2024 Unit 14 Restraint and behavioral emergencies v1.1.pptx

An updated presentation of a behavioral Emergency Presentation to the local Paramedic Program.

1. Dealing with Behavioral Emergencies and Combative Patients in EMS PARM 2223 Idaho State University

2. Objectives Discuss the legalities of Restraint and Self Defense Discuss verbal and Physical De-escalation Discuss methods of Restraint and Self Defense Select appropriate pharmacological agents Discuss Tactical Considerations Demonstrate safe packaging transport and of patients Avoid Pitfalls and Errors in restraining patients

3. Mental Health and EMS Perception: car accidents and heart attacks Reality: mix of emergent and non-emergent patients Social determinants of health Mental health Primary care Up to 20% of the population has some form of mental health problems Most are cared for in outpatient centers Medication non-compliance is a major co-morbid factor (but not the only one)

4. Common mental illness Neurodevelopment disorders DD, autism spectrum Schizophrenia Spectrum Bipolar and related disorders Anxiety disorders OCD PTSI/PTSD Suicide attempts/ideation Agitation, violent or disruptive behaviors Psychosis leading to dangerous thoughts/behaviors Mania Intoxication states Anxiety Excited delirium

5. 5 Key tips for dealing with a patient in Psychological crisis Your safety comes first. Don’t go in if the scene is not safe Listen Remain calm (be aware of the tone of your voice) Make eye contact Show empathy

6. Empathy Make Eye Contact Listen Validate Don’t participate in delusions/hallucinations, this may compromise trust. Use positive and helpful statements such as: “I want to help you!” and “Please tell me more so I better understand how to help you.” Put yourself on his/her side of finding a solution to the problem.

7. Palmour , H., IV. (2015, September 27). Man in Wheelchair with Paramedic[Photograph found in San Diego's Top 911 User, San Diego Union Tribune, San Diego]. In PARAMEDIC TEAM REDIRECTS MOST-FREQUENT 911 USERS. Retrieved August 16, 2016, from http://www.sandiegouniontribune.com/news/2015/sep/27/frequent-users-911-parademics-homeless-er/ (Originally photographed 2015, September)

8. De-escalation De-escalation is reducing mortality and morbidity by reducing the physiologic and psychologic temp of the patient. Goal: build a rapport and sense of connection Calming Understanding Manage Resolve Verbal and non-verbal techniques

9. Ask: Where is your patient? Recovery https://k12engagement.unl.edu/Stages%20of%20Behavior%20Escalation.pdf

10. What to Avoid T hreaten the patient A rgue or contradict the patient C hallenge the patient O rder or command the patient S hame or Disrespect the patient

11. Remain/Present Calm Listen when you are “listening.” No other activities when listening. Multi-tasking is not good when you are listening. Body Language and Position Don’t stand Over patient Don’t crowd What is the overall tempo/tone of your presence?

12. Be Patient Alternative treatment interventions exist, which may avoid the use of patient restraint or make it safer. Deescelation takes time These take longer. Be patient

13. Restraint

14. Disclaimer I have been “That Guy”

15. The Fourth Amendment The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

16. Important Legal Principles Restraints are any physical or pharmacological means used to restrict a patient’s movement, activity, or access to their body. Patients have a fundamental right to self determination except in a very limited set of circumstances Patients have a right to be free from restraints unless restraint is necessary to treat their medical symptoms or to prevent patients from harming themselves or others.

17. Liability and Responsibility "...As a matter of law, any individual who chooses to restrain someone may be charged and found responsible for the intended or unintended impact.“ Dr. M. G. Conner “In Custody Death”. 2002

18. COBRA/EMTALA Patients “have the right to be free from... any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents’ medical symptoms." Consolidated Omnibus Budget Reconciliation Act of 1987

19. The Law Generally, “ it is not a constitutional violation for a state actor to render incompetent medical advice or fail to rescue those in need .” Jackson v. Schultz, 429 F.3d 586, 590 (6th Cir.2005) Two Exceptions to this legal principle Custody (restraint) State created Danger You do not have to be in LE for this rule to apply. As a governmental employee you are a “state Actor”.

