This document does not constitute legal advice. It is meant to serve as a discussion by those who chose to read and apply the principles contained in this document. Organizations utilizing the material in this document, shall consult with their Medical Program Director and legal counsel prior to implementation. This was written in response to a question from a Medical Program Director and it cites Washington State Law. There is applicability in all states related to the principles contained in this article.
It is also timely based on some recent grand jury findings related to the use of restraining holds on individuals deemed to be a threat. As EMT’s and Paramedics, we find ourselves in the same or similar position to either restrain a patient or to protect yourself from harm by a patient.
QUESTION – The question is related to the restraint of a patient either by physical restraint, chemical restraint or restraining through the use of devices such as straps, belts, webbing or some other form of soft restraints.
Various protocols have been developed by many Medical Program Directors using the language currently in place dealing with the restraining of mental health patients found under the various RCW’s and WAC’s.
There are no direct citations or references (that I can find) related to the use of restraints related directly to EMS providers either in the WAC’s or RCW’s. Much of the reference materials are found in the various protocols related to mental health institutions and those WAC’s and RCW’s.
Most of the protocols require the EMT’s or Paramedics to call Medical Control first to obtain permission to restrain a patient OR to involve the local police in the restraining procedures.
There are several points to remember when restraining patients:
- It is not unlawful to ‘strap and load patients’ if that is accepted professional practice and the action is taken in the patient’s best interests (not the paramedic’s convenience) and the patient consents (either expressly or by implication e.g. by cooperating with the process);
- It is not unlawful to restrain a person if that is accepted professional practice and the action is taken in the patient’s best interests (not the paramedic or EMT’s convenience) and, if the patient is unable to consent, the decision is reasonable in the circumstances and in the patient’s best interests;
- It is not unlawful to restrain a person who is suffering a mental illness if that is accepted professional practice (which may include seeking some endorsement from the medical director if that is the procedure adopted in the approved protocols) and the paramedic believes based on reasonable grounds, that such action is necessary to protect the patient or other people who may be at risk such as paramedics or a police officer in the ambulance.
- The mere request made by a police officer for the paramedics or EMT’s to restrain the patient is not sufficient. If paramedics are transporting the person it is their professional duty to act in their patient’s best interests and that may well mean resisting a police officer’s desire to unnecessarily restrain the patient.
- The use of chemical restraints must be in accordance with training, and the paramedics or qualified EMT’s must use drugs that are authorized for that purpose.
- Remember it’s not for police to tell paramedics how to apply a restraint any more than a police officer will direct a paramedic to treat a person with a traumatic injury
As in any use of patient restraint, TRAINING IS REQUIRED.
An example of a Training Directive is:
- All Paramedics and EMT’s having direct contact with those patients who may cause harm to themselves or others must have ongoing education and training and demonstrated knowledge, on an regular basis, of:
- Techniques to identify behaviors, events, and environmental factors that trigger emergency safety situations;
- The use of nonphysical interventions skills, such as de-escalation, mediation conflict resolution, active listening, and verbal and observational methods, to prevent emergency safety situations;
- The safe use of restraint (physical and/or chemical), including the ability to recognize and respond to signs of physical distress in residents who are restrained or in seclusion. Types of physical restraintsStrapping or beltingConversationUse of medicationsRelease protocolsPoliceTransport timesLongGround
- Transportation Modalities
- Use of and how much they assist
- When and how to release a patient from restraints
- Types and doses
- “Talking Down”
- Use of non-physical means of intervention
- Physical force – adequate resources
- Reason and purpose for the training
Patients have the right to refuse treatment and/or transport if they are of legal age and are competent.
Competence is defined as the capacity or ability to understand the nature and effects of one’s acts or decisions. A person is considered to be competent until proven otherwise. There are situations, however, in which the interests of the general public outweigh an individual’s right to liberty:
- The individual is threatening self-harm or suicide.
- The individual presents a threat to the community because of a contagious disease or other physical dangerousness.
- The individual presents a specific threat to innocent third parties.
Certain medical, traumatic and psychological conditions can cause incompetence and behavior that interferes with the ability of EMS personnel to care for the patient, or that threatens the physical well being and safety of the patient or others. These conditions include, but are not limited to: drugs, metabolic disturbances, central nervous system injury or insult, infections, hypo/hypertension, hypo/hyperthermia, hypoxia, psychological disorders, poisons and toxins.
Washington Law  authorizes the use of reasonable force upon or toward the person of another without the other’s consent when the following circumstances exist or the actor reasonably believes them to exist: when used to restrain a mentally ill or mentally defective person from self injury or injury to another or when used by one with authority to do so to compel compliance with reasonable requirements for the person’s control, conduct or treatment.
