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B_Lonardo
11-08-2007, 11:31 AM
As a paramedic in an urban system I am trying to promote the city to allow us to carry handcuffs, as do many of the other urban systems around us, for example Boston EMS, and Worcester EMS. I am looking for opinions from law enforcement (police officers) on this topic. Does EMS in your community carry handcuffs? Do you feel that they should ? Do you send an officer to all EMS requests? I am looking for any opinion, it doesn't just have to be positive! I encourage all feedback! We, often do not get a crusier on all of our calls because they are just to busy to free a car !

Also, do any of your police departments incooperate paramedics as part of the SWAT (or equivelant) team?

Norman
11-08-2007, 11:39 AM
I think that all the trucks should have some flex cuffs just in case, but I don't really think that the normal EMT needs a pair of steel cuffs. If they are bad enough to cuff around here the police are usually already there. If they are combative might think about an EOD. I also believe that the EMT-B/drive should ALWAYS be allowed to carry a concealed handgun, but that pretty much never happens:rolleyes:

SgtScott31
11-08-2007, 12:36 PM
I'll throw my two cents since I am an EMT-IV and LEO....


Restraints? Yes

Cuffs? Not necessarily. There are other ways to restrain a patient.

I will agree with Norman on one aspect, that if the call is possibly violence-related, LEO's are there in most cases. In some counties, LEO's roll with EMS on almost every call. In my county (Metro Nashville/Davidson Co), normally MNPD rolls with EMS on calls related to domestics, violent behavior, ETOH (or alcohol-related).

Handgun for EMT's? No...whether you realize it or not (Norman), allowing an EMT to carry a firearm introduces that weapon to every call you go on. An otherwise unarmed person who becomes belligerent/violent for whatever reason (whether it be alcohol-related, behavioral, diabetic) now has access to a gun; and law enforcement may or may not be there to help you out. I just don't see EMS personnel staying proficient enough in use of force issues, handgun training, deadly-force training to warrant carrying it. Some may have a different opinion, but that's my take on it. The only time I've seen weapons on ambulances are in the middle-east, and normally they are assault rifles. Totally different circumstances involved though.

I think pepper spray/mace would be ok and would be effective enough to incapacitate the indivudal and allow you to either (1) gain control or (2) escape to safety.

bigeagle
11-08-2007, 02:01 PM
I've been medic for 7 years in an urban area. Been in plenty of fights and had more combative patients than I can count. Never have I needed handcuffs. 4 point restraints right to the stretcher or strapped to a back-board works fine.

Why would you need handcuffs? If they're cuffed in the back than they can't be secured properly on a stretcher. If you're going to cuff with arms in front then they can still swing at you. I'd rather 4 point with one hand over their head. Works great.

MrsPagan
11-08-2007, 02:42 PM
Ok, I work for the FDNY as an EMT, handcuffs no but soft restraints yes. We actually use triangular bandages as our soft restraints, and if the guys really that bad ESU will wrap em in a nice black burrito (that’s a nick name we call em). You don’t need soft restraints all of the time, I've had my shares of EDP's, drunks, and drugs, most of them aren’t all out fists flaring, but the few that are yea...def. The ones that are already arrested, PD has it covered. Usually if the call's that bad we wait for PD no matter what, you shouldn’t put your safety in jeopardy if you feel uncomfortable.

just joe
11-08-2007, 04:54 PM
I am a police officer and EMT We try to send officers on all medic runs. Handcuffs = No and soft restraints = Yes. I agree with the above three posters.

Norman
11-08-2007, 05:27 PM
I'll throw my two cents since I am an EMT-IV and LEO....


Restraints? Yes

Cuffs? Not necessarily. There are other ways to restrain a patient.

I will agree with Norman on one aspect, that if the call is possibly violence-related, LEO's are there in most cases. In some counties, LEO's roll with EMS on almost every call. In my county (Metro Nashville/Davidson Co), normally MNPD rolls with EMS on calls related to domestics, violent behavior, ETOH (or alcohol-related).

