I.
PURPOSE
To establish a standard/guideline to be utilized only when necessary and in those situations where the patient is exhibiting behavior that the pre-hospital care provider believes presents a danger to the patient and/or others
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. This procedure applies to patients being treated under implied consent, Police Emergency Exam Request, Court Decree of Incapacity or as Authorized by Medical Direction. Patients who are refusing treatment should not be subjected to this procedure unless police are on scene.
II.
STATEMENT
Use of a physical restraint on patients is permissible if the patient poses a danger to himself or others. Only reasonable force is allowed. The use of a chemical restraint on a patient is indicated where safe physical restraint poses a risk of injury to the providers and/or the patient AND where the patient continues to fight against physical restraints.
A. Reasonable Force: The minimum amount of
force necessary to control the patient and prevent harm to the patient or
others.
B. INDICATIONS: Restraints are to be applied to patients only in limited circumstances:
1. Behavior or threats that create or imply a danger to the patient or others.
2. Safe and controlled access for medical procedures.
3.
Changes in mental status that impede the treatment of
the patient.
4.
Involuntary evaluation or treatment of incompetent
combative patients.
5.
A written order by the Physician ordering the transfer
or an “On-Line Medical Direction” order allowing the restraints to be utilized
in the pre-hospital arena.
6.
The patient is being transported in the custody of the
Police Department and the arresting Officer is in the presence of the patient.
C. PRECAUTIONS
1. Restraints shall be used only when necessary to prevent a patient from seriously injuring him/herself or others. They MUST NOT be used as a punishment or for the convenience of the ambulance crew, but for the provision of safe transportation and treatment.
2. Any attempt to restrain a patient involves risk to the patient and the pre-hospital provider. Efforts to restrain a patient shall be done only when there is adequate assistance present.
3. During restraint procedures, every attempt should be made to avoid positions that may be associated with traumatic asphyxia.
4. Patients must have a Physical examination performed (if permitted) prior to applying restraints. They should be assessed for extremity injury and for any neurological, metabolic or traumatic injury. Pre existing conditions, such as but not limited to: hypoxia, hypoglycemia, narcotic overdose, should be treated utilizing the appropriate patient care guideline.
5. A post restraint Physical examination must be performed. Assessment and documentation of Pulses, Motor and Sensation distal of each restraint and any injuries that may have occurred during the restraint process must included.
Issue Date: Signature:_____________________________________
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Revised |
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6. Ensure that the patient has been searched for weapons by law enforcement personnel.
7. In the case of a violent or threatening patient, immediately contact the local Police Department for assistance.
8. Any patient in hand cuffs, shackles or “in custody” must have law enforcement, Department of Corrections or Sheriffs/Marshals with the patient at all times, including the patient compartment of the ambulance during transport.
III.
VERBAL
DE-ESCALATION PROCEDURE
A. Guidelines
1.
Make every attempt not to aggravate or worsen
pre-existing injuries or medical conditions
2. Attempt to control the patient with non-violent crisis intervention techniques
B.
Procedure
1. Be aware of Proxemics
a. Avoid invasion of the patient’s personal space
b. Maintain a safe distance and refrain from touching
2. Be aware of Kinesics
a. Do not use intimidating body language
b. Keep your hands in front of your body in a non-threatening manner
c. Use a supportive body stance while protecting your exits
3. Use Empathic Listening techniques
a. Use therapeutic rapport
b. Listen to patient's concerns
c. Only one provider should communicate with the patient
d. Empathize, use positive feedback
4. Be aware of your Paraverbal Communications
a. Maintain a soothing tone of voice
b. Control your Tone, Volume and Cadence of speech
5. Set Limits as needed
a.
Limits should be simple, clear, reasonable and
enforceable
b.
Limit the number of choices
c. Calmly set boundaries of acceptable behavior
IV. PATIENT CAPACITY ISSUES
A. Medical decision making capacity is defined as the ability to give informed consent to go through a particular medical test or intervention or the ability to refuse such intervention.
