CHAS' REVIEW of Exercise Restraint

AUTHORS: W. Ann Maggiore, JD, NREMT-P
& Robert B. Palmer, PhD, NREMT-P
Published in the Journal of Emergency Medical Services (JEMS)
March 2002, Vol. 27 No. 3, pages 84-104.

Excerpts from "Exercise Restraint" are posted in NAVY BLUE text.

This article's biggest problem is one that faces ANYONE writing an article about this subject: You simply cannot adequately provide information about more than ONE patient restraint issue in any SINGLE patient restraint article.
Merely to cover the Restraint Asphyxia dangers of restraint requires a 3-part article. Adequate coverage of "legal" issues regarding restraint requires at least a 2-part article! (Part 1 of my 3-Part All Tied Up & No Place To Go article contains MY inadequate coverage of "legal" restraint issues.)
By seeking to cover both "Medical & Legal Issues" regarding restraint in one article, the authors were doomed to failure long before "Exercise Restraint" reached publication.

I'm not an attorney – don't play one on TV; didn't stay at a Holiday Inn Express last night. But, I believe that W. Ann Maggiore presented accurate "legal" issue information.
Unfortunately, her information was limited to merely "introducing" a few of the legal problems associated with inadequate or inappropriate restraint provision. The article entirely failed to specifically describe HOW emergency care providers can avoid legal difficulties related to patient restraint.

Instead of wasting space "justifying" the article's publication by summarizing several studies that identify how emergency care providers are uneducated when it comes to restraint, and how development of PROTOCOLS for safe and effective restraint techniques is grossly neglected – instead of wasting space "justifying" the article's publication with "Examples of circumstances that led to lawsuits" – I'd MUCH rather have read something ABOUT "how to handle violent situations without exposing yourself to unreasonable legal liability!"

Subjecting a patient with decision-making capacity to physical or chemical restraints may leave you open to lawsuits for assault, battery and false imprisonment, as well as medical negligence." Ok. So, HOW do I determine an individual's decision-making capacity without subjecting myself to lawsuits for assault, battery and false imprisonment, as well as medical negligence?!
"To defend against the legal challenges that frequently arise, the [restraint] protocol must call for detailed documentation of the reasons for restraint application, the methods employed and the monitoring of restrained patients." Yeah! So? What ARE the details that we should document? Gosh. They're not offered in this article.

There are plenty other examples of restraint medicolegal issues that were "introduced" in this article, yet never explained. But, I'll stop citing them!
W. Ann Maggiore is an accomplished EMS attorney and care provider. I dearly would appreciate her writing a 2- to 3-part article ONLY about the medicolegal aspects of patient restraint, and EXPLAINING how we can avoid setting ourselves up for litigation! If no hoity-toity hard-copy magazine (such as JEMS) will publish it: I'll post it HERE ... MERGINET.com would post it ... EMSVillage.com would post it! Tons of On-Line EMS and Fire and Law Enforcement "Webzines" would post it.
Yo, Winnie! If you WRITE it, it WILL be posted!

I can't spend much more time on this silly, inadequate article. So, here comes a quickie "summary" of its other inadequacies:

• "A syndrome known as agitated delirium, associated with cocaine and methamphetamine use, can cause sudden death."
  NOT BY ITSELF! It is the combination of agitated or excited delirium AND forceful-prone-restraint that causes death. This article is incredibly inadequate in it's coverage of restraint asphyxia. But, again, ONE article cannot cover the issue.

• "Preventing sudden death is the most important factor in management of agitated delirium. You can best accomplish this with a combination of physical and chemical restraint."
  This article inadequately (even ERRONEOUSLY) addresses physical restraint. And, its focus on chemical restraint is entirely wasted upon the VAST MAJORITY of EMS providers (of ALL certification levels), because FEW of us have the ability to chemically restrain people in the field. Even if we could, we FIRST would have to physically restrain them so that we can get an IV initiated ... or be able to bare their BUTT for an IM injection. Consequently, safe and effective PHYSICAL restraint directions are the first – most important – requirements of any restraint protocol. None were adequately provided by this article.

• Oh! I LOVED this part: EMS organizations across the country have very different views on what restraint methods are appropriate for EMS services. Jon Politis, director of Colonie (N.Y.) EMS, says, 'We have no formal training or protocols for physical restraints; we call law enforcement.' ... Russ McCallion, EMS operations chief for the San Francisco Fire Department, says, '...We use soft gauze restraints and handcuffs if the paramedic has been through police department-approved training.'"
  Plz see the "Why Is 'HAVE THE POLICE RESTRAIN THEM' Entirely Inappropriate and Inadequate to ALL "PATIENT RESTRAINT PROTOCOLS" section of my Web Site's PATIENT RESTRAINT PROTOCOLS Directory.