This authority is found in RCW 9A.16.020 Use of force – When lawful, Section (6) Whenever used by any person to prevent a mentally ill, mentally incompetent, or mentally disabled person from committing an act dangerous to any person, or in enforcing necessary restraint for the protection or restoration to health of the person, during such period only as is necessary to obtain legal authority for the restraint or custody of the person.
If an EMS provider feels uncomfortable with any patient, even when they have not been actively combative, the provider has the right and duty to provide the patient and others with the security of patient restraint. Verbal threats are a legitimate reason for restraint.
The following is a suggested guideline or protocol for the use of physical or chemicl restraints in the prehospital care setting. It is not intended to dictate police action that may be necessary to subdue someone.
Patient Restraint Protocol- Physical and Chemical
- Assess Situation.
- If no threat of immediate danger:
- General Approaches:
- Transport the patient as quickly as possible without causing undo emotional or physical harm.
- If the patient appears to have a significant mental disorder and is refusing transport, consider police and/or mental health professional assistance.
- Never stay alone with a psychiatric patient. Always have enough help to restrain a violent or potentially violent patient.
- Do not confront any armed patient.
- Protect yourself and others.
- Immediately request law enforcement.
- Look for medical reasons for the agitation and treat accordingly, i.e. head injury, hypoglycemia, drug overdose, intoxication, etc.
- Restraining a Patient
- Purpose and precautions.
- To prevent harm from occurring to the patient or others when all other reasonable methods have been exhausted.
- Restraining an individual should be an assist to police unless waiting would result in increased risk of injury to EMS personnel.
- A patient should only be physically restrained in a manner that is quickly reversible and allows for complete access to the patient.
- Any patient placed under arrest should be transported with the arresting officer either in the transporting unit or following close behind for back up and/or support if needed.
- All EMS personnel assisting in the restraint of a patient shall use personal protective equipment and universal precautions.
- At no time should the actions of EMS personnel jeopardize the airway or respiratory effort of the patient, e.g. holding of the neck, chest restriction, or any other maneuver that would interfere with the life support needs of the patient.
- The patient must be positioned in a manner as to ensure adequate airway control and to allow for IV access.
- Ideally, if available, five persons should be involved in a coordinated take down of the violent patient each holding one extremity and/or the head.
- As gently as possible, secure the patient to a backboard with secure restraints.
- Padding should be used to protect the patient from self-injury.
- Transporting patients with handcuffs behind the back is NOT an acceptable position of transport unless any other means of transport or restraint would put EMS personnel at risk of injury. Law enforcement must ride with the patient in the transporting unit if the patient is handcuffed behind the back.
- The patient must be checked and treated for any other medical or traumatic illness, i.e. hypoglycemia, OD, etc.
- Chemical Restraints
- Chemical restraint with droperidol, if not contraindicated, should be given as soon as possible.
- If prolonged transport and continued agitation, contact Medical Control for possible IV/IM Lorazepam administration.
- Diazepam 2-10 mg SIVP or Lorazepam 1-2 mg IVP or IM may be considered. Be prepared to secure airway and ventilation prior to administration
- Prone or Hobble
- Restraints are not appropriate for EMS due to the risk of death from positional asphyxia and the lack of proper access for medical assessment and procedures.
- If a patient is found in prone or hobble restraint, immediately roll the patient to his/her side and accomplish appropriate EMS restraint.
- Restrain one or more extremities and progress to full body restraint as necessary. This can be accomplished with soft roll gauze or wrist and ankle restraints. Restrain only the extremities necessary to accomplish control, unless, in the judgment of the EMS personnel, it is appropriate to apply full restraint initially. Each extremity is restrained to the stretcher. Cot straps must be in place.
- If handcuffs are used, law enforcement, with the key, must accompany the EMS provider. The EMS provider will monitor neurovascular status of hands.
We all have the responsibility to take care of your patients who are compromised in some form or manner. It is up to you to make sure your patients arrive at a medical facility better than you found them in the field or at home.
JOHN K. MURPHY JD, MS. PA-C, EFO, Deputy Fire Chief (Ret), has been a member of the career fire service since 1974, beginning his career as a firefighter & paramedic and retiring in 2007 as a deputy fire chief and chief training officer. He is a licensed attorney in Washington State since 2002 and in New York since 2011 and a licensed Physicians Assistant and former firefighter/paramedic. Mr. Murphy consults with fire departments and other public and private entities on operational risk management, response litigation, employment policy and practices liability, personal management, labor contracts, internal investigations and discipline, and personal injury litigation. He serves as an expert witness involving fire department litigation and has been involved in numerous cases across the country. He is a frequent Legal contributor to Fire Engineering Magazine, participant in Fire Service Court Blog Radio and a national speaker on fire service legal issues.
For more information please contact me at 206-940-6502 or at firstname.lastname@example.org
 Edited to cite the Washington Law for the reader – Murphy, J. K. 2014
 Washington State Paramedic Protocol