Special Patients Or Special Restraint Situations
By C D. Miller, Paramedic
SEIZURES & RESTRAINTS do NOT go together! If a patient begins to seize, CUT THE RESTRAINTS LOOSE. Rapid release from restraint is incredibly hard to accomplish if you're using leather or mechanical restraints - isn't it?!?! 
Seizures produce violent muscular contractions that can fracture bones even when restraints are not being employed. If a restrained patient seizes, and the restraints remain in place, and the patient fractures something, THE RESTRAINER MAY BE CONSIDERED RESPONSIBLE FOR THE FRACTURE! 
SEVERELY DEVELOPMENTALLY DISABLED patients, PATIENTS ON PCP, or
PATIENTS EXPERIENCING METHAMPHETAMINE PSYCHOSIS:
When combative, these types of patients are incredibly strong and pose a serious danger to themselves and care-providers! When a "normal" person exerts his muscles, the point at which he can no longer exert the muscle is the point at which a PAIN response is felt. One of the effects of PCP overdose or methamphetamine psychosis is a LOSS OF PAIN RESPONSE. This is why such patients can exhibit "superhuman" strength, seriously injure care providers who have less than an "army" present to control them, and even fracture their own bones once restrained. Similarly, severely developmentally disabled patients also frequently have NO PAIN RESPONSE. They feel a "stimulus" when pain is experienced, but they do not perceive the stimulus as "pain." They may even "entertain" themselves by self-mutilating acts such as peeling their cuticles down the length of their fingers, or banging their heads against brick walls. Because PCP users, patients experiencing methamphetamine psychosis, and severely developmentally disabled patients lack a pain response, they are extremely dangerous when combative, and present a lethal hazard to EMS providers! 
To "safely" restrain such patients, you must first have a small army available for safe manual restraint. If you do not have five or more people to help you control the patient, leave the patient alone! Remove all third parties from the patient's immediate vicinity and wait for additional assistance to arrive before approaching the patient. Once five or more team members are present, one person should "call the shots" and coordinate a safe and controlled take-down of the patient, subsequently coordinating application of chest and lower limb restraint belts, then double-strength soft safety bracelets. Again, appropriate anchoring is vitally important to the success of restraint. 
PREGNANT WOMEN: Why would you EVER need to restrain a pregnant woman?! For all the SAME REASONS you would need to restrain any other patient - that's why. With pregnant women, however, remember the SUPINE HYPOTENSIVE SYNDROME that can be caused by placing them flat on their backs. When a pregnant patient is placed in a supine position, the weight of her gravid uterus can compress the inferior vena cava and impede venous return to the heart. This causes hypotension and can threaten fetal perfusion. As with ANY transportation of a pregnant patient, keep the restrained pregnant patient's weight on her left side by counseling her to stay on her left hip. 
If four-point restraints are required for a pregnant woman (one who will not cooperate with staying on her left side), restrain the chest and wrists as you normally would, BUT RESTRAIN THE ANKLES SEPARATELY, AT OPPOSITE CORNERS OF THE PRAM. This means that the left ankle is restrained to the right corner of the pram, and the right ankle is restrained to the left corner of the pram. Remember to place the lower safety belt over her legs, just above the knees. This positioning will "encourage" the patient to keep her weight on her left hip and help avoid supine hypotensive syndrome. 
MALE vs. FEMALE PATIENTS AND RESTRAINTS: Is there a difference? I have absolutely no research studies to cite. To my knowledge, no one has ever done a study of gender differences in combativeness, or restraint success or failure. However, having worked for many years at a state psychiatric facility (prior to my EMS training), I have a LOT of personal experience in restraining violent men and women. It is my opinion that severely combative women are much more dangerous than combative men! 
If you gather a small army and physically restrain a severely combative man, once manually restrained, he usually stops fighting. After he is placed in restraints, he'll often spend some time "testing" the restraints, but will eventually give up the struggle. Angry, severely combative women, however, will never stop trying to hurt you! 
