All Care Providers are Required to Read the following Articles
PRIOR TO studying and implementing the Seven Patient Restraint Protocols:

1. All Tied Up & No Place To Go, Parts 1 through 3 (http://www.charlydmiller.com/RA/alltiedup1.html).

2. Restraint Asphyxia – Silent Killer, Parts 1 through 3 (http://www.charlydmiller.com/RA/restrasphyx01.html).

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:

• unnecessary patient agitation, escalation, and "combative" incidents ...
  
• entirely avoidable patient and provider injuries ...
  
• delayed and/or inadequate assessment and care provision.

1. "Less-restrictive means of 'restraint' (such as verbal cues or de-escalation) should always be used before resorting to hands-on or mechanical restraint."
   A confused emergency patient will often cooperate with verbal cues and/or de-escalation techniques. However, if confused, even the most "cooperative" emergency patient can "reasonably be anticipated" to become strongly resistive and "uncooperative" when any uncomfortable emergency care procedures are required – such as IV access.
   
2. "Physical or mechanical restraint of an individual is always a 'last resort.'"
   Again, if confused, even the most "cooperative" emergency patient can "reasonably be anticipated" to become strongly resistive and "uncooperative" when any uncomfortable emergency care procedures are required – such as IV access.

REASONS For EMERGENCY
PATIENT RESTRAINT:
(Listed in order of Most-Frequently-Encountered to Least-Frequently-Encountered Reasons.)

1. Restraint For Safe & Thorough Medical Assessment & Care, When Patient-Interference or Resistance is REASONABLY ANTICIPATED, due to Patient CONFUSION or
   an ALTERED LEVEL OF CONSCIOUSNESS. FOR EXAMPLE:
   • Postictal seizure patients are not often "combative," yet they are almost always confused, and can reasonably be anticipated to violently withdraw or strike out in response to being stuck with a needle. If their postictal level of consciousness doesn't improve to "fully oriented and cooperative with treatment" after 5 minutes of oxygen administration, additional care procedures (such as IV establishment with blood sample draw) must be initiated. Thus, "prophylactic" restraint (restraint applied before the patient becomes "resistive to treatment" or strikes out) is required to protect the patient and providers,
     required to prevent injury, required to prevent delays in treatment.
   • CVA patients may regain the use of one or more limbs after oxygenation, but remain confused. If unrestrained, they will withdraw and/or strike out while being treated. They may inappropriately remove their IV, and may cause injury to themselves or others.
   • Diabetic Hypoglycemia patients, head-injured and confused patients, ...
     even when they are not actively "resistive" to conversation and examination, these kinds of patients can reasonably be anticipated to violently withdraw or strike out in response to being stuck with a needle, or "confined" to a long back board, and the like.
     ESSENTIALLY, ANY Patient with an ALTERED LEVEL OF CONSCIOUSNESS REQUIRES RESTRAINT. They must be "prophylactically" restrained prior to implementation of ANY medical procedure that will cause them the slightest bit of discomfort.

2. Restraint For Safe & Thorough Medical Assessment & Care, When IMPROVED PATIENT CONDITION Can REASONABLY Be ANTICIPATED To Result in CONFUSION, RESISTANCE, and/or COMBATIVENESS. FOR EXAMPLE:
   • Unconscious hypoglycemic patients often "improve" from unconsciousness to becoming resistive, or even combative, for a period of time. If unrestrained during this phase of their "recovery," they may violently remove their IV, and/or may cause injury to themselves or others.
   • Unconscious drug ODs ... Unconscious head injury patients ... and the like ... may "improve" from unconsciousness by becoming confused, resistive to treatment, or even combative.
   • EVERY INTUBATED PATIENT REQUIRES RESTRAINT!
     Unconscious INTUBATED patients who respond to ventilation WILL extubate themselves prior to fully regaining "consciousness." (Without deflating the ET cuff first!) In addition to causing significant soft tissue trauma (with associated edema and/or hemorrhage that later may lead to life-threat), self-extubation can result in the patient's condition deteriorating "back" into unconsciousness, producing additional cerebral or pulmonary "damage," while responders struggle to regain control over the airway.
   • EVERY UNCONSCIOUS PATIENT REQUIRES RESTRAINT!
     It is reasonable to anticipate that an unconscious patient will respond to appropriate emergency care by beginning to regain consciousness. It is reasonable to anticipate that an unconscious patient will require a period of time before becoming fully alert, well oriented, and entirely cooperative with the emergency care they vitally require. During recovery from unconsciousness, should the patient injure themselves or others, interfere with or delay vital treatment, the providers who neglected to provide for the patient's protection – the providers who neglected to restrain the unconscious patient – are RESPONSIBLE for any injury incurred or caused by the unrestrained and unprotected patient, RESPONSIBLE for any treatment delay that occurs secondary to the unrestrained and unprotected patient acting in a manner that "undoes" or interferes with vital emergency care.

3. For Safe & Thorough Medical Assessment & Care of "COMBATIVE" PERSONS when a Medical Condition or Trauma is suspected to be associated with causing their combativeness, or if TRAUMA has occurred secondary to their combativeness (and they additionally require spinal immobilization).

