YOU, THE VIOLENT PSYCH, AND THE RESTRAINTS.......

[Richard B the EMT]

I quickly mention, per the FDNY EMS protocols, which might be dissimilar from your local protocols, we don't put M95 masks on the patients, as, while they can breath through them, they are supposed to provide protection for inhaled air through them, and the moisture from the sputum will quickly cause them to start to dissolve. Then, also, you cannot watch their lips for change in color due to a change in the patient's condition.

[VentMedic]

I quickly mention, per the FDNY EMS protocols, which might be dissimilar from your local protocols, we don't put M95 masks on the patients, as, while they can breath through them, they are supposed to provide protection for inhaled air through them, and the moisture from the sputum will quickly cause them to start to dissolve. Then, also, you cannot watch their lips for change in color due to a change in the patient's condition.

If that's NY's protocols then they may have some reason behind them.

I have yet to have an N95 mask dissolve from sputum or sweat. The double elastic band makes them a more secure fit than the single band O2 mask. Usually a surgical mask of good quality will be sufficient.

Healthcare providers wear masks to also protect the patient that is immunosuppressed. In the OR and other situations which require very clean or sterile technique, masks are worn to protect the patient's exposed wounds. So, a mask can work both ways.

FDA statement

http://www.fda.gov/cdrh/ppe/masksrespirators.html

If you opt for the 12 L NRBM, make sure they are not at a high risk for airborne diseases or that they do not have a bloody mouth from the struggle. You don't want to inadvertently expose other professionals or bystanders. There are other ways to check for inadequate breathing without looking at the lips which do not always provide a good indication for some ethnic groups.

I am not that paranoid that I do this for every patient. We are exposed to people with active TB regularly and as long as they are not spewing droplets around us, the risk is there but not as great. Patients that come from an at risk environment just require a few precautions if I am going to be in very close contact. It just keeps me out of the workers' comp office or from taking precautionary meds and/or testing that I would prefer not to do. I do work in an area with an International airport and seaport. We have a huge jail and prisoner population being treated at the hospital although most are transported not by EMS but by medical professionals from DOC in special vehicles for safety issues. We also have a significant amount of drug and violent crime in the city. And, we have a high incidence of TB and Hep C in our at risk populations. In the hospital we utilize every type of legal restaint available for the extended care of a violent patient. This includes transport throughout the hosptial for procedures.

Not everyone may have these same concerns in their area. I've just been around it for 30 years and have become accustomed to taking precautions when there is a chance for a stuggle while trying to do patient care.

[CBEMT]

Another question about this topic......Why is it so easy to say never? This is EMS, do any absolutes truly exist? I guess my point of asking the inital question is: If you do have to transport a Pt in prone position, what steps would you take to monitor? Why is it an absolute NO NO? I will concede (for obvious reasons), and I think most of you feel the same that it is not the RECOMMENDED way of transporting. As FIREDOC just stated, not all combative Pts get transported this way, but is it never going to happen? what if it does, how are you going to handle it?

The only reason I can think of for transporting a patient prone is an impaled object in the back that is positioned in such a way as to make transport on their SIDE impossible (hint- there aren't many ways for that to happen).

As far as combative, no- combative patients should NEVER be transported prone.

Why are you so hell-bent on justifying a procedure that's been shown to kill people?

[Eydawn]

If there is no other way to transport a psychiatric patient other than prone, then I'm not transporting them. I'm waiting for additional resources that will allow me to get the patient into a position that doesn't compromise their health or my legal standing. If it means waiting for out of county ALS to get there so they can administer a sedative, so freakin' be it.

And you're supposed to follow protocols for a reason. It's good practice and CYA for you, and presumably protective for the patient. Case in point, I got my ass kicked by a client this weekend (and exposed to blood, hurrah for serial tests...) but did I go and punch her in self defense? Of course not... I used the protocols outlined for me and we both got through her aggressive outburst with minimal injury, and good legal standing. Could I have punched her? Of course... would it have been the correct thing to do? Nuh uh!

Prone transport only for those not mentally compromised (AKA no mental illness or psychiatric emergency) and unable to ride in any other position due to injury/impalement. Gotta agree with CBEMT here.

