This series, introduced in the January issue, discusses patient restraint procedures that have resulted from the work of more than a dozen Colorado EMS providers. These providers are currently studying the feasibility of predicting violence in the field and restraining high-risk patients preemptively. In the conclusion to this series, this article reviews a provider's vulnerabilty to attack during patient assessment. To read this complete series online, visit www.emsresponder.com.
Anytime we are within arm's reach of a patient, we are at risk. Taking a BP, listening to lung sounds or starting an IV places our patient's hands in close proximity to our bodies. Following are examples of right and wrong patient-handling techniques.
Safety during assessment
Figure 1 shows an EMT starting an IV. The patient in the picture has ready access to the provider's groin area, due to hand placement. Caregivers are generally focused on the patient, which makes them vulnerable to attack, and a painful one it is!
To start an IV, place the patient's arm in an almost hyperextended position over the cot rail (Figure 2). This arm bar lock is very effective in controlling a patient's arm during an IV attempt. The lock can be held alone, but it is easier and more effective if done with your partner's assistance. Be cautious about going too far when extending the arm, since a fracture/dislocation of the elbow can occur. The restraint method suggested by my co-author of this series, Thom Dick, in the March issue, of crossing the patient's arms over his chest is a great way to gain IV access to the "handcuff" vein.
Figure 3 shows another mistake that is commonly made. The EMT has tucked the patient's arm under her outside arm, which subjects her to being pulled onto the patient's lap. The area between your potential assailant's arms (in martial arts this area is referred to as "the inside gate") should be considered an area of highest danger! As often as possible, work on the outside of the person's arms (the outside gate). This reduces the chance of injury and offers a better chance to escape. To avoid the dangers shown, simply move the patient's arm to the area between him and you, tucking only his forearm under your own. This makes it more difficult for him to strike you, and makes it easier for you to escape. If you place the patient's hand under your arm, you risk pinches and muscle grabs that are quite distracting.
Approaching the patient
Rolling over a patient who is prone or in a fetal position also leaves us vulnerable to being struck, grabbed, stabbed or having a gun drawn on us by the patient.
When approaching a prone patient, avoid rolling him so he faces you, as that enables him to attack your legs, pelvis or torso with a weapon while your hands are busy (see opening photo on page 71).
If the patient is prone, roll his far shoulder toward you to weaken his ability to attack (Figure 4).
Approaching the patient from the rear, place one foot approximately 8"-10" behind his head and your other foot far enough to the rear of his hips (generally 10"-12") to allow you to lean forward and place your knee against his posterior hip, as seen in Figure 5. This will keep him from making a fast roll toward you and make it nearly impossible to kick at you with the upper leg. Place the hand closest to the patient's head on the shoulder that is, or will be, on top. Place the hand closest to the patient's hip on his top arm on or above the elbow as you roll him over. As you roll the patient toward you, his top arm comes free of the ground, and firm, but gentle, pressure to his upper arm just above or at the elbow will allow you to feel if he makes any sudden or forceful move to clear himself to attack or use a weapon. If he moves to get something from under his body, or you see something in his hand, force his arm and hand down to the ground using your weight and strength to pin his hand and the weapon to the ground. At the same time, lean forward with both knees, bringing the knee that was behind him down onto the side of his head. The knee that was resting against his hip is forced forward, effectively pinning him to the ground (Figure 6).