Coping with Violent People: Level II Physical Restraint

Coping with Violent People: Level II Physical Restraint

Article Feb 28, 2007

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. We are currently studying the feasibility of predicting violence in the field and restraining high-risk patients preemptively. Our resulting strategy is comprised of the following steps:

  1. Identifying people and circumstances in advance that are most likely to produce violent behaviors
  2. Verbal de-escalation
  3. Mitigating the effects of fight-or-flight syndrome (in patients and caregivers)
  4. Take-downs (which we leave to police)
  5. Application of two levels of physical restraint, both manual and with the use of appropriate equipment
  6. Use of chemical restraint
  7. Self-defense techniques that have proven their worth when situations escalate unpredictably
  8. Some useful documentation skills.


     We discussed steps 1-4 and 8 in the January issue and level 1 physical restraint in the February issue. This month, we discuss level II physical restraint.

     Level II physical restraint is our term for restraining violent patients, or patients who, by the crew's assessment, are likely to become violent. The crew's assessment should include their scene assessment, consideration of the risk factors mentioned earlier, and the principles of threat assessment in The Gift of Fear (discussed in Part 1, January 2007, p. 45).

     Our goal is to either predict violent behaviors in advance or de-escalate violent behavior to the point where a patient might accept restraints voluntarily while a crew is in a position of tactical superiority. If communication is clearly not possible, we rely on police to do the take-down, then employ a minimum of five trained people to do the "tie-down"-restraining the patient supine to the ambulance cot.

     The cot should be fully lowered for two reasons: Keeping the patient's center of mass as low as possible decreases the chance of injury if the cot is upset, and it enables the team to use its weight as a resource, minimizing the necessity for them to be individually stronger than the patient. The handrails on the cot should be lowered to keep them out of the way. They will be involved in the manual restraint process later. The cot's buckle straps should be buckled together and/or tucked out of the way to prevent them from getting trapped under the wheels.

     The smallest person on the restraint team usually coordinates the tie-down and assumes responsibility for controlling the patient's head, since that role requires the least amount of physical exertion. This person is considered the leader. To us, less exertion means the leader is least likely to succumb to fight-or-flight changes and is therefore the most likely to remain cerebrally functional and communicative. The leader has five responsibilities during the restraint procedure:

  1. To coordinate the restraint process from the only vantage point that affords a view of all team members at once.
  2. To hold the patient's head and thus prevent the patient from biting other team members.

         The leader is equipped with clean split-leather gloves as personal protection against penetrating bite wounds. The leather gloves also provide the best possible grip on the patient's head, especially if the patient is struggling and perspiring.

  3. To continue efforts to communicate with the patient.

         At a distance of about 12" from the patient's head, this person has the best view of the patient's facial expression, and can hear and speak to the patient calmly and quietly.

  4. To observe other team members for escalating behaviors (i.e., fight-or-flight syndrome).

         Key behavioral traits, in order, are unwarranted tachypnea, clumsy speech, unwarranted shouting and uncharacteristic cursing.

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  5. To minimize the patient's view of the procedure by immobilizing the head in anatomic position.

     We have been informed by numerous experienced caregivers who have been restrained in this manner during training exercises that being totally unable to see or anticipate the restraint team's activities gives the crew a distinct advantage over the patient.

     The whole procedure should take less than two minutes. Each remaining team member firmly grasps a distal extremity with two hands. The wrist team crosses the patient's arms over the chest, and each member then bears down on an elbow and controls a wrist, thus using his own weight as a resource. The ankle team initially grasps the ankles, but one member quickly throws a leg over the patient's knees, straddling him in a seated position facing toward the patient's feet. He then reaches behind himself and raises the cot rails. By pulling upward or pushing down on the cot rails, he can moderate his weight on the patient's knees-neither allowing the patient to move nor hyperextending the patient's knees-and freeing his partner to attach the restraint equipment. (It is physically impossible for a caregiver to manually restrain someone and apply equipment at the same time.)

     The sitting team member should face away from the patient, so, if the patient gets loose and sits up, the team member can stand up and step away. Facing forward, he is much more likely to trip and, facing away from a loose patient means his face, abdomen and genitalia are not vulnerable to a patient's attempts to punch, bite or grab him. A single blow to a caregiver's face can be completely disabling for at least a minute.

     The first move by the team member in charge of the patient's ankles should be to attach one of the cot's buckle straps just above the patient's knees, behind and beneath his partner's buttocks. They should then force the knees medially against one another and strap them firmly into full extension. That quickly frees the caregiver who has been sitting on the patient's knees, thus enabling two people to apply equipment instead of just one.

     It is essential for the buckle straps on the cot to be in good condition. If they are old, frayed or worn, they tend to get twisted in their buckles, which frustrates a crew's efforts to tighten or loosen them in the course of restraining someone.

     Cross the patient's upper extremities at the nipple line and restrain to the upper frame of the cot on opposite sides. If they are crossed too high, patients sometimes extricate their head and neck from beneath the elbows one at a time (especially if they can bend their knees). If that happens, they can be very difficult to re-restrain. If crossed too low, the patient may still be able to sit up and bite.

     Why cross the upper extremities? Every other mechanism we have tried results in a palms-up position for the patient's hands. That's an especially important distinction for male caregivers, since, in its travel position, the cot places the patient's hands at about the height of the caregivers' genitalia. It's also a great way to prevent a fully restrained patient from biting. Finally, with the arms crossed, if the patient gets too frisky, both arms can be tightened instantly by raising the head end of the cot.