When restraining a WOMAN anticipate that she will continue trying to injure you in any way possible, no matter how many people are holding her down! She will continue trying to scratch you with a free fingernail, or bite you, or knee you, or injure you in any way possible - until HELL FREEZES OVER. This includes after she has been securely restrained with chest and thigh belts, and 4-point soft safety bracelets. 
Again, this opinion is based only upon my personal observation and experience, but I believe it to be true. (Remember that, I'M A WOMAN, so don't get all up in arms about my opinion being sexist.) Watch out for combative women, they will hurt you! 
RELEASE FROM RESTRAINTS: If a patient was combative prior to restraints, THE RESTRAINTS SHOULD STAY ON UNTIL THE PATIENT HAS BEEN TRANSFERRED TO THE RECEIVING FACILITY!!! Do not allow "bargaining" - the safety of you and your patient is not up for debate. The only exception is the onset of seizures. If the patient seizes, CUT THE RESTRAINTS (good luck getting leather or mechanical restraints off quickly). Stop the ambulance and have your partner assist you with the care of the patient. Once the seizure has stopped, replace the restraints - unless you are dealing with STATUS seizures; then use PHARMACOLOGIC restraints, simultaneously treating the seizures. 
If the patient was restrained because of confusion or anticipated combativeness (hypoglycemia, TIA, postictal states), the number of restraints may be reduced once the confusion is corrected. But some restraint (at least one wrist) still should be continued. Anyone who was combative because of hypoglycemia may become hypoglycemic (and combative) again. Combative postictal patients may have another seizure (become combatively postictal again). Combative TIA patients may have another TIA. And so on. If you remove all restraint and the patient's combativeness returns, you've endangered yourself and your patient. 
Section IV: Spinal Immobilization Of Combative Patients:
Combative patients who require spinal immobilization present a special challenge to emergency care providers. As a matter of fact, they require a Spinal-Immobilization-Protocol all of their own! Unfortunately, to date, NO ONE has researched and substantiated a protocol for the safe and medically appropriate method of spinally immobilizing a combative patient. What follows are my personal opinions and observations about this subject. I do not have any medical research to base these upon! They are developed solely from my personal experience, and my understanding of the kinetic forces involved with combative patients. 
To a great extent, patients are responsible for assisting with - cooperating with - their own care. This basic assumption underlies the vast majority of emergency care protocols. However, when altered levels of consciousness (secondary to trauma or acute medical causes) impede a patient's ability to cooperate with appropriate, "standard," care procedures, altered protocol procedures must be employed. Patients are people. Their individual needs don't always follow "standard" protocols. As emergency care providers, our basic, universal goal is to provide the best, most appropriate, care and protection for each individual patient, without further injuring the patient or endangering others. 
My Protocol For Spinal Immobilization of Combative Patients is based upon the following: 
1.	standard, historical spinal immobilization protocols (designed for cooperative patients) 
2.	common sense anticipation of stresses involved with combativeness and the application of standard spinal immobilization protocols 
3.	altered spinal immobilization protocol approaches anticipated to provide the best possible patient care and protection when the patient is combative and resistant to treatment.
Before any care or control can be safely initiated, enough providers must be present. At least FIVE or more people are required to safely control and treat any combative patient - especially one requiring spinal immobilization. That's one provider per limb/major-body-section, and one provider to obtain and apply restraints/immobilization devices. (Prior to the accumulation of such a "small army" of providers, keep care providers and third parties away from the combative, probably spine-injured patient, to ensure their safety.) 
RULE #1: GO TO GROUND AND STAY THERE! Providers must act simultaneously, as a team, and control the "take-down" of the patient so that a minimum of additional injury is risked. Get the patient on the ground and keep him there. As soon as possible, make sure that the patient is placed supine (see positional asphyxia information in SECTION II). 
RULE #2: AVOID WRESTLING WITH THE PATIENT'S HEAD! If the mechanism of injury suggests potential cervical spine (C-spine) injury, you must assume that C-spine injury exists. In my opinion, following the "standard" spinal immobilization protocol of immediately controlling (immobilizing/restraining) the patient's head and C-spine when the patient is physically resistive to immobilization increases the risk of neurologic compromise should C-spine injury actually exist. Attempts to manually restrain a patient's head against his will - wrestling with the patient's head - significantly increases the stresses upon the patient's C-spine. I suggest that, leaving the combative patient's head alone causes less cervical spine stress and less risk of increased injury. 
