What do you do with psych patients?

[Just Plain Ruff]

Restraints have some very serious consequences if they are used improperly and should not be taken lightly.

There is a reason why so much has to be documented in a hospital setting and many steps must be taken before restraints are put on. In EMS many providers use restraints as a crutch or a first resort rather than a last resort to deal with psych patients.

I have used restraints many times, almost all of those times have been as a last resort or because the patient was a danger to me or themself. There is definately no room in my ambulance for a violent and out of control patient. I can tell you that I would give my left foot and arm for the hindsight to be able to go back and be able to determine which patient was going to need restraints and have the time on several of those calls to place the restraints proactively or prior to them getting inside the ambulance but that's just a dream.

Lying to a patient, I try not to but there are sometimes that lying is needed but in a psych patient usually not a good idea especially if that lie involves lying to them about where you are taking them. That's like dropping a bees nest on top of a bald bear with you and the bear inside a enclosed steel box. Not a good idea.

Edited July 11, 2013 by Captain ToHellWithItAll

[BushyFromOz]

There is a reason why so much has to be documented in a hospital setting and many steps must be taken before restraints are put on. In EMS many providers use restraints as a crutch or a first resort rather than a last resort to deal with psych patients.

And i would be one of them

Any hint of aggression of violence in this acute presentation, even if it was before my arrical at scene for transport then they get restrained, and this includes interfacility transfers.

I will not put my self at risk of a patient returning to their former aggressive self when its just me and my partner driving down a freeway in a shoebox, they get soft restraints.

Edited July 11, 2013 by BushyFromOz

[scubanurse]

You make the assumption that therapeutic communication skills always work, and that a patient intially responsive and co-operative will remain so

I absolutely agree with the statement that there is nothing worse than a crazy guy in the back who gets a little to upset with you. Even the best communication strategies can fail and calm patient can beceme very agitated and agressive without provocation or warning. Unfortunatley, it part of the parcel for some mentally ill people, but i dont condone lying

I liken it to two wet cats fighting inside a shoebox going down a slippery slide.

I did not make that assumption. I know very well that it will not always work, but an honest effort should be made first. I have seen some very violent and volatile situation diffused with effective communication skills.

I understand your desire to maintain a safe environment in the back of the ambulance, but really, restraints shouldn't be a first option. I have seen some otherwise calm and collected patients become agitated and combative when placed in restraints. How would you feel if just because you had lost your temper, then calmed down and became compliant, just to be tied up "just in case". I would be pissed and do everything I could to get out of the restraints.

[Just Plain Ruff]

Actually maybe I wasn't clear, what I was getting at was the providers using restraints on every single psych patient just to be safe. The patients who have exhibited no violent behaviour at all, the child who was having a emotional breakdown, the woman who was upset over a breakup. I have seen several providers put these types of patients in soft or hard restraints just because the "possibility" of that patient going off. They had no valid basis of agressive behaviour prior to the call or during your eval but they just put them in restraints.

Your reasoning is Sound Bushy.

does my explanation make more sense?

[BushyFromOz]

I did not make that assumption. I know very well that it will not always work, but an honest effort should be made first. I have seen some very violent and volatile situation diffused with effective communication skills.

I understand your desire to maintain a safe environment in the back of the ambulance, but really, restraints shouldn't be a first option. I have seen some otherwise calm and collected patients become agitated and combative when placed in restraints. How would you feel if just because you had lost your temper, then calmed down and became compliant, just to be tied up "just in case". I would be pissed and do everything I could to get out of the restraints.

Of course you did. You bashed the vollie from NJ up with your therapeutic communcations speech and then slapped the guy with a "you dont know how to communicate" comment. The forums are full of how limited EMS education is over there, how much of that would be covered in your average EMTB course? I bet this guys isn't the only one with a shortfall in knowledge... system error much?

My desire to maintain a safe environment in the back of my truck comes from a compliant psychaitric patient attempting to bash my head in without warning to obscond from the vehicle between hospital and the recieving facility. The very fact these people are deemed no longer competent through abnormal behaviour and thought process to make their own decisions makes this more than "losing your temper". Im not talking about the run of the mill depressed person with suicidial idealogy, I'm talking about the paranoid pschizophrenic who 5 hours ago was a raging storm and is now compliant. Once in a vehicle and its just you, the patient and your partner it becomes almost impossible to get restraints on if they arc up, so they get restrained or the don't travel with me "just in case"

Its legal and my safety trumps their need to feel loved every time.

Your reasoning is Sound Bushy.

does my explanation make more sense?

Yeah brother, no problems

[Just Plain Ruff]

Violent schizo patients who were violent 5 hours ago and are now compliant and are going in a 8x8 foot box with just me in the back with them, get restrained every single time.

[Mateo_1387]

...

My desire to maintain a safe environment in the back of my truck comes from a compliant psychaitric patient attempting to bash my head in without warning to obscond from the vehicle between hospital and the recieving facility. The very fact these people are deemed no longer competent through abnormal behaviour and thought process to make their own decisions makes this more than "losing your temper". Im not talking about the run of the mill depressed person with suicidial idealogy, I'm talking about the paranoid pschizophrenic who 5 hours ago was a raging storm and is now compliant. Once in a vehicle and its just you, the patient and your partner it becomes almost impossible to get restraints on if they arc up, so they get restrained or the don't travel with me "just in case"

Its legal and my safety trumps their need to feel loved every time.

...

"Just in case"...

I'm shocked that with your smug attitude of lacking U.S. EMS training and education that you spout off crap like this. The moral and legal issues of restraining another person are more profound and farther reaching than "just in case".

