Coping with Violent People: Level I Physical Restraint

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. Documentation skills.

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


Reusable restraint equipment per ambulance:
     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 24"
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.

Level 1 Physical Restraint
     Nothing poses more risk for a lone EMT or paramedic in the back of an ambulance than a patient whose restraint status suddenly changes en route to a hospital. Our goal is to do our best risk assessment prior to loading, solicit a high-risk patient's consent, restrain amply without a struggle, and thus keep both the patient and crew safe throughout transport. We have identified two distinct kinds of patients who require physical restraint: those who are likely to become violent and those who are not (but who still warrant some form of restraint). The latter group is comprised of people who are minimally cooperative and are attempting to do something that poses a risk to them, such as forcibly remove a urinary catheter, an N-G tube or an IV. Given the equipment options we discovered, we decided these patients do not require the same kind of restraint equipment as those who pose a violent physical threat to themselves or to us.

     Level I physical restraint is our term for restraining non-violent patients or patients who are not likely to become violent. It employs the ambulance cot's three standard buckle-straps and shoulder harness, and Velcro ankle and wrist restraints that can be kept on the ambulance cot all the time. The Velcro restraints include one pair of Morrison Model 1290 wrist cuffs (also available as Bound Tree # B0112A) and one pair of Posey Model 562755 ankle restraints.

     Level I restraints can be applied effectively by a two-person crew working at an unhurried pace. Level I restraint should always be preceded by negotiation, just like any restraint process. Our view is that anytime a crew wonders whether they should restrain a patient, they should.

     Velcro has some limitations. It fails in shear at about 7.5 lbs. per square inch-if it's clean, dry and in new condition. Absent any of those conditions, you never know how strong it is. But the Morrison restraints are amply strong, compact and quick to apply. And although the Poseys use Velcro closures, they are double-reverse closures, meaning each restraint employs two paired Velcro interfaces acting in opposite directions. Coupled with a knee-level buckle strap, they simply don't fail. We decided they were strong enough to fasten the ankles of our Level II (violent) restraint patients, yet comfortable enough for our nonviolent ones. So we chose the same ankle restraints for both, and we keep them attached to our cots all the time.

Spit Protection
     Violent people don't just bite; they also spit. Some spit a lot. To protect our crews from that experience, we administer mask oxygen to every violent patient (because they burn lots of it), and we employ the oxygen mask as a primary spit deflector. But plenty of people can shuck an oxygen mask without the use of their hands. For them, we resort to the SpitSock spit shield invented by Eva Stearns of Ramona, CA. The SpitSock is a transparent bag made of fine netting (like beekeepers use) that fits over a patient's head. It's kept in place by a mild elastic band around its open end. It doesn't interfere with an oxygen mask, whether applied over or under the mask, and it doesn't obscure the patient's vision nor that of the caregivers.

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-based9-1-1 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.