As soon as a patient evidences strong (combative) physical resistance to C-spine control, such control should be discontinued. Then, immediately employ these three simple, specific verbal cues: 
1.	"Please stop moving your head." 
2.	"You probably have a neck injury from the force of that accident." 
3.	"If you keep moving your head you may become paralyzed or even die."
Continue repeating these three verbal cues throughout the remaining steps of immobilization. No, these verbal cues probably won't work - remember, these patients have an altered level of consciousness and are unlikely to understand or follow cues. But these cues sound a lot better on video tape than yelling, "Stop moving your head!" and the like (or worse). Avoid arguing with the patient. Simply keep repeating the three magic cues, and carry on with patient care. 
If head-banging ensues, provide padding around the patient's head. A blanket or "head bed" will eventually be needed for spinal immobilization anyway. 
If the patient attempts to bite or injure others with her/his head, then you will be forced to restrain the patient's head to prevent injury of others. Although in-line cervical spine "traction" was discontinued years ago, it is probably the best, most effective way to restrain a combative patient's head and still protect her/his C-spine. Anchor your fingers around the patient's jaws and apply slight in-line, axial traction. Avoid hyperextension and apply only enough in-line traction to prevent biting and head-butting. Once this sort of in-line traction is applied, however, it must be manually continued, without pause, until the patient is completely immobilized and no longer combative! 
Likewise, do not attempt to wrestle a cervical collar onto a combative patient. Since any cervical collar (C-collar) provides little (true) immobilization, one may or may not be applied after the patient is better controlled. 
SPECIAL NOTE: Once the patient is manually restrained, if you have the ability to administer a chemical restraint, you may consider doing so. Unfortunately, you'll have to inject it intramuscularly (IM), because you don't have an IV established and are unlikely to establish one until after the patient is completely restrained and immobilized. Thus, the amount of time before onset of IM injected chemical restraint will be lengthy in most cases. Additionally, I do not advocate the use of chemical restraint prior to complete examination and thorough evaluation of the patient's injuries and medical condition (especially when the patient's problem may be related to toxic or poisonous chemicals already present in his system). Thus, I prefer to wait until the patient is restrained, immobilized, examined, and evaluated before introducing any EMS chemicals. 
RULE #3: BRING THE BACK BOARD TO THE PATIENT! Remember RULE #1? "Go To Ground And Stay There." That means that the back board must come to the patient. If you attempt to lift and move a combative patient - even when manually restrained by a provider holding each limb and major body part - you risk dropping the struggling patient, risking further injury to both patient and providers. 
In a lovely, level, and clear environment (such as clear streets and highways), it shouldn't be a problem to slide a long back board under a manually restrained patient. Rather than sliding the board in from the side, however (where two or more providers are positioned, restraining the patient), slide the board under the patient from the head-down (or the feet-up). 
Unfortunately, uneven terrain or piles of debris will interfere with sliding a board under the patient. In that case, get the board as close to and as level with the patient as possible. Working as a team, all providers must minimally lift and slide the patient onto the board. 
Scoop stretchers are rarely helpful in any combative-patient restraint or immobilization situation. First, there's too many bodies on and about the patient to allow for efficient "scooping." Additionally, if attempting to "scoop" a patient who is on uneven or debris-filled terrain, you invariably meet with problems. Either you unevenly scoop-and-stress the patient's spine, or you scoop-up a bunch of debris along with your patient. Use a long back board. It's a good thing. 
RULE #4: SILVER DUCT TAPE IS YOUR FRIEND! If applied in correct order and utilizing a specific manner of body-part restraint/immobilization application, silver duct tape can be a very effective, rapid method of securing the combative patient to a spine board. If you don't have silver duct tape, strong (double-folded) versions of Kerlix(r) or Kling(r) roller gauze are your next-best friends. 
