The most important person on the scene of any emergency situation is the rescuer or EMS professional that is providing care. The second-most important person on the scene of any emergency situation is that rescuer or EMS professional’s partner or partners. Every attempt should be made to treat and transport any and all injured or ill patients, but not at the risk of endangering the lives and/or health of the people called to action during such emergencies. In the face of a patient who is altered or combative, restraints of some type may be warranted, and if properly applied, pose little to no risk to patients or to the professionals applying them.

Any time a patient is exhibiting an altered mental status, medical or traumatic causes must be considered, and patients should only be restrained if they are a danger to themselves or others. Preferably, and per local protocol and guidelines, law enforcement should be present and approval should be gained from medical direction. In the event that the providers have decided that restraints are necessary to prevent harm to the patient or harm to others and permission has been granted either directly from online medical control or through protocol, it is important to follow certain steps.

Restraints Protocol

• It is imperative for an EMS professional to have adequate help at the scene and to plan the restraint in detail prior to undertaking the task, as many patients that are exhibiting altered mental status will be extremely difficult to control.
• Only the force necessary for restraint should be applied and every participant must make sure to remain in control of themselves.
• The range of motion of the patient’s arms and legs should be estimated (the "striking distance"), with the intent to stay beyond that range until ready to apply the restraints. Once the decision has been made, adequate help has been gained, and a plan is in place, act quickly.
• One EMS professional should be assigned the job of talking to the patient throughout the restraint process.
• Ideally, four EMS professionals, one assigned to each limb, should approach the patient all at the same time, and work to secure the limbs of the patient with equipment approved by medical direction.
• A patient should never be secured face down also known as prone, and
• EMS professionals should have access to the patient’s airway at all times.

For spitting patients or patients who are exerting excessive force, considerations for the administration of oxygen by nonrebreather mask should be made. As with any patient in an emergency situation, airway, breathing, and circulation (ABC) should be reassessed frequently.

• The documentation of the indications for restraining a patient and the technique used to restrain them could be used in legal situations later, so the rescuer or EMS professional should be sure to include everything that happens and why in great detail.

Some types of restraints commonly approved by medical direction for use in EMS services include the

• simple cravats or triangle bandages,
• sheets,
• soft restraints, and in certain cases,
• handcuffs (with law enforcement always at the side of the patient, even during transport).

TRIANGLE BANDAGES: fashioned to function as restraints by opening and unrolling them until they are long and a few inches wide.

The triangle bandage should be folded over where the loose end are together and then pulled through the closed end, creating a cinch-like mechanism. This is threaded over each of the patient's hands to the wrists and secured to the stretcher or cot, usually one hand above the head and one hand at the side. This same method of constructing a restraint from a triangle bandage can be applied to each leg, with the constructed restraint cinched at the ankle and secured with both legs straightened out, secured to the stretcher or cot. These restraints function in such a way that they tighten as the patient struggles to free themselves.

ROLLED OR FOLDED SHEET: Often, a rolled or folded flat sheet can be used instead of triangular bandages to restrain the legs of a patient exhibiting altered mental status or combative nature. Another option for using a folded sheet is to place it around the patient’s torso, to prevent him or her from creating distance between themselves and the stretcher or cot. Close attention should be used any time a restraint is applied to the chest of a patient to make sure the restraint does not impede adequate respiration.

Commercially manufactured soft restraints are available for purchase and are an option for longer periods of restraint or when higher-quality restraints are necessary.

HANDCUFFS: Handcuffs are able to be used (again, per protocol or medical direction) only when a patient is extremely violent or is in police custody (i.e., under arrest), and still only when a police officer with the key is able to be at the side of the patient for the entire transport.

Restraining patients who are exhibiting dangerous altered mental status or who are combative is a skill that requires quick thinking, adequate personnel, the correct equipment, and frequent reassessment, but can be done professionally and with respect.