Handgun for EMT's? No...whether you realize it or not (Norman), allowing an EMT to carry a firearm introduces that weapon to every call you go on. An otherwise unarmed person who becomes belligerent/violent for whatever reason (whether it be alcohol-related, behavioral, diabetic) now has access to a gun; and law enforcement may or may not be there to help you out. I just don't see EMS personnel staying proficient enough in use of force issues, handgun training, deadly-force training to warrant carrying it. Some may have a different opinion, but that's my take on it. The only time I've seen weapons on ambulances are in the middle-east, and normally they are assault rifles. Totally different circumstances involved though.

I think pepper spray/mace would be ok and would be effective enough to incapacitate the indivudal and allow you to either (1) gain control or (2) escape to safety.

I was not saying that handguns be required, only allowed if the EMT gets a CCW or the like. The reason I say that is I persoally know of medics getting shot at and etc. I think that pepper spray would present a major problem to future patients who may have allergies. That and the back of a bus is so small I would hate be in it after someone got sprayed.

Sorry to the OP for getting off topic. I still think that a couple flex cuffs could come in handy. As mentioned though triangular bandage and KED/Long spine board FTW.

wisened
11-09-2007, 10:01 AM
I am just reaffirming most of what I have read above. I am both a Paramedic and a Police Officer, and having been on both sides i would certainly encourage use of restraints where appropriate but not with steel handcuffs.

As an EMT you are a caregiver and the patient's advocate. Steel on skin is never the choice you want to advocate for them if you have other options available. Cloth 4x4's and some kerlix can make instant soft restraints for you, and cost little or nothing. Get blood on them? So what, they are disposable. Plus you should already be carrying that in your supplies. I have done this multiple times and have yet to see anyone be able to tear loose unless you tie them to a sharp edge, but again some 4x4's or abd dressings would protect that.

Most medical suppliers do offer cheap and disposable soft restraints. The padded leather ones will cost more but if cared for can still be used long after your grandkids retire.

Other reasons to choose soft restraints include:

- limb placement flexibility. You can usually choose length of the strap you are securing a limb with, handcuffs are as you get them. This can become important when trying to secure or maintain IV access, BP monitoring (Critical especcially in head injuries = combative), as well as some other medical assessments and treatments.

- you can safely assess radial pulses without fear of pinching your fingers between their bones and the metal. not so with handcuffs.

- people come in all sizes, soft restraints can be adjusted for that size. what if the person you hare securing is small and squirmy, or extremely large? Edema in extremities can change the size during some medical conditions as well, making your risk of compartment syndrome type injuries a possible risk. Soft retraints would allow for more expansion and can be more easily adjusted or just plain cut off if necessary. If you have to much pressure on the cuffs and you can't easily remove them after that sweeling has ocurred you could have issues there as well.

- nerve and joint damage is more likely with metal cuffs than with soft restraints.

- Metal cuffs will scrape the paint on your fancy cot :)

- Metal cuffs you will need to carry a key and always have it available. Soft restraints can be removed by any medical personnel.

I could list more, but I am hoping you will see where I am coming from. Again as a Paramedic with a lot of years of experience, I would really discourage the use of any kind of metal restraint. Even if just for the perception. Even as a cop I don't like to use handcuff's because people know that when they come out their freedom is being taken away. Your ability to build trust and enhance your care can be hampered just because you used the wrong tool. I again really throw out the idea of the Kerlix and 4x4's because none of those are going to set off alarm bells for most patients and you san use them effectively for most transports. If you need more, you can always consider chemically restraining them with the proper medical orders for sedation as well.

Jon

bigeagle
11-09-2007, 10:08 AM
If you need more, you can always consider chemically restraining them with the proper medical orders for sedation as well.

Jon

Yet another good point.

11b101abn
11-09-2007, 12:05 PM
If ther person is in custody, then the only option if they are concious is to cuff them to the gurney. If unconcious then no.

If in custody, then an officer will escort the bus to the hospital.

Fierarm=No

Body armor=yes. (in an outer carrier).