Whatever you use - duct tape or roller gauze - apply the restraint/immobilization material in the following order and manners: 
1.	Immediately above the patient's knees: Attach one end to one side - above the knee - draw it tightly across the patient's legs, and attach the other end to a corresponding site on the other side. By attaching/immobilizing the patient's knees first, you immediately "free" two providers (the ones holding each leg) to assist with rapid application of the remaining restraint/immobilization devices. 
2.	"Cross" ("X") the patient's shoulders: Attach one restraint end to the board immediately above one shoulder, then run it diagonally across the very top of the patient's chest to the opposite side, pulling it tightly, and attach it to the board immediately below the opposite armpit. Repeat on the other side. This technique successfully immobilizes the patient's chest to the board by means of an "X" over the shoulders. This technique is specifically designed to avoid interference with chest expansion (respiration). 
3.	"Cross" ("X") the patient's hips: As with the shoulder restraint, begin by attaching the restraining material to one side of the board, at a site above one hip. Then run the restraint diagonally across the pelvis, pulling it tightly before attaching it to the opposite side of the board, about where the femur joins the pelvis. Repeat on the other side. 
4.	Immobilize each wrist: If the patient is persistently combative, attempting to defeat the shoulder restraints, consider restraining one wrist above the head, the other below the hips. Remember to apply gentle traction of the extended wrist, anchoring the restraint at a point distal to the hand/wrist, so that this limb is "restrained" in an extended position and truly immobilized - not simply "tied up." 
5.	Next, wrap a restraint around the ankles and attach it from side to side over the ankles. 
6.	Now you must decide whether to immobilize the combative patient's head, or to obtain IV access and initiate chemical restraint. If IV chemical restraint is at your disposal, it may be a better choice at this point (thus minimizing the amount of patient resistance to head immobilization, and minimizing the stresses placed upon the patient's unprotected, unsupported C-spine). However, remember that you haven't performed a full examination or evaluation of the patient's injuries or medical condition as yet. Thus, chemical restraint may be equally as deleterious as head immobilization while the patient is still resistive and combative for unknown reasons. 
7.	Whatever you do, when you are ready to immobilize the patient's head, use TAPE (silver duct tape or white-cloth) and apply it across the patient's forehead, from side to side, placing it DIRECTLY OVER THE PATIENT'S EYEBROWS! The eyebrows (the patient's superior orbits) will provide a substantial anchor for keeping the resistant patient's head from moving. This is not a cruel or depilatory manner of immobilization! As long as the tape is torn down the middle and removed by pulling it from the center out (in the direction of eyebrow hair growth), only a very few eyebrow hairs will be removed with the tape. 
8.	And, now you may attempt to slide a C-collar into place - as long as it doesn't require struggle and manipulation of the C-spine to apply it! If any struggle or cervical spine manipulation is required to apply a C-collar, you are risking further injury to a patient who is already (for all intents and purposes) fully immobilized.
At this point, your combative, spine-injured patient has been completely immobilized in a manner that has minimized potential for care-provider-caused ("iatrogenic") aggravation of injuries! You may now cut away the patient's clothing, conduct a thorough and unimpeded exam, and perform all necessary care measures. 
Section V: Miscellaneous Restraint Techniques:
SHEETS AS RESTRAINTS can be handy if your safety belts are missing, nonfunctional, or the patient is too obese for the belts to safely reach across his chest. First, fully unfold a sheet. With a partner's assistance, each of you take opposite corners and twirl the sheet to wind it up upon itself, forming a fabric "rope," of sorts. Draw the rolled sheet all the way around the patient and pram/board/scoop if possible. If not, securely anchor one side first, then draw it over the patient and pull the rolled sheet tightly across to the other side. Then securely anchor the other end. Placement of sheet restraints is the same as that of belt restraints. Be sure to anchor the sheet in a manner that will prevent it from sliding downward, impeding the patient's ability to breath or allowing the patient mobility of his upper body. 