B. When tasked to determine the mental capacity of a patient to refuse treatment, ask yourself these questions about your patient:
1. Is the patient in danger of hurting himself or others?
2. Is there or could there be an underlying medical emergency that may lead to death or worsen considerably if not treated soon?
3. Is there an emergency medical intervention that must be made to avoid a worsening in your patient's condition?
4.
Does your patient understand the risks of refusing
these treatments or interventions? Have you made those clear?
5.
These questions apply only to the patient's immediate
situation, not to long-term medical care.
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V.
PHYSICAL
RESTRAINT GUIDELINES
A.
Use the minimum physical restraint required to
accomplish necessary patient care and ensure safe transportation:
1. If law enforcement or additional personnel are needed, call for it prior to attempting restraint procedures
2. Do not endanger yourself or your crew
3. Patients that are actively seizing should never be restrained.
B. The acceptable physical restraints are soft in nature and pose no threat to the patient’s extremities and/or physical presentation. These devices should be used to restrain the patient and not injure.
C.
Avoid placing restraints in such a way as to preclude
evaluation of the patient's medical status (airway, breathing, and
circulation). Consider whether placement of restraints will interfere with
necessary patient care activities or will cause further harm.
D.
Patient will be restrained in a face up position.
E. Restraint Types:
1. The recommended Physical Restraint Device is a medical soft restraint. Other acceptable means may be a tied (not taped) pillowcase or towel.
2. Only the extremities shall be restrained and these restraints must be assessed every five minutes.
3. If necessary, use cervical spine precautions (CID) to control violent head or body movements
4. Place padding under patient's head and wherever else needed to prevent the patient from further harming him/herself or restricting circulation
5. Medical Direction MUST approve any variation of a restraint device.
6. Unacceptable Device/Methods: Some unacceptable means of restraint are:
a. Leather restraints, oxygen tubing, tape, string/rope
b.
Handcuffs (not in the custody of an accompanying
Police Officer/Corrections Officer etc.).
c.
Any restraint tied around the head, neck or
chest.
d.
Restraining a
patient’s hands and feet together behind the patient (hog-tying) is not
allowed.
e.
“sandwich” between Long
Board and Scoop is not allowed.
f.
Restraining in the prone
position is NOT ALLOWED. This position as been associated with traumatic
asphyxia and death.
g.
Any position that may limit breathing, airway
management or treatment/evaluation of the patient.
7. Any patient in hand cuffs, shackles or “in custody” must have law enforcement, Department of Corrections or Sheriffs/Marshals with the patient at all times, including the patient compartment of the ambulance during transport.
F. Complications of Restraints:
1.
Aspiration can occur, particularly if the patient is
supine. It is the responsibility of the
2.
Nerve injury or soft tissue damage may occur
from restraints that are applied tightly.
3.
Traumatic Asphyxia.
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G. PEDIATRIC
CONSIDERATIONS:
1.
H. PREGNANCY
CONSIDERATIONS:
1. Pregnant women should be restrained in a semi-reclining or left lateral recumbent position.
VI. CHEMICAL RESTRAINT GUIDELINES
A. Sedative agents may be used to provide a safe, humane method of restraining the violently combative patient who presents a danger to themselves or others and to prevent the violently combative patient from further injury while secured by physical restraints
B. These patients may include but are not limited to the following:
1. Alcohol and or drug-intoxicated patients
2.
Restless, combative head-injury patients
3. Mental illness patients
4. Physical abuse patients
5. Physically restrained patients who continue to fight against restraints.
C. Chemical Restraint Procedure
1.
Assess the possibility of using physical
restraint first; evaluate the personnel needed to safely attempt to restrain
the patient
a.
Consider law enforcement intervention
2.
Contact On-Line Medical Control prior to
administration and clearly state the need for sedation if you think it is
necessary for safety or patient care
3.
In cases of extreme
patient combativeness, and the following conditions exist:
a.
