Wednesday, September 14, 2011

Combative Patient Restraint During Spine Boarding

One of the tasks assigned to AT educators is to properly instruct aspiring ATC's on the logistics of spine boarding (back boarding) of patients.  I have found that students respond readily to repeated rehearsal of the tasks associated with efficient and timely spine boarding.  However, the difficulty often lies within the patient themselves.  What to do when a patient is non-compliant or combative? When students practice in simulation, the assumption is that the patient is either unconscious or conscious and will automatically comply with verbal communication from the medical staff.  It has been my professional experience that this is not always the case.  If the athlete is unconscious and becomes alert midway through the process, they may be confused and, understandably, resist personnel who are attempting to do their job.  If they have suffered a head injury, or in the classic "fight or flight" mechanism, their reactions may be in complete contrast to the compliant patient we all envision when anticipating performing the act of spine boarding.  So what to do?  Well, in this case, go to the experts.  EMS personnel spine board more patients than most, if not any other health care profession.  And they do so in a variety of challenging and not so ideal environments. 
Question my students have posed after mock scenarios:  Do I restrain a combative patient who attempts to resist the immobilization process mid-way through?

My response: GREAT question. 
So we turn to Firehouse Magazine, and an interesting article found here. 
Take Home Points:
1.There are 4 methods of restraint:  Verbal, Non-Verbal, Physical & Chemical.  Use Verbal and Non Verbal as your first choice.  When those fail, physical restraint may be necessary.
2.Have four people ready to control each limb (this shouldn't account for everyone, though).
3. Use necessary, but not excessive force.

Mike Weaver writes in this article that much like firefighters training again and again for fires (which occur relatively infrequently when compared proportionately to training exercises), personnel can become more adept at handling challenging cases when they present.  He suggests this same logic be applied to spine boarding the combative patient.  Some take home points here:
1. Position the patient to your advantage: Holding them in a "T" position (arms abducted and elbows extended to 90 degrees, legs straight) takes mechanical advantage away from the patient.
2. Acceptable minimum number of trained personnel should be six persons.
3. Don't "crowd" the patient.  Give some space.

Some general rules I teach students to follow:
1. Don't assume that because you know all of your athletes, that they will automatically respond to you in a positive manner.
2.  Maintain a calm demeanor and constant eye contact with the patient (best if done by person at head position).
3.  Don't take it personally; they are in physical distress, and perhaps psychological distress.  Remain calm and in control.
4.  Remember, at sporting events, it's likely family and friends are in the direct vicinity.  Do your job, but be professional about it, in both physical and verbal commands.
5.  Use your verbal commands, and negotiate with the athlete.  Remember that excessive force at the head can actually increase severity of the injury; potentially catastrophically. Your struggle to hold the head and neck down may actually hurt them more.
6.  Know your equipment.  Every spine board and buckle/strap system is different, and there are many variations currently utilized.  Familiarize yourself with these wherever you go.

Great food for thought, a true gray area. Feel free to share your thoughts!

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