combative patient

[crotchitymedic1986]

Man do i have an invention for you, unfortunately I can not find a link to it, but this product is very similar: http://www.buckleboss.com/

It is a buckle guard that covers your stretcher belts/buckles, so that the patient can not unrestrain themselves. If you are using the over the shoulder harneses, along with abdominal and leg/knee belts properly, it would be difficult for a patient to come off of the stretcher during transport. Even if they do, it will take a few minutes of them trying, which gives you the chance to defend yourself or get out of the vehicle. I am not a proponent of abandoning the patient in the vehicle while you watch them tear up your rig, as when they escape into traffic and get hit by a car, you will have alot of explaining to do (not advocating you put your life in risk, but its kind of hard to garner public sympathy when the patient is dead, they had no weapon, and you are scratch/bruise free). You should also google the old Merginet article "Positional Asphyxia - Death By EMS", as it is a very good and indepth review on how to deal with these patients, proper restraint, and improper restraint.

P.S. There are several soft buckle guards used for children, I am recommending one that is solid steel, and very heavy duty. The one i am thinking of is simply a steel rectangle that encompases the seat belt female coupling, with a slit in the middle that is big enough for a car key to fit through (can use any key or straight/slender item to go through the slot and push the orange seatbelt release button).

Edited January 6, 2010 by crotchitymedic1986

[fireflymedic]

Herbie -

Point well taken. However, my previous service that I worked for was written in the protocol that if we had a combative/potentially combative patient that PD followed unless under arrest in which case they were immediately inside and you always took someone with you. As for psych patients - we ALWAYS had PD in the ambulance with us. There was no room for arguement on that. Kept us safe in addition to having the access of chemical restraint if needed (which we tended to use cautiously, but would use if needed). Now, if we predict a problem, and you are going to be combative - fine, but we will ensure that me and my partner are safe.

On the other token, if you have a severely combative patient that is practically houdini (as I've had a few times) and thrashing around to no end and chemical restraint is not an option, full immobilization on a backboard is an option. I have been known to do it, and when combined with spider straps does a very effective job of restraint, and also makes him easier to transfer (note if you put a pt in restraints - this is a wise thing to do so when you transfer them, you will not have to release the restraints and chaos ensure - fasten restraints to the backboard). The ER docs do appreciate this and also, with full immobilization, he won't be able to thrash around effectively spitting at you. If all else fails - restrain one arm above the head, another at the side and at least they can't use both arms effectively.

Take care out there !

[Siffaliss]

Thank you for the replies!!!! unfortunately we have no protocols for medicinal restraints or "sedation." numerous other paramedics have called out base facility and asked for it and it was denied. looking back i should have taken a rider.. however he didnt seem like he was going to give me as many issues as he did while we were on scene. i guess i just didnt expect things to head south so quickly.. the obvious answer to this question seems to be "kick his ass!!" HOWEVER! i enjoy working as a paramedic and want to continue to do so. we did try the NRBM, but he was thrashing around so much it stayed on his face for all of 3 seconds..

That was my question, why not chemically restrain but I guess there's the answer. Still, if he's still posing a threat during transport why not get the po-po's back? Another question which I think was already asked, was he of relatively sound mind? GCS 15 and posing no immediate danger to himself? If so, why was he transported? Did the family make up the story of him cutting himself with glass to get you there faster?

If you have no spit hoods and the NRB wasn't staying on his face, try a pillow case (sans pillow). Your patient can still breathe just fine, but cannot spit on you

Edited January 7, 2010 by Siffaliss

[scott33]

PD every time.

[fireflymedic]

To OP - I think it's a general consensus perhaps it's time to have a discussion with your training officer to see why that's not an option and have them look into getting it to be one !

[Just Plain Ruff]

Ok, I haven't posted in a while but this is a good one.

One way to change the toon of the dumbass doctors who won't give you orders for chemical restraints.

Let the patient be completely combative when you arrive at the ER, Let the patient go bat crap crazy in the ER, have him hit the doctor and knock him out. Then call the cops and have them shoot the bastard.