20. Balance Individual rights vs. Public Safety Safety and interest of the patient vs. rights of the patient

21. Scene Safety Search Rule : Not all searches are created equal Weapons Rule : “Plus One Rule” Location Rule : Beware of Bedrooms, Kitchens, cars, and Garages. Creamer Corollary: Also be aware of couch cushions and other cubby holes. Cole Corollary: Be aware of confined spaces and nearby furniture if there is an altercation Approach Rule Talk at a 45-90 degree to the patient. Beware the “prison crouch”. Standing Over the patient makes you vulnerable in a lunge Distance Rule : Distance from patient -Time to respond = Safety Beware of the “Prison Crouch” or “Prison Squat”

22. Key Points Remember he/she is a patient , not a criminal , and the combative issues are a symptom of their illness or injury. Restraint of a subject for legal/criminal/law enforcement reasons NOT related to provider safety or a medical reason, should be left to Law Enforcement Restraint (if needed) is a TEAM effort with both EMS, Fire, AND Law Enforcement

23. When is restraint indicated… When a person exhibits a behavior or psychological syndrome that is associated with a significantly increased risk of the person suffering death, injury, pain, or disability; or causing death, injury, pain or disability to another person.

24. KEY POINT “Restraints should be applied humanely with only the minimum amount of force needed to effect the medical restraint.” “The least restrictive, but effective, restraint should be used” American College of Emergency Physicians 2007 Position Paper on “Use of Patient Restraints”

25. “Ideal” Restraint

26. What are the deadly 5 H’s? H yperthermia Increased heat production through exertion, struggle Increased heat production through toxicological causes Decreased offloading heat via restraints H ypoxia Relative vs. absolute H ypercarbia Increased CO2 production, Decreased CO2 removal H + (acidosis) Heat, hypoxia, and CO2 H ypoventilation Absolute Relative Dead Air Space concept. Phonation vs. respiration

27. 5 tips for proper restraint Must not move into a positon to harm self (purposely or inadvertently) Falls Choking on straps Positional dyspnea/ asphxia . NO PRONE RESTRAINT. NO SANDWICHING Reaching IV’s, etc Must not move into a positon to harm providers Biteing Clawing Spitting (spit hood) Must allow monitoring Prevent Egress Invert seatbelts Keep a body between patient and door If in Handcuffs an officer (with a cuff key) must accompany.

28. Pharmacological Agents ACP Protocols M-14 and R-03 Benzodiazepines Diazepam Midazolam Anti-psychotics Haldol Droperidol Zyprexa Adjunctive Medications Benadryl Zofran

29. Ketamine ( NOT CURRENTLY IN OUR SWOs) NOT CURRENTLY IN OUR SWO”S Dose is different from RSI!!! 0.5-5 mg / kg Huge variance in practice! Advantages Very rapid onset, Airway Reflexes tend to remain intact Multiple Routes (IM, IV) Typically effective in one dose Disadvantages No SZ suppression ?? Maybe maybe not Increased monitoring Must monitor SPO2 and ETCO2 closely Misc DEA Schedule III Often successful when other drugs fail Yes it increases HR and B/P, but this was rarely clinically significant SPO2 decreases have been reported, but this may be due to restraint position rather than the drug. NOT CURRENTLY IN OUR SWO’s! 

30. Key Point: At Doses high enough to rapidly “take down a patient” (5 mg/kg), the risk increases substantially. Up to 30% intubation rate

31. Remember, Everything you do is under scrutiny

32. Even when you do everything right, things can go ary … https://www.youtube.com/watch?v=GdzpoS8pTks&list=PLRfAlimdH7KJF9ICZQYZVjfFBBaFTcczO&index=135&t=533s

33. And when you are not diligent, things go wrong quicker… The Case of Elijah McClain

34. Factors in his death Held /restrained for 15+ minutes Anchor Bias “He is on something” Ketamine administered Proper dose per AFD protocol : 5 mg/kg IM NOTE: Up to 30% ETT rate at this dose Administered 500 mg (full vial) EM weight 140 pounds (64 kg) 7.8 mg/kg

35. Pay Attention In September 2021, the three police officers (Woodyard, Rosenblatt and Roedema ) and two paramedics (Cooper and Cichuniec ) were arrested and charged through a Colorado grand jury with manslaughter and other lesser charges for the death of Elijah McClain

36. Not done yet…..

37. Post Restraint Monitoring Documented every 5 minutes Focused on : Hypoxia (SPO2, LOC , Respiratory rate and effort) Hyperthermia (temp and Activity) H+ Acidosis/Hypercarbia (ETCO2) Cardiovascular Collapse (EKG, B/P, and HR) Distal PMS

38. Documentation “The use of restraints should be carefully documented, including the reasons for and means of restraint, alternatives to restraint, and the periodic assessment of the restrained patient. ” American College of Emergency Physicians 2007 Position Paper on “Use of Patient Restraints” “Documentation of patient assessment, reason for restraint, restraint procedure, frequency of reassessment, and care during transportation should occur for all patients who require restraint. These components should be evaluated during system continuous quality improvement processes. Systems should consider reviewing every case of patient restraint for compliance with the PPR protocol.” National Association of EMS Physicians Position Paper on “Patient Restraint in Emergency medical Services”

39. Pitfalls Choke Holds (Don’t do them) Sharps (watch them!) Documentation (MAKE SURE YOU ACTUALLY DO A REPORT) Indications for restraint Other options tried De-escalation attempted Imminent need for restraint Clear and specific Medical Care provided while being restrained.