4. For Safe & Thorough Medical Assessment & Care, and/or Transportation, When INVOLUNTARY Treatment of Persons INCOMPETENT TO REFUSE TREATMENT is Required. ("Behavioral" emergencies – the least-frequently-encountered reason for patient restraint.)

Legally, a patient may NOT refuse treatment, and will likely require
SOME form of RESTRAINT, if she/he is:

• UNCONSCIOUS
• CONFUSED (to person, place, time, OR situation)
• INTOXICATED, and exhibiting signs and/or symptoms of ILLNESS or INJURY
• A MINOR CHILD, and exhibiting signs and/or symptoms of ILLNESS or INJURY
• DEVELOPMENTALLY or PSYCHOLOGICALLY DISABLED,
  and exhibiting signs and/or symptoms of ILLNESS or INJURY
• VERBALLY or PHYSICALLY HOSTILE and/or THREATENING of others,
  and exhibiting signs and/or symptoms of ILLNESS or INJURY
• SUICIDAL (either verbally threatening or actively gesturing)

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

• Restraint is ONLY EVER applied for the PATIENT'S BENEFIT.
  If the patient did not benefit – in SOME way – from having been restrained, the patient was inappropriately restrained. Conscious, fully-oriented patients (capable of demonstrating "competency") have the RIGHT to refuse treatment and transport. Conscious, fully-oriented patients who provide permission for assessment and treatment do NOT require restraint.

• Restraint must ALWAYS be accompanied by CONSISTENT and REPEATED
  VERBAL ASSURANCES that the patient is "SAFE" ...
  CONSISTENT and REPEATED VERBAL ASSURANCES of
  the Care-Provider's INTEREST IN THE PATIENT'S WELFARE.
  Restraints are NEVER applied for "punitive" reasons. Nor should the patient's sense of self-worth be physically or verbally undermined by those who restrain her/him. Should substantiated witness testimony (that of two or more individuals) indicate that any care-provider made ANY type of derogatory comments to the patient, or about the patient – before, during, OR after restraint application – inappropriate restraint was performed.

• Restraint must NEVER cause INJURY.
  If ANY restraint device, or material, or method, results in patient INJURY,
  the patient was inappropriately restrained.
  "Reasonable exceptions" to this rule include unavoidable SUPERFICIAL INJURIES, such as: skin abrasions incurred during a confused or combative patient's persistent struggle against restraint; or superficial "skin-tears" of individuals with extremely brittle skin (such as the elderly or long-term diabetics); and the like – SUPERFICIAL INJURIES that could not be avoided.

• Restraint must NEVER, EVER, cause "PAIN!"
  Appropriately applied restraint WILL BE "uncomfortable." When an individual is strongly resistive to treatment and restraint, shoulder and lower body safety-belt-restraints require SIGNIFICANT TIGHTNESS to be as effective and SAFE as possible. Still, all restraints should be applied in a manner that is as "comfortable" as possible (avoiding painful pressure upon unprotected bony structures, and the like). If ANY restraint device or method can be demonstrated to cause "UNNECESSARY PAIN," the patient was inappropriately restrained.

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.

• The LEAST amount of restraint is that of Basic Body Safety Belt Restraints
  (ONE "shoulder/chest" restraint and ONE lower body restraint),
  WITH ONE wrist restraint.
• If ONE wrist restraint proves inadequate to ensure safety and thorough assessment/care,
  restraint of BOTH wrists should subsequently be employed.
• If the Basic Lower Body Safety Belt Restraint is CORRECTLY employed,
  ANKLE restraint is rarely required.
• However, should an appropriately-placed Lower Body Safety Belt Restraint prove inadequate to restrain the patient's lower body, Ankle Restraint should subsequently be employed.

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:

1. Thorough and complete examination and assessment cannot occur
   when a patient is restrained in a prone position.
2. Thorough and complete emergency care cannot be rendered
   when a patient is restrained in a prone position.
3. The most severely "combative" individuals are almost ALWAYS also TRAUMA VICTIMS!
   Thus, they ALSO require SPINAL IMMOBILIZATION.
   Spinal immobilization cannot occur when a patient is restrained in a prone position.
4. Forceful-Prone-Restraint has frequently been documented as contributing to
   DEATH from Restraint-Related Positional Asphyxia ("Restraint Asphyxia").

Confused Resistance
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.

Combative
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.

Positional Asphyxia
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.

Restraint 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.

"Mechanical" Restraint
is when restraint is achieved by using devices (handcuffs, straps, rope, or the like).

Forceful-Prone-Restraint
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."

Hobble
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.

Gauze Strap
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.

Wrist Restraint
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.

Ankle Restraint
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:

• 2) Restraint Protocol for EVERY Unconscious Patient

• 3) Resistively Confused Patient Restraint Protocol

• 4) Violently Confused or Combative Patient Restraint Protocol

• 5) Response When Forceful-Prone-Restraint (or Hobble Restraint)
  is Employed Prior To Your Arrival

• 6) Spinal Immobilization Protocol for the
  Violently Confused or Combative Trauma Patient

• 7) Documentation Guidelines for Every Restraint Application

• "Quick Look" On-Scene Restraint Reference Card

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