Let the doctor know that this would have been avoided had he have had the balls to give you sedation orders.

Or better yet, get your medical director to write you a protocol that precludes you having to call the hospital. If the hospital isn't going to look out for you then your medical director should.

One other thing, the first time one of you guys get's hurt from the doctor not giving you sedation orders, take the doctor and hospital to court citing that your injuries were a direct cause of them not giving you orders for sedation.

Or you can do what some medics I've worked with, IV em, Versed em, Sux em and tube em. Tell the doc that you were concerned about their ability to protect their airway and you RSI'd em. Not saying it will cover your ass but someone has to.

And finally - when in doubt, stop the ambulance, get out and wait for the police. No sense in getting yourself hurt. The ambulance and it's equipment can be replaced, YOU CAN'T Be. Most times when the police hear that the patient assaulted you they are not so nice.

If your service isn't going to help you keep safe then you need to find a new service or you need to work to make the changes happen. Your safety is 100% your responsibility. Protocols and medications only go so far.

[HERBIE1]

Herbie -

Point well taken. However, my previous service that I worked for was written in the protocol that if we had a combative/potentially combative patient that PD followed unless under arrest in which case they were immediately inside and you always took someone with you. As for psych patients - we ALWAYS had PD in the ambulance with us. There was no room for arguement on that. Kept us safe in addition to having the access of chemical restraint if needed (which we tended to use cautiously, but would use if needed). Now, if we predict a problem, and you are going to be combative - fine, but we will ensure that me and my partner are safe.

On the other token, if you have a severely combative patient that is practically houdini (as I've had a few times) and thrashing around to no end and chemical restraint is not an option, full immobilization on a backboard is an option. I have been known to do it, and when combined with spider straps does a very effective job of restraint, and also makes him easier to transfer (note if you put a pt in restraints - this is a wise thing to do so when you transfer them, you will not have to release the restraints and chaos ensure - fasten restraints to the backboard). The ER docs do appreciate this and also, with full immobilization, he won't be able to thrash around effectively spitting at you. If all else fails - restrain one arm above the head, another at the side and at least they can't use both arms effectively.

Take care out there !

We don't have the option of chemical restraints. As for having PD with ANY psych patients- seems a bit excessive to me. "Psych patient" does not automatically mean combative or violent, but I guess it also depends on transport times and how far away back up may be. In my experience, with all the psych patients I've dealt with, very few are actually violent or even aggressive, for that matter. Again, a patient may also become violent or combative with no warning but I'm also pretty good at talking someone down from being aggressive.

[Siffaliss]

We don't have the option of chemical restraints. As for having PD with ANY psych patients- seems a bit excessive to me. "Psych patient" does not automatically mean combative or violent, but I guess it also depends on transport times and how far away back up may be. In my experience, with all the psych patients I've dealt with, very few are actually violent or even aggressive, for that matter. Again, a patient may also become violent or combative with no warning but I'm also pretty good at talking someone down from being aggressive.

One good point ... yes, you can get the 17 year old who takes 10 Tylenol ES because they had a fight with their boyfriend and is furious and depressed and all that good stuff. Or you can get that person who says they're depressed and are thinking about suicide, but no clear ideations. They're asking for help (fine, even though it's 3am and I haven't slept). I always trust my gut, as it's never been wrong. If I think we need po-po's along, I will request them. If not, I still ensure I have easy egress. It's usually the calls you least expect something to happen on that something happens ... like two medics on a random MVA last year, gun pointed in their faces by a possibly postictal patient. You simply never know.

[emtgrimreaper]

take the ruber seals out and bag off of a non-rebreater. that will stop him from spitting on you. and stop the biting. we had to do this once

[flight-lp]

Combative person + no chemical restraint protocol = person going with PD.

It's 2010, time for your local EMS to catch up on the times and offer interventions appropriate to the patient population.

Personally, I would have offered this kind individual a nice cocktail of Ativan or Haldol and Benadryl. Should he politely decline and continue his demonstration of low level Darwinism, he gets a consolation gift consisting of Anectine and an endotracheal tube. I am a firm believer in prophylactic RSI.