Transporting Violent Patients

Exactly a year ago, we discussed problems associated with encountering violent patients in field situations. Recent reports indicate that certain methods of transporting these individuals in ambulances or police squad cars can prove fatal.

For reasons of patient and personal safety, it may be necessary to restrain an out-of-control person. One technique often used is the "hobble restraint," or "hogtie." This involves binding the wrists behind the back, lashing together the ankles and then attaching the wrists to the ankles. The patient is then usually transported by ambulance or squad car, lying on his or her chest.

According to a number of studies, this method can be fatal in certain cases. Most of the literature has to do with deaths that occurred in police vehicles. Reports are now beginning to show up in EMS literature as well.

"In a person with the wrists and ankles tied tightly behind their back and placed in a prone position, there is potential for restriction of motion of the diaphragm and chest," said Sam-uel Stratton, M.D., of the Department of Emergency Medicine at the Har-bor-UCLA Medical Center in Califor-nia (Annals of Emergency Medicine, May 1995). "Such positioning can lead to asphyxia."

Positional asphyxiation (PA) is diagnosed based on three major criteria: the person must go into arrest while in a position that interferes with lung function; he or she must not be able to escape from the position; and there is no other likely cause of death found on autopsy.

"The mechanism of death appears to be sudden, fatal cardiac dysrhythmia or respiratory arrest induced by a combination of at least three possible factors related to increased oxygen demands and decreased oxygen delivery," said Ronald O'Halloran, M.D., of the Ventura County, CA, Medical Examiner's Office (American Journal of Forensic Medicine and Pathology, 1993). "First, the psychiatric or drug-induced state of agitated delirium coupled with police confrontation places stress on the heart. Second, the hyperactivity ... coupled with struggling with police and against restraints undoubtedly increases oxygen delivery demands on the heart and lungs. Finally, the hogtied position clearly impairs breathing in situations of high oxygen demand by inhibiting chest wall and diaphragm movement."

In accounts of 16 incidents of PA, there appear to be few warning signs. It is well established that extra care should be given to those who are under the influence of drugs or alcohol. In all but four of the deaths, drugs and/or alcohol were found in the victim's blood stream at autopsy. In all cases, the impact of the drugs was not established. Also, note that no one kind of substance accounted for the deaths. It does appear articles that alcohol in combination with other drugs increases the likelihood of PA.

How sudden the onset of PA can be is illustrated by Stratton. He discussed a death that occurred while the person was being transported in an ambulance with continuous cardiac monitoring. During transport, there were fluctuations in pulse from 136 to 60, then back to 102. Asystole developed within a minute. There needs to be a balance found between the possibility of PA and the need to provide a safe environment for the patient, responders and public.

"Methods to avoid possible asphyxiation should include placing a restrained individual in a lateral or supine position rather than in the prone position," Stratton said. "When hobble-type techniques are used, there should be slack to in the restraints to allow for movement of the chest wall."

In many cases, it may be possible to use handcuffs or flexible plastic bands to restrain the person to a stretcher or the bench seat in the rear of the ambulance. Another possible response would be to place the hobble-restrained patient on his or her side during transport. This would probably only be usable if the trip to the hospital is short. Otherwise, there would be concerns about impairment of circulation to the extremities the person would be laying on.

Most experts suggest a five-point restraint. Cuffs are attached to all four extremities and straps secure them to the gurney. A device is then placed around the waist to further control the patient. Often, the hogtie is placed long before entry to the ambulance is made. In these cases, placing the cuffs and then binding the legs together and the arms together without joining them can stabilize the situation. It is easy to place straps on the cart and then release one extremity at a time for securing to the gurney prior to transport.

Many in-hospital psychiatric units are adopting reinforced fabric restraint sets. With new fibers available, these are nearly as strong as the ones made of leather. They are much easier to clean following exposure to body fluids. A complete set can be bought for about $75, within the financial reach of most services.

It is important from a liability standpoint to have procedures in writing that outline your response to a restrained patient. This should include frequent physical assessment for possible difficulty breathing. Of the 11 cases of PA discussed by O'Halloran, at least seven resulted in wrongful death suits against the agencies involved.

Kurt Ullman, a Firehouse® contributing editor, is a registered nurse and regional chairman of the volunteer Indiana Arson and Crime Association.