Safe Restraint of Agitated Patients
By James J. Gerace and Michael W. Dailey, M.D.
The radio keys up. Dispatch hears gasps, pants for air, and finally, “One in custody.” Officers struggle with a person experiencing a mental health crisis, despite knowing about his instability and wisely preplanning his arrest.1 They followed their training and had emergency medical personnel on scene before initiating contact and attempting a physical restraint.
Officers handcuff the subject securely behind his back, but he continues to struggle against the restraints. The arrestee needs to be medically cleared at the hospital before he is processed at the police station. One officer tries to verbally redirect and calm him without success.
After placing the patient on a stretcher, he begins flailing around, growling and screaming while he tugs at the handcuffs with Herculean effort.
Officers attempt to keep the arrestee from falling off the stretcher as EMS personnel transfer it to the ambulance. Suddenly and unexpectedly, the patient goes limp. The next transmission over the radio is, “Dispatch, he is not breathing. We are starting CPR.” Police and paramedics initiate lifesaving measures, but the handcuffs impede them.
In this hypothetical scenario, it is unclear what happened. Will the officers remove the handcuffs? Are they equipped to handle a medical intervention if a patient’s condition rapidly or unexpectedly deteriorates? Have the officers’ leaders prepared them for such a situation?
These important considerations should not be left to chance. Public safety personnel must be caring and compassionate and demonstrate concern when interacting with unruly individuals or those with mental illness. Agencies must establish policies designed for the safe transfer and proper medical care of subjects in custody.
Agitated, hyperactive, hyperadrenergic, or hyperagitated delirium are all medical terms describing the physiological state of a patient who is out of control, energized, incapable of stopping themselves, or unable to be redirected. In the past, it has been controversially called excited delirium syndrome,2 a medical diagnosis that is not accepted across many specialties of medicine (perhaps correctly) as it is not caused by a single condition.3 This behavioral and physical situation can arise from mental illness, drug intoxication, alcohol use, low blood sugar, head injury, and many other medical reasons.
Regardless of the semantic concerns of the condition’s correct name, it creates an incredibly dangerous situation that impacts those being restrained.
The human body is remarkable and always works to maintain homeostasis, or normalcy. Restraining a person alters their body’s ability to respond as it normally would. When someone exerts themselves, they make lactic acid, causing them to breathe quickly and deeply, blowing off carbon dioxide and normalizing their acid base balance. Once restrained, the movement of their chest is limited, and the person cannot breathe as deeply; therefore, they cannot buffer the acid in their blood.
Someone with this condition is most safely served if medically sedated. EMS providers make this decision and are permitted to use several different classes of sedatives based on local protocols.4 Following drug administration, the patient is monitored and transported to a hospital.
For over 20 years, officers and EMS personnel in Colonie, New York, have been using a medical backboard to restrain agitated persons. They believe this is the best practice to reduce negative in-custody patient outcomes, allow medical evaluation, assure safe monitoring and patient transfers to the hospital, and minimize staff injuries. The team uses an incident command approach to the situation, making shared decisions to assist with the subject’s safety.
The steps taken to effectively restrain a person in custody onto a backboard depend on the patient’s level of agitation and cooperation.
Low to Moderate Agitation
Restraining a slightly or moderately agitated handcuffed patient requires two officers, a backboard, and an extra set of handcuffs. The control officer maintains contact with the individual’s upper torso and monitors his vital signs, while the securing officer attaches the backboard straps and handcuffs. This technique involves eight steps.
1) Officers sit the patient upright on the ground.
2) The securing officer lays a backboard on the ground behind the patient and slides it underneath his lower extremities with help from the control officer, who elevates the patient slightly.
3) While the control officer holds onto the patient’s upper body, the securing officer attaches the backboard straps across the individual’s thighs and lower legs. Securing the patient’s legs first prevents him from kicking the officers when the handcuffs are transferred to the backboard.
“Public safety personnel must be caring and compassionate and demonstrate concern when interacting with unruly individuals or those with mental illness.”
4) Both officers move to opposite sides of the patient’s upper body.
“Agencies must establish policies designed for the safe transfer and proper medical care of subjects in custody.”
5) While the control officer maintains a strong grip on one of the patient’s arms, the securing officer reaches across the backboard to remove the handcuff from the wrist that the control officer is holding (the other handcuff is still attached to the patient’s other wrist) and transfers it to the backboard on the side closest to the securing officer. The patient’s arm should be secured in a neutral position, parallel to his body.
6) The securing officer then moves to the same side as the control officer and retrieves a second pair of handcuffs to secure the patient’s other arm the same way. Both wrists are now independently secured to the backboard with handcuffs.