Wendy

CO EMT-B

[letmesleep]

I'm not hell bent on transporting in the prone position, just wondering why people are so afraid too. I see the evidence that it is a danger for the Pt, but there is NO absolute in EMS, so how is it that people here are so stuck on the NEVERS. Just trying to open the thought process' a bit after reading another thread and seeing many who stated (and this isn't a direct quote at all) that it's difficult as hell to monitor the Pt when they are thrashing around in restraints. Agree, but not impossible! I guess remembering the "old" days when we talked too, and observed our Pts without the neato little devices we have now is getting the best of me. How many times have you seen newer folks sit back after a Pt was restrained and start typing out their PCR? Prone may not be the best decision out there, but is there NEVER a time that it may be need or utilized? thats all.

EYDAWN, I guess using the protocols is a good way to stay "within the law" or as you stated "good legal standing", but if I get lucky and don't harm the psych Pt, then how am I any different than those FFs that ignored command in the freelancing thread? As long as I get lucky there should be NO recourse, right?

I really am not trying to pick a fight here, I just don't understand the NEVERS.

[Eydawn]

Setting a backburn on your own property is different from deviating from protocols you use as a medical provider while working. Apples and oranges here.

But I see what you are saying.... Sure, you can take the risk and get lucky and not kill your patient or contribute to their demise... but is that really what we're going for here? It's not like we *never* have any other options available. Sometimes we may have very limited options... but I can't justify transporting an agitated psychiatric patient in prone position! I can *never* justify it in my own head knowing what I know about the damage that kind of restraint has done to people.

Let's use something else common... what about the old practice of epi down the tube? I have heard of it being done... and I know its even proved beneficial in isolated instances. You can't get venous access... is it worth the risk? It's against most people's protocols... so do you do it because it *might* work? The intent, as with prone restraint, is to care for the patient... but is the result worth the risk?

Wendy

CO EMT-B

[JPINFV]

I'm not hell bent on transporting in the prone position, just wondering why people are so afraid too. I see the evidence that it is a danger for the Pt, but there is NO absolute in EMS, so how is it that people here are so stuck on the NEVERS. Just trying to open the thought process' a bit after reading another thread and seeing many who stated (and this isn't a direct quote at all) that it's difficult as hell to monitor the Pt when they are thrashing around in restraints. Agree, but not impossible! I guess remembering the "old" days when we talked too, and observed our Pts without the neato little devices we have now is getting the best of me. How many times have you seen newer folks sit back after a Pt was restrained and start typing out their PCR? Prone may not be the best decision out there, but is there NEVER a time that it may be need or utilized? thats all.

EYDAWN, I guess using the protocols is a good way to stay "within the law" or as you stated "good legal standing", but if I get lucky and don't harm the psych Pt, then how am I any different than those FFs that ignored command in the freelancing thread? As long as I get lucky there should be NO recourse, right?

I really am not trying to pick a fight here, I just don't understand the NEVERS.

Would you be happier if we used the words "standard of care" and "unncessary risk?"

[firedoc5]

The only reason I can think of for transporting a patient prone is an impaled object in the back that is positioned in such a way as to make transport on their SIDE impossible (hint- there aren't many ways for that to happen).

As far as combative, no- combative patients should NEVER be transported prone.

Why are you so hell-bent on justifying a procedure that's been shown to kill people?

Transporting a pt. prone is something used for the very combative, violent subject. Once they are prone, 1) They are never left alone, 2) They usually still have a couple of people restraining them. 3) They are not left prone for any extended period of time, when they calm down enough that they will not hurt themselves or others they are turned over. 4) Prone, supine, fetal position, they could die. 5) I'm not going to say that you might not have dealt with extremely violent, out-of-their minds, subjects. Perhaps you have. I'm still old school you might say, and through experience I've seen what works the best.

PS I'm not saying it's something you should do, but it's something you could do.

[letmesleep]

"standard of care", you'd be suprised how many providers out there would utilize the prone position in this day and age as a last resort. As FIREDOC has pointed out, there MAY be times this procedure is needed, but there is also a way to do it to minimize the risk of harm. My point here is not to sell anybody on the idea, and as it's been proven with research there is a huge risk, but should WE judge others for using it? Open your mind, put someone else's shoes on. I only want to know why prone should NEVER EVER EVER be used, why are we so hung up on such an absolute?

here you go.....I *NEVER* asked you to change anything, just asked why I shouldn't use this means of transport.

[reaper]

1. We have other ways to restrain Pt's that due work, without the risk.

2. It has been documented from years of experience to raise the risk of death.

If you have that violent of a pt, then have back up ride with you.