There are 2 situations where EMS will asked to transport someone against their will

1. The patient lacks capacity

2. Patient is pink slipped

May need to use either mechanical or chemical restraint - mechanical is almost always used with some form of chemical if the patient is resisting the restraints

What gives EMS the right to take a patient without a pink slip (involuntary emergency temporary admission for psychiatric evaluation)?

The patient lacks capacity to make informed decisions, cannot articulate the risks and anticipated outcomes of their decisions (EMS doesn't have to agree with their positions)

4 components to capacity

1. Patient consistently communicates a choice

2. Patient understands medical issues at hand

3. Patient must understand consequences (risks / benefits) of a decision

4. Must be able to reason through risks 

Without this criteria met, EMS is obligated to do what is in the patients best interest

Taking a patient with capacity against their will and without a pink slip is kidnapping

Leaving a patient without capacity is abandonment

Medical control can be helpful if the situation is not clear, may be medical / legally protective 

Ask that Medical Control speak with the patient in these cases

Pre-plan the transport if there are cases where patient does not want to go

Alcohol and substances alone do not remove capacity. 

If one is so intoxicated that they do not meet the capacity criteria, then EMS will need to take the patient. 

Dementia does not necessary remove capacity

Power of attorney only applies when the patient lacks capacity

If a judge designates a person to lack competency, then a guardian is appointed. Guardians have full authority over a patient regardless of capacity.

Wills mean nothing to medical care. 

Pink slips are for patients with capacity, but are presenting with immanent risk to self. Can be issued by Dr. or LE.

Restraint Use

• Patients who lack capacity to make decisions and are combative are legally allowed to be restrained

• Patients shall never be restrained with any technique that impedes breathing

• Patients shall never be restrained prone

• Neurovascular checks on restrained limbs shall be conducted a minimum of every 15  min

• Commonly one arm is restrained over head, on arm down to side

• Use purpose made restraints whenever possible - posey type restraints or non-locking leather restraints

• If Police have patient handcuffed or shackled, officer must go with patient to unlock if there is an emergency

• Once restrained, sedatives and / or antipsychotics should be used to keep the patient from injuring themselves

Trigger points for use of major tranquilizers varies by doctor. Make sure you know what your medical directors expectations are for its use.

UH EMS Protocol for escalation of medications based on severity of patient presentation - olanzapine>midazolam or lorazepam>haloperidol>ketamine

Once patient is medicated, monitor ALL THE THINGS. HR, EKG, BP, Spo2, Co2, Glucose, GCS, MSP's  - wide net, look for causation AND TREAT

Handcuffs are not restraints. Must be in care of law enforcement. Officer needs to be with. Cannot follow. EMS cannot take custody of people.

If patient is sick enough to need sedation, patient is EMS problem and must be transported by EMS, not law enforcement.

Buy purpose made restraints. Its poor practice to ad-hoc restraints. Safer all around.

4 point restraints to prevent patient from working themselves into a position where they could cut off circulation.

Never face down, always position to prevent positional asphyxiation. 

Minimize the patients chance to do harm, maximize their ability to ventilate.

RASS score

RASS is one of the most commonly used scales to determine the sedation level, and it measures the severity of agitation and sedation with a score of +4 to −5

+4: combative

+3: very agitated

+2: agitated

+1: restless

 0: alert and calm

−1: drowsy

−2: light sedation

−3: moderate sedation

−4: deep sedation

−5: unarousable 

Goal is to safe the scene with medications, the goal is not unarousable.