7) The officers lay the patient down flat on the backboard. If he refuses or resists, both officers can place one of their shoulders against the patient’s and use their weight to safely lower him to the board.
8) Both officers secure the straps across the patient’s upper chest, under his arms, and across his waist.
For highly agitated patients, it is recommended to follow the same backboard restraint procedure but after administrating sedation. If it is not possible to sedate the patient before restraint, the medicine should be given as soon as practical once there is a safe opportunity for injection.
Law enforcement agencies should work with their EMS personnel to assure there is a plan for safe, medically indicated and directed care for these patients. Paramedics must make medical decisions and diligently monitor a chemically sedated patient while law enforcement maintains the custody of the patient and safety of the situation.
Should medical intervention become necessary, a patient secured to a backboard is already in an ideal position to receive it. There is no frantic and chaotic toil to remove handcuffs when seconds count. A backboard provides a firm, flat surface if CPR or intubation is needed. Further, the positioning of the patient’s arms allows for rapid IV administration.
If a hyperactive patient goes into cardiac arrest, EMS providers must have absolute access to the individual to help prevent a fatal incident.5 Officers should transition to a caregiver mindset rapidly, initiating compressions and ventilations as well as deploying a defibrillator, if available. EMS cardiac arrest care must center on the need to manage ventilations aggressively and treat presumed acidosis (i.e., high acid levels).
Transferring an arrestee at a hospital is fraught with potential injury to the subject, first responders, and hospital personnel. The goal in cases where people are resistant, assaultive, or otherwise difficult to manage is to move them from a narrow EMS stretcher to a wider hospital gurney.
Traditionally, handling a handcuffed individual who is agitated or uncooperative means dragging or lifting them and potentially landing them on their wrists, causing injury. All lifting and moving points — arms, legs, and handcuffs — are on the patient.
When a patient is restrained to a backboard, officers and/or medical staff can simply lift the board and move it to the hospital stretcher. This prevents an uncontrolled handcuff or limb that could injure officers or hospital personnel. Handcuffs can then be exchanged for hospital hard restraints as ordered by the medical staff.
Twenty-first century policing in America is at a tipping point. All police executives and prehospital care organizations are urged to critically examine their current policies and practices on the restraint of agitated patients. They must consider how their people would react to the scenario presented. Leaders should train their personnel to recognize and address unexpected custodial medical emergencies rapidly and safely and work with EMS to care for distressed subjects. The backboard restraint method and team approach described in this article is effective and will protect everyone involved.
“[U]sing a medical backboard to restrain agitated persons … is the best practice to reduce negative in-custody patient outcomes, allow medical evaluation, assure safe monitoring and patient transfers to the hospital, and minimize staff injuries.”
Deputy Chief Gerace serves with the Colonie, New York, Police Department and is a graduate of FBI National Academy Session 282. He can be reached at email@example.com.
Dr. Dailey is chief of the prehospital medicine division at the Albany, New York, Medical Center and serves as medical director of numerous public safety agencies in the New York Capital Region. He can be reached at firstname.lastname@example.org.
1 Male pronouns are used for illustration throughout the article.
2 Gary M. Vilke et al., “Excited Delirium Syndrome (ExDS): Treatment Options and Considerations,” Journal of Forensic and Legal Medicine 19, no. 3 (April 2012): 117-121, https://doi.org/10.1016/j.jflm.2011.12.009.
3 Benjamin W. Hatten et al., “ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings,” American College of Emergency Physicians Hyperactive Delirium Task Force, June 23, 2021, https://www.acep.org/globalassets/new-pdfs/education/acep-task-force-report-on-hyperactive-delirium-draft-.pdf.
4 Natalie Sullivan et al., “Ketamine for Emergency Sedation of Agitated Patients: A Systematic Review and Meta-Analysis,” American Journal of Emergency Medicine 38, no. 3 (March 2020): 655-661, https://doi.org/10.1016/j.ajem.2019.11.007; and Viola Korczak, Adrienne Kirby, and Naren Gunja, “Chemical Agents for the Sedation of Agitated Patients in the ED: A Systematic Review,” American Journal of Emergency Medicine 34, no. 12 (December 2016): 2426-2431, https://doi.org/10.1016/j.ajem.2016.09.025.
5 Tina Čakš Golec et al., “Sudden Cardiac Death in Excited Delirium, and How to Prevent It,” Signa Vitae (October 2021): 1-6, http://doi.org/10.22514/sv.2021.222; and Patrick Joseph Maher et al., “Prehospital Resuscitation of a Man with Excited Delirium and Cardiopulmonary Arrest,” Canadian Journal of Emergency Medicine 16, no.1 (January 2014): 80-83, https://doi.org/10.2310/8000.2013.130824.