Soft Restraints = Hard Times for Healthcare Providers!

Restraint situations are probably the single most dangerous time in which EMTs, medics and nurses find themselves the victim of a violent encounter. 

Restrained patient chokes and threatens to kill medic

Man Slips out of Handcuffs- Jumps Out of Ambulance

Punched in the face-Female EMT attacked while attempting patient restraint

EMTs attacked when patient slips out of restraints

Many more similar stories in our Assault on Staff Log

I get asked a lot of questions regarding restraints: When do we put them on? Who applies them? What is the best technique to use?

I hope to answer some of these very important questions with this article.Ultimately_Responsible

What is most important to understand, before we go any further, is one must answer the question of care, patient protection or custody. Those involved in the health care profession must only restrain to provide care or to protect a person from harming themselves or others, but only when the aggressive nature is due to a medical emergency, i.e. CVA, Dementia or head injury.

If the aggressive/assaultive actions are due to drugs, alcohol or any other conscious objective desire to cause harm, law enforcement needs to be the ones placing restraints and taking a person into custody. Anyone within the medical profession, specifically EMS and ER staff, has at some point had to make a decision about the use of restraints.

Hospital Security Guard Murdered in the ED: The case occurred in Springfield, Missouri where a security guard was murdered by a person being treated in the emergency room. It involved a person who was being restrained.  Police had arrested the suspect after he fled a crime scene.  Police responded to the suspect’s father’s house after the father reported he had been assaulted by the suspect. The suspect fled and police used a K-9 to track and arrest him. During the arrest, the K-9 bit the suspect. The police took the suspect to a hospital emergency room to be treated for his wounds.

At the hospital, according to police reports, the suspect became combative. When a police officer and two hospital security officers attempted to restrain him, the suspect allegedly kicked one of the security guards in the back of the head.  A short time later the security guard collapsed into a coma and died a few days later. A medical examiner said the death resulted from the kick. The suspect was found guilty of second degree murder and was sentenced to life in prison. (1)

In the medical field restraints are used to protect the patient from harming themselves or staff. They are not to be used for punitive reasons or to punish a person. Most laws pertaining to the use of restraints by EMS state they can only do so in an emergency and either in the presence of a physician or under a physician’s order.  Many department policies on restraints may not be in line with state statute.(2)

This case is so important for several reasons. First here is a clear cut case of a “patient” becoming an “attacker”. A person was being treated for his wounds and became aggressive/assaultive. In this particular case, this person needed to be restrained by law enforcement and not medical staff.  Many times healthcare providers are involved with “patients” who need restraint for medical reasons. With this particular case there was no reason for a healthcare provider to try and apply restraints.

The second reason this case is so important is it shows how a “kick” can be deadly. Here the suspect was supine on a bed and turned and kicked the security guard that was down by his feet. I can not count the number of times I have been or seen others restraining a person at the foot of the bed. Many healthcare providers have been “kicked” and fail to pursue criminal charges after they have been assaulted.  Remember the leg is longer and stronger than the arms.

When people ask me about a specific technique to use for “restraints” I tell them there is none. There is no magic technique. There is however two principles that must be followed; Body Parts to Body Mass and Control the Middle Joint.

Body Parts to Body Mass means to press the body part to the body mass of the individual you are trying to medically restrain. Control the middle joint to apply the actual restraint device. Elbow Control is the principle that must be followed while applying restraints is to the upper limbs. Simple elbow control controls the entire arm. Grabbing a person by the wrist does absolutely nothing to control the strength of that limb. The only way grabbing the wrist will work is if you begin to apply a joint lock. A joint lock is a pain compliance technique. Remind me again why you were placing the person in restraints? If you are using a pain compliance technique that is custody not patient care.

To prove my point, I usually refer people to the ever popular TV show with real police officers on the street.

Most people would agree that the average officer on the street has quite a bit of experience in placing a person in restraints. Many episodes will show an officer attempting to place someone in restraints (handcuffs). Most of the time a lone officer is unsuccessful in applying the restraints, when the person being restrained does not wish to be restrained;

The officer is usually successful with:

  • A cooperative, submissive restrain-ee or
  • Overcomes the restrain-ee’s wishes via pain compliance, therefore having the restrain-ee “wish” to be restrained or
  • Overcomes the restrain-ee using strength and superior numbers.

Which brings me to the next point; how many people do you have/use to properly medically restrain a patient? According to the NAEMSP, released on a position paper, it takes five people to medically restrain a patient. Does that make you re-think your restraint policy or techniques?

Here are some of the pitfalls with restraints:


Directly related toYou can go to the hospital with them or jail with me”

Lack of individual training: The average provider does not have training in restraint techniques. Across the country the average training time offered to staff is 4 hours or less.

Lack of cooperative training: Even if a person did receive training in how to apply restraints, it is rare the minimum numbers of 5 people are similarly trained in the application of the restraints.(3)


Custody vs. Care: Many EMS and health care providers fail to perceive the danger in not separating a
“patient” from an “attacker” and attempt to take custody of a person. Again, custody is a law enforcement action not a medical one.

Excited Delirium and Positional Asphyxia: A lack of recognition of person(s) at risk for Restraint Asphyxia/Positional Asphyxia. Any person that has struggled with law enforcement and was physically restrained must not be restrained prone. Law enforcement have trained for years to recognize ED. Most of the time I teach DT4EMS’ EVE the majority of medically trained participants have never trained for the excited delirium scenario.

Failure to report injuries: resulting from patient/attacker aggressiveness. Most agencies compel reporting if you received a scratch while working yet there is not the same requirement if a staff member is assaulted. Sometimes it may be the lack of differentiation of an attacker from a patient. Then the provider’s not aware a criminal assault occurred.

On restraints in particular… let’s look at training time devoted specifically to them:

POLICE (Average Training Hours)
•40-80 Defensive Tactics (AKA Mechanics of Arrest and Control Tactics)
•8 Actual Handcuffing (defined as a temporary means of restraint)
•8 Baton (Skills end with handcuffing (restraining) a subject)
•4-8 OC/Pepper Spray (ends with handcuffing a subject)
•4-8 Taser (ends with handcuffing a subject)
•40-80 hours rage time (“if it has a head cuff it” meaning after shooting, handcuff the subject)
•Hundreds of hours of laws (criminal/traffic etc) to teach when to and when NOT to take custody (apply restraints i.e. handcuffs)


MEDICAL STAFF (Average Training Hours)

•0-4  on the application of a soft-restraint.
•0- the mechanics to “control” a person to get them into a position in which to apply the actual restraint.
•0- on when to or when not to place a person into medical restraints.
•0- Critical thinking skills to recognize custody vs care.
See any problems? Again, when you research WHEN most of the assaults are occurring in medicine… you will see it happens most during some sort of “restraint” situation.

With the use-of-force being the issue that it is in medicine at the present time, I am not sure we will witness a change anytime soon. Just make a note that we were here, on this date, pointing out the issues that are staring healthcare in the face.

For More:


(1)      accessed on 10-12-2009 at 1012  hours

(2) RSMO 563-061 Use of Force       accessed 12-14-2009 1034 hours

(3) According to the position taken by the NAEMSP it takes five people to medically restrain a patient. The paper can be viewed here: