CPCP: Using Proper Restraint with Physical Restraints

Dr. Bennett Poss MD

Dr. Bennett Poss MD in the teacher’s position

Dr. Bennett Poss is one of our stellar psychiatry residents and he delivered a very thorough Clinical Problems in Consultation Psychiatry (CPCP) the other day, on the use of physical restraints in the  hospital. Violence against health providers is, unfortunately, a common problem in many hospitals.

At our hospital, we have a specialized Code Green team which the psychiatry consultation service is a part of under these circumstances when medically ill patients become threatening or physically violent to nurses, residents, staff physicians, and others. This happens most often when patients are so sick they become delirious. It’s ironic because delirium is a medical emergency and they are as dangerous to themselves as they may be to others because of the disorganized state of their brains leading them to be so agitated that urgent medical care is virtually impossible to provide. The Code Green team is specifically trained in nonviolent management of violent behavior to maximize safety for all persons in the vicinity of the event.

As Dr. Poss points out, it’s vital to present a respectful, listening posture and to demonstrate a willingness to listen to patients as long as they are able to participate meaningfully in a dialogue. Using the “yes, and” approach instead of “yes, butting” someone who is liable to feel further interfered with by simply hearing the word “but” can work. Agreeing to disagree without insisting on being right can be the safest way to get beyond an impasse.

Dr. Poss is a tireless and inspiring teacher according to the medical students–and me. And like any good psychiatric consultant, he’s pretty good at putting out fires in the general hospital.

But he doesn’t have a little red firetruck like I do 😉

My firetruck

Feels like Christmas around here already. THANK YOU!!!

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  1. Jim,

    I like your fire truck. Putting out fires in a general hospital keeps psychiatry very relevant there.

    Excellent presentation.

    I think that that one of the aspects of physical restraint that is frequently not considered is the age of the patient. One of the problems with Homo sapiens is that we have what anthropologists characterize as a “fragile skeleton.” It gets more fragile with age. There are many situations with the elderly like the agitated and aggressive Alzheimer’s patient that would lead to physical restraint when the patient is too fragile to be restrained. In those situations there may need to be one or two staff in attendance to redirect the patient or to restrain them by hand until a medication might start to work.

    Another related topic is one-to-one staff in attendance for managing suicide risk, aggression, safety of any restraints, and fall risk in the general hospital. This practice is frowned upon by administrators who are watching salary budgets – but until a human robot comes along there is no substitute for the human factor when it comes to safety in these situations.

    On inpatient psychiatry units I have found that teamwork to identify patients who are potentially violent and aggressive and immediate intervention with medication is useful to prevent seclusion procedures. It is also useful to make sure everyone is using the same language. When emotions are running high, people often forget how to describe violence. The Overt Aggression Scale (OAS) is readily available and useful for that purpose.

    Liked by 1 person

    • firetruck brigade

      Thanks, George, for comments coming from an experienced clinician. We can also sometimes avoid restraints by using the TADA approach, https://thepracticalpsychosomaticist.com/2013/08/19/tada-tolerate-anticipate-dont-agitate/

      The firetruck idea comes from a former president of the Academy of Psychosomatic Medicine:

      “A consultation service is a rescue squad. At worst, consultation work is nothing more than a brief foray into the territory of another service…the actual intervention is left to the consultee. Like a volunteer firefighter, a consultant puts out the blaze and then returns home… (However), a liaison service requires manpower, money, and motivation. Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned to him.”–Dr. Thomas P. Hackett Jr., MD

      The little Brio Firetruck comes from Psych Practice blogger, who thought my mascot giraffe, Nigella, needed a fire truck to go with it.


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