letmesleep Posted July 9, 2008 Author Posted July 9, 2008 I would hope that wanting to go home as intact as you came to work is the goal of all of us, but do you seriously NEVER deal with a violent Pt? It doesn't matter if they are psych or medical (and I do agree that both of these Pts fall under EMS care as stated above), again "what if" till your blue in the face, but realistically aren't you ever going to have to deal with a Pt that is combative and/or violent? I do agree that PD should be there to assist, as well as, just being a professional witness to protect EMS, but are we really going to just "dump" these Pts off on the men (and women) in blue because "they are to violent, and I'm not dealing with that"? Talk about picking and choosing your calls. Yes protect yourself and your partner, but handle your own business, now how are you going to restrain your Pt? As far as the positional asphyxia is concerned, I read the "lesson" about how the ribs expand and the muscles work, and yada yada. Let me ask you then, If the risk isn't worth it then why splint a spine on a LBB? How is the LBB any different other than typically your not "forcibly" strapping this Pt down? Do you not secure your Pts to the LBB snug to maintain spinal immobilization? Is it just supine position vs prone? What are your thoughts on this? As a disclaimer concerning people being offended......don't be, a little devil's advocate never hurt anybody. I'm just looking for your thoughts, and asking you to step outside your box, open your mind. We have multiple means of monitoring our Pts these days, and If your Pt's respiratory system becomes compromised common sense should tell you it's time for a change, restraints should NEVER NEVER be a substitute for monitoring your Pt. That would be like using playstation to baby-sit your kids. 1st and 10..........
p3medic Posted July 9, 2008 Posted July 9, 2008 Your not going to effectively monitor vitals in a patient that is thrashing wildly on the cot, face down. Do you think your pulse oximetry probe or etCO2 is going to stay in place? Perhaps some electrodes, you'll see the tachycardia and artifact until he brady's down and dies on you. You decide to transport someone face down on a cot, in restraints and they die, you will be owned. There is enough literature warning cops, and hopefully EMS professionals of the very real danger of transporting patients in restraints while prone. Take a fat patient and lie them on their stomach and see how well they breathe. Now roll around and fight with them, raise their temp, hr, bp and mvo2. Now place them prone. See what I mean? Bad idea, and completely different than lying supine on a board. I have been in this situation, not heard about or read about, but running the call. The patient fought and fought with the cops until he didn't, and at that point it was all done. He had immediate resuscitation and stayed very dead. Sure, the drugs and agitation added to it, but I would bet his chances were better if he were not face down. I carry a cuff key on me at all times. If the cops cuff them, they come, and under no circumstances will they be transported in the prone position. Off my soapbox.
firedoc5 Posted July 9, 2008 Posted July 9, 2008 With my luck the pt. wants to kill my partner and rape me. We always had a high rate of drug and substance abuse so we got a lot of practice restraining patients. We always carried leathers. Had too many of the nylon webbing straps snap. I'm sorry but not once did I experience a highly combative pt. having airway problems. If the are fighting hard, I guarantee they are getting plenty of air. Pay attention to their face, airway, and head placement. Normally we didn't immobilize their head to where they couldn't turn it. Even with biters, you just learn to stay away from their face. We were always careful though of not placing weight down on the patients back. We would take a rolled up bed sheet and stretch it across the back and tied down to the frame of the cot, not the sides. If the pt. calmed down enough, either through exhaustion or sedation then he would be turned onto his back. NRM is a good idea for spitters. Just don't forget to give them some O2 through it. If we were in city we had a max. ETA of 15 mins. anywhere we were. Many times we didn't take the time to completely restrain with leathers or whatever. If we had the manpower (FF, PD) then good old fashion brawn was used and whatever restraints you could place in the amount of time en-route. You can also use the rolled up sheets across the back of the legs, feet, upper back, etc. Even across the butt. Be prepared. Some will try and fool you. They'll seem to calm down thinking you will let up a little. But when you do, watch out. Until you can positively assess that they are ligit in not fighting anymore, the restraints stay on.
