All Care Providers are Required to Read the following Articles
PRIOR TO studying and implementing the Seven Patient Restraint Protocols:
Patient Restraint is employed To Ensure Patient and Provider SAFETY,
AND to Facilitate the THOROUGH Examination and Care of ANY
Individual Exhibiting an ALTERED LEVEL OF CONSCIOUSNESS.
This description clearly encompasses that of MANY situations involving confused resistance to treatment, and/or "acting out": agitated/violent postictal states, agitated/violent hypoglycemic states, agitated/violent head-injured patients, and the like.
Unfortunately, management of "Behavioral Emergencies" or extremely "Combative" individuals seem to be the ONLY restraint situations that emergency responders prehospital and inhospital emergency responders THINK ABOUT, when they think about individuals who require "restraint."
This universal thought-process-error often leads to inappropriate and inadequate emergency restraint practices and procedures being implemented. Since situations involving emergency management of extremely "Combative" individuals or "Behavioral Emergencies" are the least-often encountered emergency reasons for employing patient restraint, this universal thought-process-error ALSO often results in restraint NOT being employed when it should be.
DELAYED EMERGENCY RESTRAINT OFTEN LEADS TO:
REASONS For EMERGENCY
(Listed in order of Most-Frequently-Encountered to Least-Frequently-Encountered Reasons.)
Legally, a patient may NOT refuse treatment, and will likely require
SOME form of RESTRAINT, if she/he is:
Only "REASONABLE FORCE" may be used when implementing physical control. A general rule for what amount of force is "reasonable": The use of force
equal to, or minimally greater than, the amount of force being exerted by the resisting patient.
"REASONABLE FORCE" is also required to be "SAFE" FORCE.
Enough providers must be present to insure patient and provider safety during the restraint process,
prior to initiating any form of physical control.
For a slightly-to-moderately confused patient, as few as two providers may be sufficient to SAFELY accomplish restraint. However, NEVER hesitate to DISCONTINUE restraint activities if the patient becomes more agitated or resistive, and begins to pose a safety risk to self and providers. Discontinue physical control efforts, and wait at a safe distance for additional assistance to arrive.
Optimally, a minimum of FIVE people should be available to physically control a truly "COMBATIVE" patient during restraint application. ONE PERSON to control each limb/major joint (right shoulder/arm, left shoulder/arm, right hip/leg, left hip/leg), and ONE PERSON to "direct" the restraint process and initiate application of restraints.
If you do not have enough people to ensure the safety of patient and providers during restraint application, NEVER hesitate to WAIT at a safe distance for adequate assistance to arrive BEFORE initiating restraint!
While you withdraw to a safe distance, remove ALL other persons from the patient's immediate vicinity (ensuring the protection of others).
SAFE & EFFECTIVE RESTRAINT
Must Also Be "HUMANE" RESTRAINT
Only The LEAST-RESTRICTIVE Means of Control May be Employed.
Only the MINIMUM amount of restraint required to SAFELY perform thorough assessment and care for the patient should be employed. Thus, restraint application should be a gradual process.
Use of PRONE RESTRAINT is CONTRAINDICATED
In the event that a combative patient is the victim of an object posteriorly impaled in their body, she/he STILL must be "spinally immobilized," in addition to providing stabilization of the impaled object AND restraint! Since spinal immobilization cannot occur in a PRONE position, immobilization and restraint for this type of situation MUST be accomplished in a LATERAL position. Lateral spinal immobilization (or restraint) is extremely difficult to effectively achieve! It will require significant amounts of padding for stabilization of both the impaled object and the patient's spine, and will likely require continuous "manual" (hands-on) contact, by multiple providers, to achieve the most effective immobilization and restraint.
THANKFULLY, I've NEVER heard of a case such as this. The only reason I mention such a scenario is to demonstrate that there ARE NO EXCEPTIONS to the rule that
PRONE RESTRAINT is CONTRAINDICATED!
PRONE RESTRAINT is CONTRAINDICATED for several reasons:
describes anyone who is resistive to assessment and treatment due to confusion or some other form of altered level of consciousness (head injury, hallucination, or the like). The individual is not purposefully attempting to harm himself or others. The individual is merely withdrawing from others, or avoiding contact with others by pushing them away. Confused Resistance may cause an individual to non-specifically "strike out" in the direction of those causing her/his FEAR.
Minor Resistive Confusion (or only "Resistively Confused")
describes someone who's acts of confused resistance are performed with a degree of strength that requires only one or two providers to safely and effectively overcome. The confused individual may be agitated due to fear or anger (or both), but is merely withdrawing from others, avoiding contact with others by pushing them away, or non-specifically "striking out" at others in a defensive manner. An individual exhibiting Minor Resistive Confusion is not acting in a manner likely to cause "serious" harm to himself or others. Someone only Resistively Confused is not acting in a manner that suggests a purposeful INTENT to harm himself or others. When others discontinue contact with him, a Resistively Confused individual will discontinue attempting to harm others.