SPIT SHIELDS are difficult to argue as being for "patient safety," but easily defensible as precautionary measures to prevent the spread of communicable diseases (protection of third parties and care providers). However, placing a roll of gauze into someone's mouth constitutes assault, battery, and medical negligence (especially if the patient proceeds to vomit and aspirate). Likewise, covering a patient's face with a sheet or towel impedes your ability to monitor the patency of your patient's airway (especially in the event of emesis). 
The 1994 DOT EMT BASIC CURRICULUM suggests "Cover face with surgical mask if spitting on EMT Basics." I find that directive outrageous and criminal! A surgical mask, or other form of paper mask, does not allow you to visualize the collection of sputum or emesis. Thus, the patient may be placed at risk for aspiration. 
Additionally, if someone has an "altered level of consciousness" - such as when a patient is combative and spitting - that person ought to be given oxygen! 
SHAME ON THE DOT!!!
Every ambulance carries a nonrebreather oxygen mask or a simple oxygen mask. When employed with an appropriate oxygen flow, these devices are easily documented as "administration of oxygen," and will also provide protection from the patient spitting at you. However, never use an oxygen mask (especially a nonrebreather) as a spit shield unless you are simultaneously administering oxygen. To do so will cause hypoxia. 
THE SINGLE-HANDED-PROVIDER RESTRAINT APPLICATION TECHNIQUE: Sometimes, waiting for others to arrive and assist in application of restraints is not an option. In times like this, when you must physically continue restraining a limb while also applying a restraint, use these tips: 
•	Use your dominant (strongest) hand to restrain one of the patient's limbs. 
•	If your roller gauze isn't already open and hanging on the bar of your ambulance's patient compartment, open a roller gauze package (OK, with your teeth) and grasp the end of the roll. 
•	Holding the end, unfurl the roll and then pick up the other end so that you have both ends in your free hand. Now you are holding the ends of a doubled length of roller gauze. 
•	"Launch" the doubled length of roller gauze into the air, and catch it over the back of your free wrist (palm facing the floor). Scoot your wrist as needed so that it arrives at the middle of the doubled length of roller gauze. 
•	Reach downward with your free hand, keeping your wrist high, to grasp the lengths on either side of your wrist together. 
•	Holding onto the two sections, whip the middle of the roll from above your wrist over your hand (or rub it off of your wrist, using your thigh) - thus forming a loop. 
•	Widen the loop you have just made. 
•	Slide the loop onto your own (free) wrist. 
•	Now change hands, by grasping the patient's limb with your roller-gauze-loop-covered hand. 
•	Quickly slide the restraint ("soft-safety-bracelet"!) from your wrist onto the patient's wrist and snug it down. 
•	Secure the restrained limb to an appropriate anchor point. 
•	Check for circulation impairment!
This technique produces a "slip knot" restraint. Thus, if the patient struggles against it, the restraint will become tighter and tighter, potentially impairing circulation and allowing "play" between the wrist and the restraint anchor site. If transport time is short, you may leave the "quick restraints" in place, loosening them slightly upon your arrival at the ED. If transport time will be greater than 15 to 30 minutes, you should re-restrain these limbs using a "locked" clove hitch (as demonstrated in class), a "full knot" restraint (described in the next handout segment), or any other method of tying that prevents restraint tightening. Then cut away the slip-knot, "quick" restraint. 
THE "FULL KNOT" METHOD OF LIMB RESTRAINT: 
•	Take a doubled length of roller gauze and place it around the patient's wrist, with the wrist at the center of the roller gauze length. 
•	Tie a half-knot, tightening the restraint until it cannot be slid off the patient's wrist, but does not occlude distal circulation. 
•	Finish the knot by tying another half-knot once the appropriate size is reached - this is a "full" knot. 
•	Anchor the full-knotted-restraint at the same T-junction that any other restraint is anchored. (If replacing a slip-knot, be careful to tie this new restraint above or below the slip-knot. If tied on top of the slip-knot, when the old restraint is severed, the full-knot's material will become loose, also loosening the new anchor.) 
•	Check for circulation impairment.
