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Emergentology

Emergentology

Restraints and Restraint

Walker, Graham MD

doi: 10.1097/01.EEM.0000695540.34692.cd
    Figure
    Figure:
    restraint, chokehold
    Figure
    Figure

    I have been grabbed.

    I have been spat on.

    I have been punched.

    I have been kicked.

    I have been bitten.

    I have had feces kicked at me.

    I have had urinals—full ones, mind you—thrown at me.

    I have been called every rotten name you can think of. (My patients can be creative.)

    My life has been threatened by patients carrying weapons.

    I do not carry a weapon on me.

    Lucky for me, I have not been hurt in any of these instances. Others in our field have not been so lucky.

    Lucky for me, I had co-workers (nurses, doctors, security) in all of these instances to help protect me and to restrain:

    The patient who was drunk.

    The patient who was high.

    The patient who was psychotic.

    The patient who was angry.

    The patient who was in pain.

    The patient who was under arrest.

    The patient who was lying.

    The patient who was hungry.

    In all these instances, we were able to restrain the patient, usually through a combination of chemical sedatives and physical restraints.

    Occasionally, someone sustained a minor injury while helping to protect me: a thigh contusion, a sprained wrist, a concussion. Luckily, nothing more. Others in our field have not been so lucky.

    Restraining a patient has been identified as such a high-risk procedure in medical care (for the patient and provider) that it comes with the most powerful of physician and nurse requirements: paperwork. Here I am, a physician with nine years of schooling, four years of training in emergency medicine, and almost 10 years of attending experience, and I have to attest that the restraints I'm using are properly and safely placed. I must explain why exactly I've decided to order restraints.

    If something went wrong—the patient had a seizure, aspirated, or said, “I can't breathe”—I can't really think of any person more qualified to respond than an emergency physician. If there were a bad outcome—or god forbid a death—the case would be closely scrutinized by no less than 100 people, I'd imagine, including my peers and people who know nothing about me, nothing about the specifics of the case, nothing about emergency medicine at all.

    So, please, someone, anyone, explain to me why my restraint requires paperwork, reassessment, documentation, and constant attention in my hospital, but seemingly none of that is required when an officer of the law kneels on a Black man's neck for eight minutes and 46 seconds?

    Why is it taking the death of George Floyd—and Manuel Ellis and Eric Garner before him, as well as countless others—for us to realize that restraint (particularly restraint of the neck) can kill people, and it is only now starting to be banned?

    Eric Garner died in July 2014. The Eric Garner Anti-Chokehold Act was passed by the New York State Assembly in June. June 2020. Why is it that doctors and nurses can manage to restrain a patient with Velcro, not a knee on the neck or a chokehold to the throat, but police need to use lethal force?

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    Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter@grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

    Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • twood12188:39:53 AMI have enjoyed many of Dr. Walker’s previous articles, and I’m a fan of his app. However, this article is nothing but dangerously naive musings from an ivory tower. Comparing the restraining that we do in the emergency department to what police do on the streets shows a complete lack of understanding about life outside of the hospitals brightly lit exam rooms. <br><br> Having a full urinal thrown at you is nothing compared with being shot at or restraining someone with a knife who is actively trying to stab you. Restraining someone who is not able think clearly and make decisions for imself is very different from restraining someone who is actively trying to kill you. It is different to restrain someone in our controlled environment surrounded by support staff and monitoring equipment versus on the street in the patient’s environment surrounded by an angry mob of the patient’s family and friends. <br><br><div>This article makes the classic mistake of assuming because one knows everything about the way things work in the hospital; they know how it works in the field. The environments are unique. This assumption is a fatal flaw. Also, to say that the worst injury anyone has encountered restraining anyone is a contusion just says that he hasn’t been involved in enough restraint episodes. <br><br>I know people who have suffered sprains and fractures restraining patients. I know colleagues who were knocked out cold by patients. I have read plaques on the walls of a ED memorializing staff who were killed by a patient. Dr. Walker makes some valid points, but unfortunately, they get lost by the lack of insight into the uniqueness of the prehospital environment. Techniques, tools, and safety measures from the hospital can and probably should be adapted so that they can make their way into the hands on law enforcement, but to imply that what we do in the ED to what law enforcement does as apples to apples is dangerous.<br></div><br>
    • chazz465:55:38 PM<div>After reading Dr. Walker’s article, I relived an experience while working in a small town ED about nine years ago when I was about 65 years old. This was in a hospital with only one security guard for the entire site. I was told I needed to see a young man in a trauma room brought there by the police. He had been arrested after destroying all the windows in the halfway house he had recently entered. The halfway house manager was talking to him when I entered, and I saw that the patient was quiet and ambulatory and trying to walk away from his manager. He walked past me to the door when the nurse had just entered the door entrance, and he quickly kicked her in the stomach and took a step back.<br><br>I quickly grabbed him around the neck from behind and grappled him down to the floor. After five minutes of hanging on and the security guard not being found, a janitor came up to grab his lower extremities, and we held on until he could be given an injection of Geodon. My experience at that hospital is that whenever there is trouble like this, the nurses (male and female) get as far away from the subject as they can. <br><br>Not having the security guard around during the entire experience aggravated this problem. I admit the patient did complain of trouble breathing after which I adjusted my grasp around his neck. But I had to hold on for at least 15 minutes because the hospital had called the police department to take him back. The context of this whole experience seems relevant to today when I tell you that I am Caucasian, the nurse was a Black woman, and the patient was a Black man. <br><br>Furthermore, as a 165-pound, 5'8&quot; former Marine&#160;and Vietnam veteran, my training and quick response was not well appreciated by the hospital; they would have preferred that I just stood by and watched this dangerous person go on about his way. But I did have an awfully good friendship with that nurse afterwards.</div><br>