JPINFV Posted July 9, 2008 Posted July 9, 2008 Be prepared. Some will try and fool you. They'll seem to calm down thinking you will let up a little. But when you do, watch out. Until you can positively assess that they are ligit in not fighting anymore, the restraints stay on. Hehe, for me, at least, the decision to restrain is a final one and the patient won't be released until we arrive at, and entered, the receiving facility (assuming no extenuating circumstances).
letmesleep Posted July 9, 2008 Author Posted July 9, 2008 Another thought, and a few of us have mentioned "THE SPITTER". I have seen use of the NRB mask noted and the surgical mask, What are your thoughts on these two devices, and do you use anything else? I have heard of a pillow case being use in this situation, the trick is to keep turning it to a dry area through transport so you don't compromise the airway, Thoughts? By the way, sounds like most of the debate has been well stated about prone vs. supine, and honestly I will think differently about prone transport the next time I'm faced with that issue. Also let me throw out there that most of the practices (from the old days) that I and YOU all have mentioned are HUGE no no's these days like the LBB sandwich. Good debate, keep it going!!!!
firedoc5 Posted July 9, 2008 Posted July 9, 2008 I would highly not recommend a pillow case for spitters. Air would be diminished, but also could agitate them more. At least no one recommended a gag, even though at times it was tempting. The NRB with air flow has been what I've found the most effective. I hate spit. I'd rather someone puke on me than spit. Guys, this one's for you: One thing I'll mention is, what about having to physically restrain a woman? You really have to watch it. They can, and will, come back claiming something like, "Someone grabbed my boob!" or "He had his hand on my butt!" These claims are usually unfounded. I've heard the City Attorney and Judges state that in a combative fit, the woman wouldn't have paid enough attention to know whether someone had touched her inappropriately. Other view? Gals, chime in if you want.
Just Plain Ruff Posted July 9, 2008 Posted July 9, 2008 for the spitters, theres always the Hannibal lecter mask.
firedoc5 Posted July 9, 2008 Posted July 9, 2008 for the spitters, theres always the Hannibal lecter mask. Eh, too S & M. :?
VentMedic Posted July 9, 2008 Posted July 9, 2008 Another thought, and a few of us have mentioned "THE SPITTER". I have seen use of the NRB mask noted and the surgical mask, What are your thoughts on these two devices, and do you use anything else? I have heard of a pillow case being use in this situation, the trick is to keep turning it to a dry area through transport so you don't compromise the airway, Thoughts? The pillow case is not a good idea. You can not observe the patient if there is a sudden change in the status. If can also cause them to become more combative. A NRBM can become a dripping mess which can be flung all over you and the ambulance. The O2 would have to be running for safety which can also expose anything or anyone to droplets. The O2 can also become disconnected during the struggle which can bring about a hypoxic effect and make the patient more combative. The claustrophobic feeling of these masks can also exacerabate the situation. The surgical masks are somewhat safer. The patient that tries to "eat the mask off" becomes too preoccupied with his/her mouth full, thus creating a nice distraction for you to get the upper hand on the situation. You can double mask the mouth with the light weight surgical masks and expose the nose for an airway. We have to do this just to transport the patients in the hospital from the ED to procedures and to whatever unit or room they are going to just to protect anyone that might happen to venture into their spit path. Some of these patients from the street have active TB or other resistant bacteria in their sputum so the N-95s are used on the patient and caregivers. Security will usually help to clear a pathway to prevent exposure to other visitors in the hospital. My least favorite job in the hospital is transporting a combative TB positive psych patient to the lock down unit. Some may need to go on ventilators and may require both physical (5 points) and chemical restraints to keep them from hurting the staff. Some of the meth ODs and withdrawals from other drugs require intubation for the acute detox period so they can be adequately controlled without hurting themselves or the staff. Getting the IV for sedation and intubation can be risky depending on how quickly the IM meds take to slow them down. It makes for a long 12 hours. Thus, I prefer working the Neonatal unit in the hospital - two little velcro cuffs and they are "tied down".
dougd Posted July 9, 2008 Posted July 9, 2008 Hehe, for me, at least, the decision to restrain is a final one and the patient won't be released until we arrive at, and entered, the receiving facility (assuming no extenuating circumstances). Likewise, the only times I've had to restrain someone I've left them on until they were turned over to the receiving facility staff. Once I have to put them on, they are staying on. That said, I've had to restrain very few patients and I've usually found that being very straightforward with the psych patients I have encountered has worked out pretty well - even with the ones dispatch told me were combative. Of course, I probably just jinxed myself for the rest of the year... :shock:
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