Morally speaking, the willingness to restrict a patient's freedom willy nilly, because you had one patient become violent towards you, surely lacks a moral basis of preserving a patient's right to autonomy and right to refuse. The previous sentence speaks to your impartiality of applying restraints and is morally irrelevant in dealing with your next patient. I'd like to think you want to provide good care for your patients, but automatic restraint of psych patient's "just in case" will systematically violate personal freedoms in order provide care and prevent harm. Sure, a utilitarian view of protecting others is a consideration to be taken, but there is still one person who is not "most benefited" by the procedure. Tell me, how is restraining a patient therapeutic? Or is it just containment? Do you think your patients see restraints as treatment to getting better, or more as punishment? It seems these considerations matter when deciding to restrain a patient. With your better psychiatric education, do you even try to use less restrictive measures in your 5 hours ago raging storm but now compliant paranoid schizophrenic patient?

It makes about as much sense as putting you in handcuffs because you were royally pissed off with road rage 5 hours ago.... wouldn't want you running down and hurting someone...

Legally speaking, committing acts of battery come to mind first. I'm not the most legally savvy person, but restraining patients based on previous patient's or "just in case" situations, would seem to be a form of battery. The schizophrenic patient that previously exhibited a "raging storm" extreme of behavior doesn't mean that five hours later, while being compliant, deserve to be battered. Again, this type of systematic use of restraints violates a persons right to refuse medical care. Now, this is a double edged sword, I agree, but the point I'm trying to make is that systematic use of restraints can leave one liable in violating another person's rights.

In no way am I saying that restraints should be banished, but rather the decision to restrain should be carefully considered in regards to moral, legal, therapeutic, and safety aspects. Its not an issue to take lightly and very much should be a last resort when other less restrictive ways of behavior modification have been exhausted. In regards to safety, I realize two persons on an ambulance certainly raises concern when dealing with an acutely violent psychiatric patient. Placing patients and personnel in situations that are dangerous and make the requirement of the most extreme measures necessary as the primary intervention in lieu of not being the most appropriate treatment.....system error much...???

[craig]

In bushys defence.........yep I am backing you on this brother....here in the great land of Oz...we as paramedics can and have legal right to restrain patients in 'our care' being with physical, chemical restaints or both.

If the person is now ' compliant' ask them do they mind having them on for safety.....stating that the alternative is much worse...(a big cop sitting on them and being hand cuffed) if things go belly up.. if they are having an eipisode and require ambulance transport well then no issue...restain them then and there, or transport in the paddy waggon. Pateints in a physcosis or extreemly agitated state will not be all nice and easy and the paramount is MYPARTNER AND MY SAFETY... not the feelings of the supposed nutter in our care (term is tongue in cheek).

[BushyFromOz]

You know mateo, i wrote this nice reply to your long winded and at times completely of base rant, but i lost the post and really have lost my care factor to replying to you. But its quite clear the mental health patient your talking about and the violent non compus mentus psych im talking about are two different animals, so ill break it down to some dot points, i might even answer some of the questions you should have asked before you pulled your civil liberties speech on me.

• At no point did i say restraints are used in isolation as the only method of management
• Patients here are scheduled i.e "committed" for transport to a mental health facility in the field. In order for this to happen they must have among other things, bizarre behaviour and thought process, lack of rational thought and be a danger to themselves or others. They are extreme cases to be committed do not have a right of refusal and they do not have the right for autonomy, so your attempted civil libertarian intellectual bitch slap has failed.
• The very fact they have lack of rational though and bizarre behaviour and violence makes it absoluetly appropriate, not required, appropriate for restraint

• The very fact these patients are not capable of rational thought makes communciation strategies limited because, well, they are not capable of rational thought!

• We do not schedule (re "committ") people for "having a bad day"
• Restraint here is soft cuffs that enable a degree of movement but not enough to strike me or untie the restraints
• Yes i do talk to these patients, i even explain the necessity of them needing to be applied, and by and large those that can comprehend agree
• No i do not restrain everyone with a mental illness, I used the specific example of violent/previously violent and unpredictable because of the nature of their presentation makes it appropriate
• Your smug comment is, quite frankly, horse crap. US providers, that is, people who work in the states routinely, almost daily, comment about the lack of underpinning knowledge in the EMTB curriculum. I didn't attack your system, i defended the guy from new jersey when a lack of knowledge comment was levelled at them. You cant expect the guy to know about the ins and outs of therapeutic communciation, legal, ethical and moral obligations when you freely admit the the level of education is flawed. I dont really care either way because im not in the states, but either its adequate or inadequate, you cant have it both ways to suit your argument here mateo.
• Restraint is not therapeutic and at no stage did i say it was

And then there is this..... highlighted for your convenience

Placing patients and personnel in situations that are dangerous and make the requirement of the most extreme measures necessary as the primary intervention in lieu of not being the most appropriate treatment.

Perhaps you should tell me what is the most appropriate intervention for a paranoid schizophrenic, or any mental health patient who is scheduled, under the law i have described, which displays abnormal and bizarre behaviour, not competent of rational thought, who has already seen to be violent and aggressive without warning and is being forced into care as they no longer have the capacity for rational autonomous thought and therefore have no right of refusal, tell me again, if soft restraints is not part of appropriate management, what the most appropriate treatment should be?

What do you think i do, walk around crash tackling 16 year old depressed kids to the ground who are having had a bad day, give them 10mg of midazolam, then strap them to the stretcher prone, with a spine board on their back?

Off my soap box, i suggest you get off yours too.

[craig]

What do you think i do, walk around crash tackling 16 year old depressed kids to the ground who are having had a bad day, give them 10mg of midazolam, then strap them to the stretcher prone, with a spine board on their back?

you don't?.......what did they teach you at uni in Bathurst? better still didn't you listen when you visited us?......cheers bushman