Violent Confusion, Violent Resistance, or Violently Confused
describes someone who's confused resistance is performed with a degree of strength that requires MORE than one or two individuals to safely and effectively overcome. A Violently Confused individual seeks only to "escape" or "avoid contact with" others. His violent attempts to do so are confused, but are strong enough to inadvertently threaten harm to himself or others. Still, an individual exhibiting Violent Confusion or Violent Resistance is NOT acting in a manner that suggests a purposeful INTENT to harm himself or others. (This significantly differs from someone who is "Combative.") When others discontinue contact with him, a Violently Confused or Violently Resistive individual will discontinue attempting to harm others.
describes someone who may or may not be "confused," but is PURPOSEFULLY attempting to cause HARM to himself or others. This is not an individual who is simply seeking to "escape" or "avoid contact with" others in a violent manner. This is someone acting in a manner that suggests a purposeful INTENT to harm himself or others. When others discontinue contact with him, a Combative individual will continue attempting to harm himself or others.
is when the position of a person's body interferes with breathing, the person is unable to escape the position, and death from asphyxia (suffocation) occurs. ANY body position that obstructs the airway, OR that interferes with the mechanical components of respiration, may cause positional asphyxia.
is a Positional Asphyxia Death that is CAUSED by Manual and/or Mechanical application of RESTRAINT.
"Physical" or "Manual" Restraint
is when restraint is achieved by hands-on contact, and/or body contact, only without the use of devices.
is when restraint is achieved by using devices (handcuffs, straps, rope, or the like).
is when an individual's body is restrained FACE-DOWN (prone) upon a surface (such as the ground or an ambulance wheeled stretcher), and "force" is applied to his body in a manner that prevents him from moving OUT of the prone position. Forceful-prone-restraint may be employed by "Manual" or "Mechanical" means, or combinations of both. Within these protocols, "Forceful-Prone-Restraint" equally refers to Manual and Mechanical means of forceful-prone-restraint.
Hobble Restraint or Hobble Restrained
is when an individual's wrists are bound together behind his back, his ankles bound together with a tether-like cord (a "hobble"), then his knees bent and his bound wrists and ankles tied together. This practice has also been referred to as "Hog-Tie," "Hog-Tied," or "Hog-Tying."
refers to the device used to bind together an individual's ankles or lower legs.
"Ankle-Hobbled" or "Leg-Hobbled"
refers to the ACT of binding together an individual's ankles or lower legs with a hobble device,
but not attaching the hobble to his bound wrists.
Within these protocols, the only restraint device advocated to secure the wrists or ankles (the extremities) is a 12-ply length of non-stretch Roller Gauze. The Author calls this device a "Gauze Strap." In the absence of long back board "webbed-straps" or wheeled stretcher "safety belts," a Gauze Strap may be used for "safety belt" purposes. An appropriately applied Gauze Strap extremity restraint is strong and effective; rapidly-removed (cut) in the event of seizure; humane; economical; useful for other medical care purposes; and DISPOSABLE.
NO other extremity restraint device is Endorsed by the Author of these Protocols.
A Gauze Strap is created using 6-Ply, non-stretch, Roller Gauze. (Kerlix®, or Kling®, or any other brand of Roller Gauze available in a non-stretch, 6-Ply strength, may be used.)
Unroll the gauze and fold it in half, uniting the ends, to create a strip of
12-Ply strong roller gauze that is approximately five feet long.
Place the center/middle of a Gauze Strap at the front (anterior) of the patient's wrist. Tie a half-knot at the back (posterior) of the patient's wrist. The Gauze Strap "tails" beyond the half-knot should be of relatively-equal length. If needed, adjust the "tail"-length as you tighten the half-knot until the wrist restraint is snug enough not to slip off of the patient's wrist, but not so tight that it impedes circulation to the hand. Tie another half-knot and tighten this "full-knot" so that the wrist restraint is "locked" in place: so that it will not get tighter, and will not become loose.
Using a Gauze Strap, tie the ankles TOGETHER, using a half-knot. Assess the tightness so that the ankle restraint is snug enough not to slip off of the patient's ankles, but not so tight that it impedes circulation to the feet. Tie another half-knot and tighten this "full-knot" so that the ankle restraint is "locked" in place: so that it will not get tighter, and will not become loose.
APPROPRIATE, SAFE & EFFECTIVE, RESTRAINT PROTOCOLS:
is Employed Prior To Your Arrival
Violently Confused or Combative Trauma Patient