Coping with Violent People: 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.

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.

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