmentally disabled and mentally ill. This form of restraint also has been associated with many, many restraint asphyxia deaths.(2)

In fact, use of a form of "BASKETHOLD" restraint is the major contributor to the ONLY restraint asphyxia deaths I know of, that have occurred while the restrained individual was restrained in a SUPINE position!(3)

CHEST CONSTRICTION breathing obstruction could easily be caused by a "baskethold" crossed-arm restraint – even without simultaneous employment of a "choke hold." BUT! That wouldn't be too much of a worry ...

EXCEPT for the THESE FACTS: 1) Uneducated restrainers often equate "breathing-obstruction" with chest constriction. Thus, erroneously thinking it will prevent "breathing-obstruction," they may move the patient's crossed-arms lower on his body, forcefully compressing his abdomen instead of his chest – THAT kind of restraint is what causes breathing obstruction!(4) 2) Even if restrainers keep the arms crossed high on the chest, SOME form of ABDOMINAL RESTRAINT will probably be simultaneously employed by other excited, uneducated, responders – via Body-On restraint, or via inappropriate restraint STRAP positioning.

These kinds of techniques can easily result in
DEATH from RESTRAINT ASPHYXIA!(4)

In addition to threatening the restrained patient with restraint asphyxia, another equally important – if not MORE important – reason that a "baskethold" crossed-arm technique is entirely inappropriate to emergency medical care:

Patients suffering from an ALTERED LEVEL OF CONSCIOUSNESS
require restraint AND thorough ASSESSMENT and MEDICAL CARE!

If a "baskethold" crossed-arm restraint is used, how are "CARE-providers" supposed to adequately perform a thorough patient examination and assessment? Measure the patient's blood pressure? How are they supposed to provide adequate emergency medical care? Start an IV? ... Administer D50 to violently-hypoglycemic patients? ... Administer Valium to violently-postictal seizure patients? ... and so on ...

A "baskethold" crossed-arm restraint technique is
ENTIRELY INAPPROPRIATE to emergency medical care provision.

Thom Dick warns his readers: "Remember, you want to restrain the patient with the least amount of force necessary." That's a perfectly appropriate reminder – something that should be included in every article or protocol regarding application of patient restraint.

Unfortunately, in the "heat of battle"; when providers are having to deal with violently struggling victims of an altered level of consciousness, victims who (because of their altered level of consciousness) are so incredibly strong; WHAT is the physiological state of the RESTRAINERS?! THEY are jazzed-up on adrenalin. THEY are in a state of "crisis" or "stress." And, how does that effect their perception of the "least amount of force necessary?"

In Summary:

I could identify and explain several OTHER inaccuracies and dangerously inappropriate suggestions provided within Thom Dick's "Use of Restraints, Part 2" column. But, I've ALREADY EXPLAINED THOSE THINGS in my "All Tied Up And No Place To Go" and "Restraint Asphyxia – Silent Killer" articles.

Essentially, most of Thom's "Use of Restraints, Part 1" column is helpful. But, the ONLY helpful aspect of "Use of Restraints, Part 2" is Thom's provision of photography that clearly demonstrates examples of WHAT NOT TO DO when restraining patients!

After calling his attention to the information provided by my review, Thom Dick (and JEMS) refused to publish a "RETRACTION" of any information contained in his "Use of Restraints, Part 2" column. I'm not surpriZed. Obviously, it is painfully difficult to admit when you are WRONG – even when you are clearly demonstrated to be WRONG.

Consequently, in order to bring the reasons for why Dick's "Use of Restraints, Part 2" column should NOT be followed to public attention, OTHERS have to write to JEMS, providing their opinions of Dick's "Use of Restraints, Part 2" column, so that.

I strongly encourage EVERYONE to write their OWN review
of Thom Dick's / JEMS' "Use of Restraints, Part 2" column.
Send your review to JEMS, as a "Letter To The Editor."

Snail Mail: JEMS Letters 525 B Street, Suite 1900 San Diego, CA 92101-4495 FAX: 619 - 699 - 6246 Email JEMS Editor: jems.editor@elsevier.com

THEN, SEND ME a copy of YOUR LETTER TO JEMS' EDITOR!

c-d-miller@neb.rr.com
Whether or not JEMS publishes your letter,
I will post it in my Restraint Asphyxia Library!
Even if you don't agree with MY review,
your opinions deserve to be heard and seen by ALL.

REFERENCES:

1. Reay DT, Eisele JW. Death From Law Enforcement Neck Holds American Journal of Forensic Medicine and Pathology September, 1982 Issue. Vol. 3, No.3; pg 253-258.

2. Weiss EM, et al.; Deadly restraint. A Hartford Courant investigative report. http://www.copaa.com/newstand/day1.html October 11, 1998.

3. Claudio Cruz and Felicita Cruz, Administrators of the Estate of Claudio Cruz, Jr., vs. Allegheny Valley School, et al; in the Court of Common Pleas, Philadelphia County; CAUSE NO. 002361.

4. Miller, CD; "Restraint Asphyxia – Silent Killer" http://www.charlydmiller.com/RA/restrasphyx01.html.

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"