THE "LOCKED" CLOVE HITCH RESTRAINT: 
•	Using a doubled length of strong roller gauze, assemble a clove hitch. (If you don't know how to do one, find a Boy or Girl Scout and ask them to instruct you!) 
•	Slide the clove hitch onto the patient's limb and snug it down so that it is tight enough to prevent sliding off of the patient's hand, but not tight enough to impair distal circulation. 
•	Tie a "half knot" on top of the snugged clove hitch. This will "lock" the clove hitch so that it will not become tighter - in spite of patient struggles to defeat or escape from such a "soft safety bracelet." 
•	Anchor the locked clove hitch restraint at the same T-junction that any other restraint is anchored. (If replacing a slip-knot, be careful to tie this new restraint above or below the slip-knot. If tied on top of the slip-knot, when the old restraint is severed, the full-knot's material will become loose, also loosening the new anchor.) 
•	Check distal circulation.
TAKE-DOWN TECHNIQUES FOR THE UNCOOPERATIVE AND/OR COMBATIVE PATIENT: I don't care how much barbell weight you can lift, or how big you are, or how good you were in high school wrestling tournaments; TWO PROVIDERS (FOUR HANDS) CANNOT SAFELY CONTROL FOUR EXTREMITIES AND A BODY. There are many different techniques of safely and effectively, physically, controlling a patient - only a few general tips are presented here. If you have not been trained in "take-down" techniques, ask your local Police department or psychiatric care hospital to provide your service with a patient-take-down training session. Whatever methods you are trained in, remember: practice makes perfect! So get together with co-workers and practice these techniques from time to time!!! 
GENERAL RULES FOR SAFE "TAKE DOWN" METHODS OF PATIENT CONTROL: 
•	A minimum of three people (preferably five) are required for a SAFE "take-down" of a truly combative patient. Work as a team. 
•	IF ONE PERSON GRABS HOLD OF ONE HAND/WRIST, ANOTHER PERSON SHOULD BE GRABBING THE OTHER HAND/WRIST, SIMULTANEOUSLY! 
•	Do not let go of the wrist you are holding until your partner lets go of the other wrist!!! To do so sets your partner up for receiving a "round-house" to the face or other vital organs from the fist at the end of the wrist you should have held on to! 
•	DO NOT ATTEMPT TO WRESTLE WITH THE PATIENT WHILE EVERYONE IS STILL STANDING!! TAKE THE PATIENT TO THE GROUND!! DO NOT CONFUSE THIS MANEUVER WITH BODY SLAMMING, HOWEVER!! Again, work as a team. Everybody must go to the ground together. Use your body weight to assist and control the descent to avoid injury to yourself or the patient.

ADDITIONAL PHYSICAL RESTRAINT CONSIDERATIONS & TECHNIQUES: 
•	A jaw thrust airway maneuver will control the patient's head in an extremely effective manner! Capture the patient's jaws and apply only enough traction to counteract the amount of force the patient is exerting to combatively move his head. Do not employ simultaneous hyperextension of the patient's neck if C-spine injury is suspected. However, if C-spine injury is not indicated by mechanism, hyperextension will further assist in head control. 
The biggest advantages to this maneuver are: 
1.	no threat of airway occlusion 
2.	no threat of vagal stimulation (as may occur when a patient's head is forcefully turned to one side) 
3.	minimal threat of bystanders and family members observing this maneuver and perceiving it as being a "cruel" or "excessive force" activity on the part of care providers.

Frequently, this maneuver also preoccupies the patient with his head, diminishing the amount of limb combativeness performed, and making it easier for others to safely control the limbs! 
•	If used, a "thumb lock" does not have to be constantly painful! Simply maintain control of the patient's thumb, exerting pressure (pain stimulus) only if the patient is resisting your control. WHEN THE PATIENT IS NOT RESISTING, DISCONTINUE THE PAIN STIMULUS. 
•	An arm/wrist lock: SEE "THUMB LOCK" = SAME STUFF! 
•	Remember that patient restraint is PRIMARILY FOR PATIENT SAFETY. If you find yourself using restraint as PUNISHMENT you need to GET OUT OF THIS BUSINESS!