40. Runners Runners…

41. So lets put this together into some final tips…

42. Never restrain a patient prone. Any patient can decompensate when restrained , but Prone /near prone restraint speeds up decompensation Pressure on back or abdomen /chest speeds up decompensation Do not administer Rx while prone

43. Position the patient upright or at least supine Make sure the pt is in a position to MAXIMIZE his tidal volume and MINIMIZE effort Is he sitting up or on his side? A restrained pt should never be left prone.

44. https://www.nbcnews.com/news/us-news/two-illinois-ems-workers-charged-murder-death-patient-strapped-face-st-rcna65506

45. Phonation is not Respiration respiratory distress/arrest is a prelude to cardiac arrest “ I can’t breath” is a red flag.

46. Know your protocols Know your protocol, but do not know ONLY your protocol. Your protocol may be outdated or harmful. Following your protocols is not a defense. Make sure you are current with the latest best practices. “First, do no harm ”

47. Have a goal “It is of paramount importance to protect agitated, combative, or violent patients from injuring themselves while simultaneously protecting the public and emergency responders from injury.” (NAEMSP) Have a goal, a plan, and a idea of how you are going to get there. Articulate this plan to your crew/team

48. Consider all causes Organic Trauma Low BG Metabolic Tumors Delirium Tox Alcohol Stimulants Withdrawal Psych Fear Multi- factoral There is no one size fits all approach to these cases.

49. Consider all risk factors The same risk factors for airway are for restraint: Obesity The very young and old The 4 H’s Hypoxia Hypercarbia H+ Hyperthermia

50. Obesity is an independent risk factor for rapid desaturation and decompensation ANYONE can desaturate and decompensate. OBESE patients desaturate quicker.

51. Make sure you only restraint for articulatable medical reasons Be aware of your own preconceptions and biases Be aware that LE statements will be taken out of context Use objective criteria mRASS ? History Behaviors prior to restraint Signs of distress Refractory to lesser interventions and de- escelation

52. The mRASS

53. Chose pharmacological restraint carefully Low dose benzos for mild - Moderate agitation Droperidol for moderate agitation and/or psych Haldol for psych only Ketamine only for severe actively combative cases.

54. Be ready All monitoring & resus equipment must be at the patient's side before proceeding with restraint and/or sedation. This includes: equipment to monitor HR, SpO2, EtCO2 & BP, oxygen, blow by, nasal cannula & non-rebreather mask, airway adjuncts & bag valve mask.

55. MCHD SNORES safety bundle S – SPO2 Monitoring N – Nasal ETCO2 O – Oxygen – Lots by any means R – RASS ( mRASS at ACP) E – EKG monitoring S – Sugar (BG) Listening/Watching: https://www.youtube.com/watch?v=Q2-EZzSwVVk https://soundcloud.com/mchdpp/snores-final-mixdown

56. Restraint facilitates care , but is not a care plan in and of itself. Care does not stop after sedation or restraint, it accelerates. During sedation, one provider must be dedicated and laser focused on monitoring the pt's airway, breathing & circulation. When SPO2 cannot be monitored…HF O2 should eb administered prophylactically (NAEMSP recommendation) NC NRB Blow By Care is focused on the 4 H’s that kill patients.

57. Take it seriously Treat restraint (physical and pharmacological) like RSI/DSI intubation. Both are high-risk procedures that require a provider's undivided attention. Apnea can occur suddenly and silently.

58. Show dignity and compassion EMS practitioners must maintain the patient’s dignity to the extent possible, including use of the least restrictive method of restraint that protects the patient, the public, and emergency responders from harm. The use of appropriate de-escalation techniques should take precedence over physical restraint or pharmacologic management whenever possible Be explicit in this.

59. Document well Make sure you meet/exceed your agencies documentation requirements and/or inclusion criteria Be 10000% truthful Do not rush.

60. Sources and readings https://naemsp.org/NAEMSP/media/NAEMSP-Documents/Resources/Clinical-Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-Services-Practitioners.pdf https://calibrepress.com/2015/12/screaming-their-last-breath/ https://www.ems1.com/fatal-incidents/articles/medical-examiners-group-excited-delirium-should-not-be-listed-as-cause-of-death-n9FIBpKAQ83dBaBr/ https://www.ems1.com/violent-patient-management/articles/5-keys-for-responding-to-excited-delirium-patients-IEn5kaTNIz3fhork/

61. Questions?