B_Lonardo
11-09-2007, 01:20 PM
Thank you to all who have responded thus far. Some very helpful feedback here. A couple of interesting things came up that I want to address. First, I am completely against EMS carrying firearms. I have heard talk of tasers (our police department recently outfitted each officer with a taser) I personally have not been involved in an incident where one has been used. My concern with EMS (myself included) carrying any weapon is the risk of being overcome and losing it to someone who is suicidal or otherwise psychologically ill. I believe someone already mentioned this above. The reason I am wanted to explore the topic of restraint is that some of the patients we encouter (as do all of you) are often under the infulence of very potent drugs (cocaine, PCP, etc. ) and can become quite strong, requiring lots of power to overcome. In my system, unless a weapon is know to be involved, we only send the rescue. Unlike some other similar systems, we don't routinely dispatch an engine to medical calls. So, unless its coded in the computer as a weapon involved, or something that is known to require an officer, its just us. Now, with that said, the PD is very good to us, and helps us out greatly when they are there, but often times they don't get sent. But all of you have been very helpful, and I appreciate the feedback. As to chemical restraint: Does anyone work in a system where you can use chemical restraint on psychological emergencies in the pre-hospital setting? I have heard that New Hamphsire allows for this, but to my knowledge the state of MA does not provide for this.

MrsPagan
11-09-2007, 01:40 PM
Well my department issues us body armour because of a few techs that we're shot or confronted with a firearm, I think its a good thing, a bit to get used to. Actual firearm issued to us: No, absolutely not, there are so many dangers with us having one, you cant treat properly and worry about if the dude will snatch the weapon or worse. Techs. and medics are to treat and transport, officers are there for arrests and restraints other then soft restraints.
Not to mention we'd need additional training for how much force we are to use, etc. That's going a far way from what we are there to do, aid peoples injuries/illness' and such.

wisened
11-09-2007, 02:58 PM
B_Lonardo,

When it comes to chemical restraint you primarily need your medical director to be on board with what you are potentially facing. As long as you can medically document a need for the medication administration then legally you should be able to administer the medication.

It comes down to articulable support. If you can legally and reasonably document a condition (i.e. combative to the point of self harm or harm to others) then you can have a documentable need for the medication. What meds you use can range greatly depending upon why the patient is in the state they are in.

For possible drug overdoses you are going to be a little more limited, as you do not want to overload the livers ability to process the medications. However, full sedation may not be necessary. Instead of diazepam (Valium) could you use lorazepam (Ativan). They won't go as deep into sleep but the calming effects may be all you need to bring their threat level down to a level you can manage with communication or a combination with restraints.

Remember that diphenhydramine (Benadryl) will also have a sedative side effect. It is not unusual for some people's significant aggressiveness from drug overdoses to be reduced with some Benadryl. Research has not resolved why this is, but it is theorized that it is a form of allergic reaction in the body. Similar to Dystonia reactions from some drugs that is also reversed by Benadryl.

For Cocaine overdoses you are probably going to be encouraged by a progressive doctor to consider a sedative. This will reduce the overall stress on the body. Prinzmetals Angina form constriction of blood vessels is not the first sign you should be looking for in possible cardiac complications and this will help keep you ahead of the curve.

In extreme cases, PCP for example it may not be out of line to consider a paralytic such as norcuronium, vecuronium or succinylcholine. Of course you combine that with a sedative. It may be safer to have to provide an airway for this patient than to have to fight them.

One of the things that we had to do was to get our money person to authorize the expense of Romazicon on the trucks so that we had a reversing agent for the sedatives. This way if something changed and we needed to wake the patient up we had the means to do so quickly and safely.

Once again it is all a matter of justifying the actions you want to take with sound medical knowledge and an ability to properly articulate how your actions were a benefit to your overall patient care.

Last but not least, when you are making your presentations for options, present them with areas of benefit to the hospitals and their staff as well. Remember that you are a gateway for this patient to enter into the entire healthcare continuum. If you proposals show benefit to the patient as they progress from the street to the ER to the floor and so on, then you will be more likely to have success in getting these tools in your arsenal. If you use them or present them as something that helps you but adds to what the hospital has to deal with then you are likely to be shut down.


Jon

SMUDGE
11-18-2007, 06:47 PM
B- I hear your frustrations. I was a medic in one of your above mentioned services for a few years before becoming a cop. I learned quickly that EMS and scene safety is not always textbook, sh*T just happens;). There were many times I wished I had a pair of handcuffs to use. I think that if there is a good deal of regulation when it comes to medics using handcuffs,along with some proper training, I dont see a huge deal with it. An example of this would be use the cuffs to get someone quickly restrained, and then change them over to soft restraints once it is safe to do so. Christ, medics are trusted with paralytics, which can easily kill someone, whats the big deal about handcuffs.:) No on the OC and a big no on the handgun option. As far as body armor, I wore it religiously everyshift as a medic. EMS means you may get into a bad situation, but the difference between you and the police in these cases is that you can turn around and run away (or wait), where as cops cannot.