An danger of injury
to care givers and law enforcement exists
b.
Patient can not be restrained by
Special note: Standing Order Use of Versed for extremely
combative patients should be a last result. Contact Medical Direction if at all
possible, prior to administering chemical restraint.
c.
Adult Patients only (over 13 years old), Administer Midazolam (versed)
i.
Midazolam (versed) 2 mg IV
OR
ii.
Midazolam (versed) 5 mg deep IM
iii.
Be alert for respiratory depression and
airway compromise
iv. CONTACT MEDICAL DIRECTION FOR ALL REPEAT DOSES (see 4 below)
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4.
CONTACT MEDICAL DIRECTION FOR MIDAZOLAM (VERSED)
a.
IV:
i.
ADULT: MIDAZOLAM (VERSED) 2
MG IV.
ii.
PEDIATRIC: MIDAZOLAM (VERSED) 0.1 MG/KG IV, MAX SINGLE DOSE OF 2 MG.
b.
IM:
i.
ADULT: MIDAZOLAM (VERSED) 5 MG DEEP IM
ii.
PEDIATRIC: MIDAZOLAM (VERSED) 0.2 MG/KG (MAX DOSE 5
MG) DEEP IM.
c.
CONTACT MEDICAL DIRECTION FOR REPEAT DOSAGES
i.
IV MIDAZOLAM (VERSED) REPEAT DOSES
ii.
IM MIDAZOLAM (VERSED) REPEAT DOSES
(i
ADULT: MIDAZOLAM (VERSED) 5 MG DEEP IM
(ii
PEDIATRIC: MIDAZOLAM (VERSED) 0.2 MG/KG (MAX DOSE 5
MG) DEEP IM.
5. Prepare for possible hypotension and respiratory depression side effects
6. Vital signs should be assessed within the first five minutes and thereafter as appropriate
7.
The violently combative patient stands a lesser chance
of injury when sedated
D.
Treatment post
Police Non-Lethal Device use
1.
OC, capsicum, Mace, Etc.
a. Move patient to open space
b. Allow time for substance to dissipate
c. Decon and irrigate with water
d. DO NOT use NS, LR or soap
2.
TASER
a. Evaluate for fall injuries
b. Evaluate for Cardiac Dysrhythmias
c. Evaluate for trauma from Taser Darts
d.
Remove TASER darts if they impede treatment
AND you have obtain permission from Law Enforcement
i. Secure skin around dart
ii. Grasp dart at base, not the wire
iii. Protect hand from dart
(i Dart is similar to a fish hook and has a barb
iv. Pull dart straight out
v. Treat any hemorrhage
vi. Save dart for Law Enforcement (considered evidence)
3.
Bean Bag Round
a. Evaluate for trauma at impact site
b. Impact sites of head, abdomen and chest have high incidence of serious injury and should receive extra assessment and treatment if needed.
4. Document devise(s) used, impact sites and trauma inflicted on PCR
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E. Required Documentation (Minimum)
1. An emergency existed
2. The need for treatment was explained to the patient (regardless of competence)
3. The patient refused treatment or was unable to consent to treatment
4. Evidence of the patient’s incompetence to refuse treatment
5. Failures of less restrictive methods of control (such as VERBAL DE-ESCALATION)
6. The restraints were used for the safety of the patient or others
7. The reasons for restraint were explained to the patient (regardless of competence)
8. The type/method of restraint used and which limbs were restrained
9. Injuries that occur during the restraint procedure
10. Which agency(s) placed the restraints
11. The ongoing assessment of PMS (distal to the restraints) and the patient’s ability to breathe
12. Any assistance used for restraining (i.e.: PD, FD, Etc.)
SPECIAL NOTES:
I.
*Constant evaluation of your patient's airway
status and documentation of such is extremely important.
II.
The use of SaO2
monitoring may be useful in assessing distal circulation, but does not take the
place of Pulses, Motor and Sensation checks.
III. Law Enforcement Officials should be involved, if available, when restraining patients.