If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

- Rogue Medic

‘Hog-tying’ death report faults Fla. medics

An internal investigation by Broward County’s Fire Rescue division concluded that errors by emergency personnel may have caused the death of a Lauderhill man who suffocated after being “hog-tied” by Broward Sheriff’s Office deputies and county paramedics.[1]

This death is from October 15, 2001, so it has been over a decade and everyone in EMS should be refusing to allow patients to be placed in the prone position following restraint. Hog tying should never even be considered.

The responsible way to manage someone who is combative is to chemically restrain the patient. Physical restraint is for the purpose of being able to inject the patient with the chemical restraint.

Should the medics have known better? Yes, but it was a decade ago and there are still EMS agencies that are not aggressive with chemical restraints.

This is the responsibility of the medical director. We are supposed to be trained and equipped to not make things worse. Clearly, we can make things much worse, if we do not have the right education and medication and protocols.

We should not be treating our excited delirium patients like animals in a rodeo. As medical people, we are supposed to be smarter than the patient with the malfunctioning brain.

Diabetes, head injury, stroke, hypoxia, hyperthermia, drugs, psych, et cetera. There are many possible reasons for this behavior. Our job is to sedate the patient with the least harm to everyone involved, including the patient.


Image credit.

Tasers protect everyone, including the patient,[2] so it is safer for everyone if police use a Taser and then EMS sedates the patient. This is not likely to be effective unless aggressive doses of sedative are given.

Given the irrational and potentially violent, dangerous, and lethal behavior of an ExDS subject, any LEO interaction with a person in this situation risks significant injury or death to either the LEO or the ExDS subject who has a potentially lethal medical syndrome.[3]

They point out that a perfect outcome is expected every time.

A perfect outcome is not possible every time.

One of the problems in dealing with excited delirium is that it looks easy, but only when it is done right.

Making the treatment of unstable patients look no more eventful than the treatment of stable patients is what good EMS is all about.

When we make it look easy, some people will claim that we over-reacted. We cannot go back and handle things differently, but we should not want to. Some conditions need to be approached as if they arfe life-threatening. Excited delirium is one of them.

Why?

Because it is life-threatening.

Our job is to try to prevent death, not to cause death. If we do not protect our excited delirium patients by aggressively sedating them, we will kill some of our patients.

Footnotes:

[1] ‘Hog-tying’ death report faults Fla. medics
Report cites 9 ‘failures’ that it says cumulatively may have led to man’s death
By Elgin Jones
South Florida Times
April 19, 2012
Article Reprinted at EMS1.com

[2] Joe Lex: Electrical Misadventures – Microwaves, Cords, Plugs, TASERs, and Lightning
Published: August 30, 2010
Free Emergency Medicine Talks
Page with mp3 link to download

Dr. Joe Lex is one of the most sought after emergency medicine lecturers in the world. Listen to this and to the rest of his talks that are at Free Emergency Medicine Talks.

[3] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

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Comments

  1. I think you might want to review your comments and think before making some statements. 99% of the time, Chemical Sedation is NOT a good practice or recommended to control your patient. There are many underlying factors to consider, as you should know, and there are a reason hospitals, medical units and such carry leather restraints and other such devices including police handcuffs with an officer accompanying you in the truck. By Chemically Restraining a patient you open yourself and your EMS/Fire Department to lawsuits and losing your license. You should be a patient advocate, this does not mean “knocking them out” to better control them. Unknown medical history, allergies, head trauma… all these contribute and should be considered. By doing so could result in a medic induced code due to your actions to use drugs to control a patient. I think a little more thought should go into your blogs.

    • You of course have some evidence to support the claim that “99% of the time, Chemical Sedation is NOT a good practice…”, right? Some studies, some protocols, ANYTHING more than personal opinion and anecdotes to support such a strong claim?

      Exactly why would chemical restraint be any more (or less) likely to result in lawsuits than physical restraints; especially leather restraints or handcuffs? Hell, IMHO, physical restraints are MORE likely to result in lawsuits because of the violence required to implement them.

      Chemical restraints are just like any other procedure available to paramedics; no more and no less. NO PROCEDURES should be done without a sufficient assessment to determine the need for and risks from a given action; whether it be high-flow O2, chemical restraints, ET intubation, or whatever.

  2. Why are medics so scared of sedation? My favorite comment in a chart of a patient that I suspect of ED is, “Pt arouses to voice and is resting comfortably on the cot.” That is a properly treated patient. I have had very good results with initial doses of 5mg IN or IV of Versed and 10mg IM Versed. I always followed up the IN/IV with an IM dose since studies, cannot find the original one, have shown IM as a better route with less resedation needed.

    I know there are risks and apnea is one. Not a fan of doing that on purpose but, we can all handle that. I am seeing more and more of these patients and more and more are ending up chemically paralysed on ventilators until the Spice or Bath Salts are out of their system.

    Maybe someday my medical director will give us Ketamine….

    Shane, so you have a stance that the hyperthermia, lactic/metabolic acidosis, rhabdo, dehydration, extreme hypertension, etc. that leads to renal failure, MODS, cardiac dysrhythmias, stroke and sudden death is not something that needs to be worried about? Last I checked most of those can kill pretty quickly. All those are a direct result of the patient that is out of control and fighting and struggling. My guess is you have never walked in the house to see every piece of furniture, every appliance, bathroom fixtures, windows, etc. all destroyed by a 150lb guy standing there naked and ready to fight. Not a fun call and a VERY dangerous situation for all involved.

    • Medics are afraid of sedation for the same reason that we’re afraid of nitroglycerine. We’ve been taught, often incorrectly, that these treatments have drawbacks that outweigh their benefits. We’ve been scared into submission with tales of people bottoming out their pressures with one tab of nitro. We’ve been told horror stories about bottoming out pressure or fatal respiratory depression with 2mg of morphine. We have medical directors who tell us horror stories about these kind of drugs because THEY don’t want to place trust in paramedics to adequately assess and treat patients.

  3. Just for accuracy, a how can a patient be supine and hog-tied at the same time?

    I have transported a patient face down one time, and I was not happy about it, but I had no other options at the time. If I had access to ALS or chemical restraint I would have opted for that

    • Bullets,

      Just for accuracy, a how can a patient be supine and hog-tied at the same time?

      My mistake. I have corrected that. Thank you.

      I have transported a patient face down one time, and I was not happy about it, but I had no other options at the time. If I had access to ALS or chemical restraint I would have opted for that

      Transporting patients face down is sometimes the right thing to do. Airway protection, when the patient has problems keeping the airway clear. Injury to the back, such as an impaled object, that prevents transport seated or supine (look appropriate use of supine). Not much good reason to transport an agitated patient prone, except for poor protocols and a medical director who does not understand excited delirium.

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