Restraints, Spit, and Psych

Spit Mask MEME

I’ve yet to experience the thrill of a combative patient as a prehospital provider. Last week we logged around a thousand miles during our three 12 hour shifts. As an interfacility truck we specialize in taking patients in, out, and around town. On our third and final night, I had an opportunity to meet my first combative psychological patient.

The call kicked out as transport for a higher level of psychological care. The patient was ordered by the doctor to be transported against the patients desire. Upon arrival we enter an empty room, the cinderblock walls were painted an off white color. The patient enters the room and collects his belongings. As he approaches the stretcher the patient begins to become upset. Yelling “Where are you taking me, it’s like one o’clock in the morning.” We let him know that the doctor placed an order to transport him to another facility around seventy miles away for continued care. The patient reluctantly mounted the stretcher. We advise the patient that we’re required to transport using soft restraints. Although the idea was not well received the patient allowed us to secure his ankles.

Anyone who likes to be strapped down for fun is a freak in the sheets or an absolute lunatic.

Understandably the patient was uncomfortable, anyone who likes to be strapped down for fun is a freak in the sheets or an absolute lunatic. The patient crossed his arms and said “You’re not strapping my arms down.” I attempt to allow the patient time to allow us to secure his arms however the patient wouldn’t budge. I nodded to my partner and we physically took his arms and secured them with soft restraints.

At this point there’s no turning back. I’m the enemy. I’ll attempt to regain the patients trust enroute providing him with a bottle of water and releasing one wrist allowing him to drink and itch his face. The patient didn’t like being touched. Around halfway to the destination I adjusted the blood pressure cuff. The patient became upset yelling don’t touch me. I grabbed the free hand and told the patient I would place it back in the restraint if he didn’t settle down. The patient then spit towards my face. Luckily the patient was a little parched. I turned my head at the right time. I dodged a bullet. As I restrained the free arm the patient began sucking back snot in an attempt to spit a mucus projectile. I leaned against the patients face pushing it away from me. I told the patient “don’t even think about it” as I finished restraining his free arm.

As I sat down the patient launched a snot rocket onto the cabinet.

I moved to the airway seat to remain clear of any possible projectile path. As I sat down the patient launched a snot rocket onto the cabinet. I grabbed a surgical mask and placed it on the patients face. The patient was yelling and shouting. There was no reasoning with him so I remained quite to allow him to vent. The yelling stopped after a minute or two. We pulled into the receiving facilities bay and started unloading the stretcher. At this point I had my own safety glasses and surgical mask on. I fully anticipated getting hit with snot or a fist when we released the patient from the restraints.

As we entered the lobby the receiving nurse asked if the patient was sick. My partner told him no, and that he had been spitting. The patient then responded “I don’t know why I’m here, I’ve been completely compliant.” The nurse advised us to release him, As he walked away he ripped off his mask and faded away into a distant memory.

I learned two important lessons from this case. First, talk to your patient. Especially those who are experiencing psychological issues. Secondly, if the patients restrained, all they have left is their mouth and you need to remain aware of that fact.

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