Im not sure what the history of why and how Boston EMS started using cuffs, Worcester EMS does NOT carry them.

Good luck, stay safe
Smudge

355339
11-19-2007, 12:59 AM
I completely support paramedics having hand cuff's for safety reasons. There's no mention about using them on all patients (obviously), however it's better to be prepared against violent patients. I understand that 4-point restraints work. but if your walking a mobile drug addict down four flights of narrow stairs, being tied to a stretcher doesn't do that much good.

SMUDGE
11-19-2007, 08:17 PM
I completely support paramedics having hand cuff's for safety reasons. There's no mention about using them on all patients (obviously), however it's better to be prepared against violent patients. I understand that 4-point restraints work. but if your walking a mobile drug addict down four flights of narrow stairs, being tied to a stretcher doesn't do that much good.


Agreed, with a bit of training and regulation, they would come in handy for those times that 4 points are not an option

Mirrain
11-19-2007, 08:36 PM
I absolutely support soft restraints but not handcuffs. I have no experience as a paramedic but I can't see using handcuffs very practical for you guys. You can't handcuff someone to the bed for example and messing around with the keys and such might be more difficult than just slipping some flex cuffs on and cutting them off when you need to.

I'm on the fence as far as being armed. I know that a lot of you guys get assaulted and deal with the occasional weapon but where I am the medics stand by for police to clear the scene before they enter. I know there are always those situations where these things come up out of no where but I think having to train on guns and deal with the retention issues of your weapon while working so closely with aggitated patients might make it worse not better. The other consideration is that if the bad guys know you are armed, you actually make yourself more of a target since they will see you as the same threat as us.

the Chools
11-20-2007, 09:50 AM
Re chemical restraints... Can you administer medication to a patient without his permission?

hxd
11-20-2007, 10:33 AM
Re chemical restraints... Can you administer medication to a patient without his permission?


The short answer is: Yes, but under very limited circumstances. The general rule is that it can be done under the doctrine of implied consent or at the direction of on-line medical control. There may be other circumstances under which EMS may administer such medications to a patient without their consent, but those will vary from jurisdiction to jurisdiction.

wisened
11-20-2007, 06:23 PM
HXD is correct

Basically you need to view it this way. If they are conscious and alert enough to make the choice to cause a problem. Such as just being a jerk or being angry that EMS was called. Then most likely they are going to be medically safe to be turned over to the police and they can fae disorderly conduct charges or whatever applies.

If their medical condition is such that they have head injury, mental illness, overdose, etc. Then they are not medically able to make decisions for themselves. Therefore the view is going to be that they can be treated (chemically restrained) to protect them until their condition can be stabilized to the point that they can safely make decisions for themselves.

The gray area in between is where you can hopefully have a good working relationship with your law enforcement people. If the person is being a jerk and is actually needing medical treatment and simply choosing to not recieve it. Then you have one of two options, Have the police take them into protective custody and order that they recieve treatment. THis would require that the officer be convinced that the persons life is truly in danger if he/she refuses treatment and that the decision is likely an attempt at self-harm. Or, as sad as it may sound, you wait until the patient's condition deteriorates to the point that they can no longer refuse treatment and initiate the treatment on Implied Consent.

Implied Consent for those that do not know is a defined legal term that is recognized in the courts as the belief that a person would normally want their condition treated and would give consent to a practitioner to treat them if they were able to verbalize consent. This is why you need DNR orders and Living Wills to stop or withhold emergency treatments. Otherwise care givers will act under Implied Consent.

DeputySC
11-20-2007, 07:07 PM
EMS does carry medical restraints here. Which is a large orange straight jacket. The closest thing to handcuffs I seem are padded wrist restraints that connect to the bed or stretcher.

ninjamom6
11-20-2007, 10:50 PM
Slightly off topic, but I thought you guys might find this site interesting:

Defensive Tactics for EMS (http://www.dt4ems.net/forums/)

SMUDGE
11-21-2007, 02:09 AM
I absolutely support soft restraints but not handcuffs. I have no experience as a paramedic but I can't see using handcuffs very practical for you guys. You can't handcuff someone to the bed for example and messing around with the keys and such might be more difficult than just slipping some flex cuffs on and cutting them off when you need to.

