A few months ago we discussed the problems associated with encountering violent patients in field situations. Recent reports indicate that certain methods of transporting these individuals in the ambulance or police squad cars can prove fatal.
For reasons of both 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 either 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 happen in the back of police vehicles. Some reports are now beginning to show up in the 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," noted Samuel Stratton, MD, Department of Emergency Medicine at the Harbor-UCLA Medical Center. "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, they 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 a 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," stated Ronald O'Halloran, M.D., with Ventura County (CA) Medical Examiner's Office. "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 the accounts of 16 incidents of PA reviewed for this article, there appears to be few warning signs. It is well established that extra care should be given 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 dugs on the outcomes was not established. Also, it should be noted that no one kind of substance accounted for the deaths. It does appear from the articles that alcohol in combination with other drugs increases the likelihood of PA occurring.
How sudden the onset of PA can be is illustrated by Dr. Stratton. He discussed a death that occurred while 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 general public. The physicians make some suggestions.
"Methods to avoid possible asphyxiation should include placing a restrained individual in a lateral or supine position rather than in the prone position," stressed Dr. Stratton. "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 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 procedure. Cuffs are attached to all four extremities and then straps secure them to the gurney. A special device is then placed around the waist to further control the patient.
Often, the hogtie is placed long before entry to the ambulance to transport is made. In these instances, 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. Complete sets can be bought for around $75.00, 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 eleven cases of PA discussed by O'Halloran, at least seven resulted in wrongful death suits against the agencies involved. Local Community Mental Health Centers can be a resource in forming these.
No matter which method is used, patients in restraints should be viewed as being at high risk for possibly fatal complications. They should be monitored closely, with some means available to quickly release the restraints.
To see more articlesReturn to Home Page