     Does that restrict the patient's respirations? In our experience, not at all-even with the arms bound tightly. If you restrict the movement of the patient's chest, he can breathe with his abdomen. If you restrict the movement of his abdomen, he can breathe with his chest. He won't experience difficulty unless you restrict both at the same time. However, we have disciplined ourselves to listen to the patients and take them seriously-even if they have exhibited a tendency to lie. When a patient says, "I can't breathe," we immediately do whatever is needed to alleviate the situation.

     We routinely apply high-flow oxygen via non-rebreather mask throughout every Level II restraint procedure and aggressively monitor vital signs, oxygen saturation levels, end-tidal CO2, blood sugar and ECG, especially when a patient is struggling. Patients cannot store oxygen, and consume a lot of it when they struggle. Hypoxia is one of the precipitating factors for violent behavior.

     The restraint team should remain sensitive at all times to its own degree of control over the patient. If the patient becomes resistive enough, police should resume control on their own terms. Police support of any restraint process is absolutely essential. They have a lot to offer and they accept a lot of risk; thus, they deserve to be involved as partners, not just in the dirty work, but also in the earliest stages of planning and training.

     It has been our experience that, in violent restraint scenarios, fight-or-flight reactions occur more often in cynical systems and in systems that do not provide adequate equipment, training and support for restraint use. People in cynical systems are more likely to step outside their caregiver roles and resort to judgment and punishment. Without the right equipment, training and support, even the best caregivers struggle more and get frustrated more easily. When they get frustrated, they lose their tempers and do bad things to people.

     What's the best equipment for level II physical restraints? We found the ankle restraints mentioned earlier to be strong enough to resist the strongest patients we have encountered so far when coupled with a buckle strap across the lower thighs (just above the knees). For the wrists, the best tools we have found are padded, non-locking, synthetic leather cuffs and straps from Posey. They look like leather restraints, but they're made of reinforced nitrile rubber.

     Both the ankle and wrist restraints and the straps for the wrist restraints can be cleaned with a contact cleaner or laundered in a washing machine, but are inexpensive enough to be discarded at the crew's discretion. The wrist cuffs are as comfortable for the patient as any restraint could be, and simple enough so a caregiver can apply or remove them in about a second. The straps should be 24"-30" long to support the cross-chest technique for anyone but extremely obese patients, and should be ordered with optional roller-style buckles. Those buckles cost a bit more, but they make tightening and loosening the straps much quicker, and the straps are less subject to wear.

Chemical Restraint
     There are at least two good reasons for chemical restraint. One negates a rule long known to EMS crews: If you're the one applying the restraints, you should try to not be around when they're removed. The other concerns patients who simply will not stop struggling without chemical intervention. Persistent struggling against restraints has been implicated in cardiac arrests that do not respond to resuscitation efforts.

     A December 2002 position paper from the National Association of EMS Physicians (NAEMSP) suggested a specific order for restraints: verbal de-escalation, physical restraints, then chemical restraints. It's respected as the standard of care. But patients don't always give their paramedics such neat choices. Our interpretation of the NAEMSP guidelines is that if you have no other options, it's acceptable to restrain some patients manually while you administer the drugs, and then simply hang onto them until the drugs take effect. In systems that limit drugs to IM use, that can take 30 minutes.

     We have used IM and IV benzodiazepines as chemical restraints, but medical directors disagree over which ones to use. Some of us have had good success with Versed or a combination of Haldol and Benadryl (to counter the potential dysphoric effects of Haldol in some people). We have not heard of anyone who has experienced untoward effects from any of those drugs.

Bite Protection
     Humans are omnivores, so their mouths tend to harbor a variety of pathogens. In addition, human teeth are blunt, so they produce dirty, irregular wounds. A bite like that almost always produces infection. That's bad enough when the injury involves a shoulder or forearm. But those sites can be cleaned up, debrided and sutured and then prophylaxed with a little penicillin. A penetrating injury to a tendon sheath in a caregiver's wrist (or a joint capsule in a finger) can be much more serious. Those injuries readily seal themselves with post-injury movement and can evolve into persistent, disabling anaerobic infections.

     Reusable restraint equipment per ambulance (cost: less than $200):

     One pair of Morrison/Bound Tree Model B0112A Velcro wrist restraints
     One pair of Bound Tree Medical #562755 double-reverse Velcro ankle restraints
     One pair of Bound Tree Medical #2203 synthetic leather cuffs
     One pair Bound Tree Medical #2355 synthetic leather straps w/roller buckle, 1" x 30"

     Consumable equipment:
     Stearns SpitSock spit hood (beige), $2.75/each
     1 pair inexpensive all-leather gloves (split leather), $5/pair

     We obtained our reusable equipment from Bound Tree. As of this writing, the SpitSock is available only from the manufacturer, Stearns Wear, at P.O. Box 2128, Ramona, CA 92065 (800/541-1552 or We purchased leather gloves at a military surplus store for less than $5 per pair.

     We recommend leaving the Level I restraint equipment (reusable items #1 and #2) fastened to the cot all the time, with the ankle restraints tucked under the foot end of the mattress and the wrist restraints fastened to the handrails. These are useful for starting IVs during transport when a patient is marginally cooperative.

     Several of us who developed this procedure have endured physical blows, bites and kicks as a result of inadequate education about violent people. We were lucky. We don't know everything about dealing with those folks, but together we have confronted hundreds of them.

     We have used parts of this procedure in more than a hundred instances during the 1970s and 1980s to control people who were truly violent-stimulated by cocaine, LSD, PCP, various amphetamines and cocktails of anything they could get their hands on. We feel compelled to offer this information to people who, 30 years later, still do not have the training or equipment they need to come home safe from those experiences.

     Thom Dick has been involved in EMS for 35 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at

     Steve Rollert has worked as a full-time EMT-B since 1989 and is currently employed by Platte Valley Ambulance in Brighton, CO.


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