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Operations Team Leader for Pridemark Paramedic Services of Arvada, CO |
Received via Email to Charly D. Miller, on Wednesday, May 07, 2003.
Subject:Tricks article
Charly,
I appreciate your web site. Proper patient restraint is a critical issue that most all caregivers could use more training and information about. I was part of a restraint protocol comity at Pridemark Paramedic Services, chaired by Thom Dick. While I don't speak for Thom and don't wish to represent him, or his ideas, in this correspondence, I do feel that I can represent some of the trial and error that led our comity to adopt many of the restraint techniques shown in Thom's "Tricks" article for use at Pridemark. Perhaps your internet audience would benefit from understanding some of the thought process that led us to use many of Thom's techniques.
Regarding your statement that you are "reasonably sure" that Thom is caring and responsible, I can assure you that Thom is one of the most compassionate caregivers I have ever met. I know that Thom's motivation to better train our employees and his readers about better restraint techniques stems from his immense compassion for our patients and his understanding of how poorly trained many of us are regarding appropriate patient restraint. I would like to think that we could disagree on the best restraint techniques without questioning each other's intentions.
Regarding caregivers placing an arm across the patient's neck. I agree with you that any type of restraint that involves placing pressure on a patient's neck is inappropriate. The question that remains is how best to prevent the patient from injuring their head or using it as a weapon or fulcrum while protecting the rescuer from bites. We found that the best method seemed to be using your arm (to keep fingers out of the way) and controlling the head from the top and under the chin. The significant down side to using this technique is that it looks quite a bit like a choke hold and I do have some concern that others observing the procedure could easily get that idea and decide to use the technique themselves. I'm not personally convinced that providers cannot overcome the adrenalin and excitement of patient restraint and keep their arm off of the neck. On the contrary, an organized, well-planned restraint protocol should allow providers to stay calm and appropriate.
While the use of a jaw thrust maneuver would be ideal in controlling the head, we have not found it effective in maintaining control of a patient fighting for their life. You point out that purposefully violent patients are a small subset of those in need of restraint - a fact that I appreciate you emphasizing. (However, your suggestion that the word violent rules out patients who are aggressive secondary to an underlying medical condition seems like semantics.) Patient who resist care because of confusion, hypoglycemia, post-ictal states, extreme intoxication etc. are often very frightened and feel as if they are fighting for their lives. At Pridemark we have given the care provider at the head a set of thick leather gloves to protect the hands from bites and to better grasp a diaphoretic face and avoid inadvertently scratching the patient. Once the patient is supine, the hands move to the face and grasp the head from both sides. I would be concerned for the fingers of a provider using a jaw thrust in these situations. I don't feel that we have decided not to use this technique out of laziness or because it seems too difficult, it just didn't seem effective.
I feel that saying Thom's article advocates hair pulling is like saying that nasal intubation advocates shoving hoses up people's noses. Unfortunately, some things we do in the patient's best interest require that we cause the patient some discomfort. The rational behind using the hair is to make the top hand the primary control hand, not the lower arm (for obvious reasons that we both seem to agree on.) While I don't like the idea of grabbing my patient's hair any more than I like inserting an ET tube up their nose, I feel it is an acceptable trade-off to ensure that the lower arm does not engage the patient's neck. Using the jaw thrust technique does not seem applicable when the patient is not yet supine on the pram.
The idea of having a provider straddle the patient and face the feet did not stem from an outdated idea that we should avoid making eye contact. No such discussion ever came up in our group. The idea to have a provider sit on the patients legs came from a desire to eliminate an often used technique of a provider placing a knee or lower leg across the patients thighs. This is horribly uncomfortable for the patient. The sitting technique seems far more effective and more comfortable for the patient. I agree that the provider facing the patient and the team leader would be better, but that is an unusual position on a pram and the straddling providers legs interfere with the pram rails making restraint of the hands much harder. With the "face the feet" technique, upper body team members do need to realize the importance of protecting the provider facing away from the patient.
While we are using a cross arm technique for restraint, I do agree that this technique requires extreme diligence on the part of the rescuer to not allow the arms to constrict the chest. I would hope that any provider that uses this technique would also use supplemental oxygen, pulse oximetry, ECG monitoring and I would like to see non-invasive capnography used as a standard for any restrained patients. I think capnography waveform analysis and ETCO2 readings could provide a much more definitive look at hyposaturation and hypercapnia. I don't feel any assessment of a patient's ventilatory status is complete without looking at both sides of the equation. I would also like to more aggressive use of chemical restraint when appropriate.
I have not found the cross arm technique prohibitive to patient care. All IV access is still available except the AC's and inner arms, an area I avoid in combative patients anyway. Chest auscultation and abdominal assessment all still work.
We do use the one arm overhead and one arm to the side technique that you show in your review, however we have found that technique problematic for several reasons as well. First, we found that a patient that is combative can roll or "corkscrew" toward the downward arm even when the chest strap is tight and high in the armpit. This can leave the patient in a sideways or face down position with one arm across the face. Once face down, airway control is impossible and the procedure needs to start from square one again. Tightening the upper chest strap tight enough to rule out the patient rolling feels like it constricts the chest just as significantly as the cross arm technique. That's just my subjective opinion. Also, the upper arm tends to cramp and become an uncomfortable focal point for the patient. I think it's a good technique and would never call it "wrong" or "inappropriate" but it does have some drawbacks as well. I will continue to use it with caution as well as the cross arm technique.
I appreciate your web site and your willingness to call Thom's article on the carpet for scrutiny. Like most things in medicine, the school of thought on patient restraint is still developing. I don't rule out that much of our restraint protocol may change over time. When we review our protocol, I'm certain that your web site will prove a valuable resource. Open discussions such as these can only serve to advance our understanding of this important skill. In the end, our patients will benefit and that is everyone's goal.
Steve Whitehead, EMT-P
Operations Team Leader
Pridemark Paramedic Services
Arvada, CO
Email Charly at: c-d-miller@neb.rr.com