[Figure 8]

The authors briefly, but accurately, mention the fact that, "spineboard ... strapping methods may prove inadequate to fully restrain a combative patient." But, they never appropriately address methods that ARE "adequate." In fact, they submit Figure 8 as their example of a "medically acceptable and appropriate" means of restraint. Yeah. Right. There's a lot of medical assessment and CARE going on in that picture! This article and it's authors (as have so many others!) DISREGARD the need for medical CARE-provision when individuals are victims of an altered level of consciousness, and require restraint. Where is the oxygen provision? The IV for blood sugar sampling and medication administration?

AH! A QUICK REVIEW OF THE PHOTOGRAPHY!

[Figure 2]

HOO-RAH! At least the authors of this article consistently show patients restrained in a SUPINE position!!! I am truly thankful for that fact!!! Unfortunately, that's the ONLY safe and effective restraint technique demonstrated by ANY of the photography that accompanies this article.

[As soon as I finish this long-overdue review and get BACK to the new restraint program slides I'm supposed to be working on right now, I'll be using images from this article to DEMONSTRATE "Ineffective And Dangerous" methods of restraint!]

Oh! GOOD example of one-arm-up-&-one-arm-down ... unfortunately, the DOWN arm is ineffectively anchored. The "Upper Body" restraint strap is ineffectively and DANGEROUSLY positioned. I think there's an ineffective "hip" restraint strap running across this poor guy's GENITALS! The "Lower Body" restraint strap is ridiculously positioned BELOW the knees.

[Figure 3]

Figure 4 (below) is "RICH!" After providing so many examples of how there are NO "approved protocols" for restraint methods, the authors direct readers to rely upon them.

Multiple restraint methods exist. Check your department's protocols for approved methods.

The "Upper Body" restraint strap is ineffectively and DANGEROUSLY positioned. HANDCUFFS cause injuries and interfere with medical care. They do not belong in ANY ambulance! The "Lower Body" restraint strap is ridiculously positioned BELOW the knees.

And, as I've mentioned before: There's NO TREATMENT going on in ANY of these photos!

Figure 5 is PRICELESS! What part of HEAD INJURY (especially in the presence of an ALTERED level of consciousness) = NEED FOR SPINAL IMMOBILIZATION are the authors spacing-off here? Ah. The SAME PART that gets spaced-off by ALL the providers who end up being litigated for causing forceful-prone-restraint DEATHS – that's what part!

"Once you've restrained and adequately sedated an intoxicated individual, place them in the left lateral recumbent position – not prone."

Again, KUDOS to the authors for at least stressing (albeit in SMALL PRINT) the fact that PRONE positioning is RIGHT OUT! Unfortunately, since the authors have forgotten the fact that CARE must be administered, they are advocating an entirely ineffective "lateral" restraint positioning for a patient in need of thorough examination, assessment, and CARE provision. SUPINE restraint techniques, as described in All Tied Up & No Place to Go and Restraint Asphyxia – Silent Killer are the KEY to safe and effective MEDICAL restraint.

Figure 8 (below) is a wonderful demonstration of how TONS of wasted (dangerous and care-delaying) struggle with someone can occur, when they COULD have been safely and effectively restrained MUCH FASTER, had the restrainers known what the hell to do:

The "Upper Body" restraint strap is ineffectively and DANGEROUSLY positioned.

Oooh. Because the restraint strap positioning WASN'T "effective," they've tied a rolled-up SHEET in the SAME LOCATION. As if TWO ineffectively-positioned "Upper Body" restraints are gonna help? Nope. The arms are ineffectively restrained, and positioned in a manner that will cause headaches should someone actually want to PROVIDE TREATMENT for this individual (like, checking his blood pressure ... starting an IV to get a blood sample, testing it for hypoglycemia ... administering D50 ... etc...) The "Lower Body" restraint strap is ridiculously positioned BELOW the knees.

OH! But, a rolled-up sheet is EFFECTIVELY restraining him above his knees! Gosh. If they'd put the restraint strap in the right place to begin with, they wouldn't need the rolled up sheet!

Yet! The authors of "Exercise Restraint" identify Figure 8 as an example of a
"medically acceptable and appropriate" form of restraint.

Go Figure.

CONCLUSION

This article is entirely unhelpful in the effort to provide motivation or direction for the creation of safe and effective patient restraint protocols and practices.
I don't "blame" the authors. They knew not what they were doing.

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