“Restrain him!” – loved the legality of getting the doctor to order that!
Often it was simply verbal, but it worked for me over 40 years. Often we’d get the doctor to sign an order, but usually we would justify it simply with “soft RESTRAINTS applied to wrists for patient’s safety” (citing repeat attempts to self-remove endotracheal tubes, tracheostomy tubes, central lines, NG tubes etc).
Worse disasters have occurred like when a patient who had only minutes earlier been admitted from emergency on a ventilator woke up, pulled out his endotracheal tube and NG tube, plus IV lines, jumped out of bed, argued with everyone in ICU then even the consultant, and signed himself out against medical advice. Ripping the urine catheter out with the balloon inflated may teach him a lesson when he gets home, but the reality is all about ‘CONSENT’ – and the medical staff couldn’t out argue his rationale as he was mentally competent. That he didn’t have an overpowering medical condition that put him at risk meant we couldn’t ‘FORCE’ him to stay. And this is intensive care, where we could easily justify (in a court of law if needed) that our restraint techniques were “REASONABLE and NECESSARY” for the safety of the patient.
There IS a technique after all, and I didn’t spare even young fit persons with lifesaving endotracheal tubes if they were ventilated, unless they had a good respiratory effort and spontaneous respirations. We have all seen countless patients (of others) extubate themselves because they hadn’t been restrained, followed by emergency attempts to get them back to safety. More frantic are the attempts to save them once a central line is pulled out, while they are on intravenous infusions of noradrenaline (to keep their Blood pressure up) as now it will crash, so there are frantic boluses of IV Metaraminol, plus attempts to subdue a patient who now is no longer controlled by my favourite of drugs -“propofol” (should come as an aerosol so we can use it in emergency department waiting rooms!).
Once a person is restrained (and many simply because they were elderly, delirious, maybe demented, maybe disoriented – this is more in general ward areas) then they really need to have a nurse or carer at their bedside to ensure no disasters occur.
Restraints can become tourniquets (especially since so many of today’s newer nurses seem to have no idea how to tie a slip-knot, or how to protect the skin or wrist of a patient, let alone one with ie oedematous, frail or fragile skin – thus the skin tears!
In Emergency a confused agitated patient sucks up manpower in order to keep him/her physically controlled. The drug addicts especially the ‘ICE’ brigade can need half a dozen or more staff to control them. On occasions wonderful people from ages in their 20’s and upwards have died, or stroked out, ‘coned’, bled out etc in another bed because of these moronic addicts! (Personal opinion is that all drug addicts esp ICE should ONLY be admitted to psychiatric centres and never an emergency department wit real humans in it). Otherwise bring back the padded cells we used to use till the late 70’s as at (the original) Lidcombe Hospital. Hang up a dozen baseball bats on the walls and then throw all the crazies in there. It’s time they took responsibility for their own stupidity. We can nominate them all for Darwin Awards later.
So now we are back to reality, meaning:
- A) Restraint,
- B) Force,
- C) Consent
Though in hospitals we convince ourselves that we can use the first two on order from a doctor (some think even without a doctor), the reality is markedly different.
Even the police have to justify beyond limits that they had no other option. Security guards have less rights, but yes, protecting staff and other patients wins the argument.
So, in emergency you had better ensure that there is a ‘schedule 8’ in force (only lasts 24 hours initially), but even then, the best advice in some circumstances is to NOT use force, but use your interpersonal communication skills of smiling, tone of voice, charm, sophisticated debonair charisma, (maybe a tango demonstration?). Positive body language, and confidence, are an excellent way to build trust and confidence. You really are able to influence people in a wide range of circumstances using effective interpersonal skills.
Getting someone with those skills to take over is even better if your own technique isn’t working!
If your patient is getting a flushed face, clenching his fists, raising his hands or his voice, using too much (or too little) eye contact, foul language, or is already intoxicated, back off immediately. Empathize, don’t sympathize. Remain calm, and above all, remain professional.
Active listening (listen-don’t talk or interrupt; show respect; encourage them to continue; concentrate on what they are saying (and hope someone is drawing up the Midazolam and bringing the 4-point restraints!).
Highly important is the audience you have – other patients, visitors, the person’s family and ‘concerned others’ , and the fun thing today….yes!…. You are probably being recorded and video’d! – yes…. ….you are about to become a YouTube sensation (hope your profile shot is good!).
So, speak slowly, clearly, repeat the message, ask them what you can do to make the problem better (ignore most of the advice you will get, as they probably really meant it another way!). Call them by their name, and better pronounce it right!
Use hand movements, but don’t touch, grab, or push them, and maintain a pleasant tone of voice while you smile as you communicate.
In some cultures, nodding your head means you disagree, and shaking it means you agree, so beware! To others, pointing is offensive.
Over fifty one percent of communication is your non-verbal communication (body language) so start practicing in front of a mirror. Non-verbal adds meaning to the spoken word. Try it!
At the end, remember this:
ASSAULT means ‘to apply or threaten to apply force without consent or lawful justification’, and THREAT means ‘a communicated or implied intent to cause harm to a person or property’ – both are ILLEGAL.So when you tackle the patient, how much justification do you have? You actually CAN be sued if you aren’t fully aware of all avenues and the law. Sued as a CIVIL claim as well as CRIMINAL, and that means facing the Tribunal, maybe even deregistration. Never expecting the Inquisition won’t help you here!
So to finish, everyone has a Duty of Care under the NSW Work Health Safety Act 2011, that means the employer, the employee, and everyone who enters ‘the site’, and Duty of Care is the ‘legal obligation to take reasonable care while performing any acts or omissions that could foreseeable harm others’. (Does this ‘apply’ to aggressive patients?)
Fun, fun, fun!!!
The final insert is about ‘Restraint Asphyxia’ – ‘the obstruction of breathing due to a restraint technique used, or to the person’s body position’, and is exacerbated in the obese, those with pre-existing medical conditions, also Psychosis, and due to pressure on the abdomen. The importance is in recognising the condition, so that you can avoid it. To avoid it, you of course must check their breathing regularly, reposition them regularly, and avoid choke holds and neck/throat restraints. These issues have happened frequently, leading to the death of numerous of our ‘young’, often in emergency departments, at the roadside, at clubs, pubs, and Casinos. Security staff are frequently involved, and also police, but even hospital health care workers.
When an idiot relative was going to attack my sister-in-law, and threatened the 85 year old neighbour, I used a great choke hold till he went purple, before letting go, then we continued our melee out of the house and into the street in Balmain, till the police arrived. Good thing he was a relative I suppose!
Thank you to the NSW Security Industry Act 1997 and Regulation of 2007 for some of this information, through the Certificate II is Security Operations. I recommend this intensive two-week course to all nurses.
Bernhard Racz RN (ICU)
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