I'm on the fence as far as being armed. I know that a lot of you guys get assaulted and deal with the occasional weapon but where I am the medics stand by for police to clear the scene before they enter. I know there are always those situations where these things come up out of no where but I think having to train on guns and deal with the retention issues of your weapon while working so closely with aggitated patients might make it worse not better. The other consideration is that if the bad guys know you are armed, you actually make yourself more of a target since they will see you as the same threat as us.



Soft wrist restraints work MOST of the time, in most circumstances of a Pt. who needs to be restrained. Handcuffs would come in handy in the following scenario:
You get a Pt. who just all of the sudden goes crazy, lets say in the back of the ambulance and may be making a try at jumping out of the back. You are "wrestling" to keep the Pt on the stretcher as your partner pulls over to help you. As a medic, especially without all the DT training a PO goes through, you need/want a quick way to get this Pt. under control so no one gets hurt. It is very difficult to get soft restraints on/tied and secure with only two people,especially when they are combative. If the medics had cuffs and were trained in them-boom you cuff them to the stretcher rail, or their hands together...recover and once you get more help, you change them over to soft restraints. Flexicuffs would be good too.
A good way to see this would be:
Take the cases you have been in as a cop and think about what if you had to restrain someone with soft tie restraints instead of cuffs...it would be hard.

Im big no on the being armed scenario--for the same reasons you bring up..
Happy Thanksgiving
Stay Safe, Smudge

hxd
11-21-2007, 10:49 AM
We carry "bunny cuffs" in all of our ambulances. I can not recall a single time in over 15 years when they have been used within my agency. The primary reason for this is that in any situation that has occurred where application of the cuffs would have been appropriate, the patient has gone from calm to SHTF in a nanosecond. I'm sure there were warning signs, but my people may not have picked up on them or responded appropriately.

In EMS, we're pretty darned good and taking care of what ails ya. What we're NOT good at is taking care of ourselves and each other. Although we're getting better, situational awareness is not something we excel at. How much discussion of situational awareness is there in the typical LE academy? EMT classes typically discuss sitational awareness for two hours or less, and that's usually coupled in with the universal precautions (or BSI for the new-jacks) discussion.

How many people routinely ask the question "do you have any weapons on you?" before taking a drug dealer (or user for that matter) into the back of their ambulance? How many people sit behind their patient where they can't see their hands, or dim the lights and kick back and relax while transporting a stable patient? Why don't we stress to our EMS providers that everyone goes home at the end of our shift just as we do for police officers?

When I'm the supervisor on the shift at my EMS agency, I DO. I'm guilty of pulling my crew our of a CPR call because the scene became too emotionally charged and I could see the family starting to get violent. I'm guilty not helping my partner bandage the foot of a patient who was drunk and high because I felt it more important to put myself between the patient and the shotgun that was within his reach. And yes, I'm guilty of administering "anisthetic oxygen" to a patient who unstrapped himself from the gurney and attempted to forcibly rape a female medic in the back of the ambulance while she had her back turned.

I submit that even though our missions are different, our jobs have the potential to be just as dangerous as that of law-enforcement. Should we have all of the tools as LEOs? Absolutely not. If you OC someone in the back of an ambulance, you're going to take out your entire crew and possibly the lives of people on the road (if the ambulance happens to be moving at the time). A baton? It WILL be taken away and used against you sooner or later. I won't even venture into the liability associated with carrying a firearm. Handcuffs? Perhaps. But before we consider that, we need to TRAIN our people better. I want to see all of my people go through some type of situational awareness and DT training and drill on it first. What good are the added tools if you don't know how and when to properly use them?




Slightly off topic, but I thought you guys might find this site interesting:

Defensive Tactics for EMS (http://www.dt4ems.net/forums/)

Cool info. Thanks ninjamom. It's timely too. I have actually been working with one of the dojos that teaches the Krav Maga for Law Enforcement classes to develop a two-day DT course for EMS providers.