Death by prone

Yesterday I came across a very interesting (to me) article on a local news outlet's website.  The article (here) is about Colorado legislature voting on whether or not to ban prone restraints in all Colorado Department of Human Service programs, such as youth corrections and residential treatment centers.  The ban would not apply to programs run through the Department of Corrections (i.e. the prison system).  A prone restraint, for those of you not in the business, is when a person is face down on the floor with their arms held by two staff (one on each side).  

I am particularly interested in this because about half of my working career, post-college, has been in residential treatment centers where prone restraints were regularly used.  One facility was for adolescent girls, 11 to 18, and the other was for children, 3 - 12 (although we never had anyone under 7 while I worked there).  Using any kind of restraints can provoke surprised and disgusted reactions, usually from people that have no experience in jobs where they might be needed.  In the places I've worked, restraints were used as a last resort when patients were escalated to the point that they were a physical threat to themselves, the staff and/or other patients.  I can't speak for all facilities, but I've never seen staff eager to jump straight to restraints. 

The types of restraints I've used were a little different in each facility.  In the facility working with teenage girls, two person restraints were always used; I can't remember ever seeing one person attempt a restraint alone.  In fact, I think it was forbidden.  There, a restraint might not start in prone but usually ended up there because of the size and weight of the patients.  For the most part they were all as big, or bigger, than the staff.  Going into prone was necessary for practical and safety reasons.  It's very hard to control a combative person when they're still on their feet.  Not only are they at risk but the staff doing the restraint is also at much greater risk of injury.  (Seriously.  We had a grown man break his leg when a morbidly obese schizophrenic fell on him during a restraint.)  At the other facility, most of the kids were smaller than the staff and thus required a one-person restraint which kept both people upright.  Of course, that didn't always work as well with some of the bigger, older kids and those kids inevitably inflicted more injury to the staff because they were too big for one person to safely control.

Being in a restraint, particularly prone, is not comfortable, even when it's only being done on you for demonstration purposes.  In my experience patients de-escalate pretty quickly when being held and are then able to be safely transported for further de-escalation.  Usually restraints lasted for less than five minutes.  The restraints that lasted longer were typically in the patients that were seriously mentally disturbed and literally unable to control themselves.  Those restraints sometimes lasted an hour or more (which is torturous if you are the staff doing the restraint).

There were certain steps that had to be taken when a restraint was being done.  First, we were never allowed to restrain the legs of the patient.  Doing so could constrict blood flow and result in unconsciousness or worse.  Second, throughout the restraint we had to verbally interact with the patient to ensure they hadn't lost consciousness.  Around the time I worked with the teenage girls, another facility had had a death during a restraint and in the video I saw, the staff were definitely NOT taking the necessary precautions to keep the patient safe. 


There are a number of problems with attempting to ban prone restraints.  The biggest is that you will now have people breaking the law on a regular basis in order to keep themselves and the patients safe.  In many cases there are NO other safe ways to control an out-of-control patient.  Facilities have to be specially licensed to administer chemical restraints, such as Halidol, as needed, or to use physical devices such as a straightjacket, which is no easy feat and means a large increase in cost.  Families members of people killed during restraints argue that there are other options for controlling kids and adults without giving any examples.  They also say that other states have put a ban on facedown restraints and that patients are still protected.  However, no one from any of those states testified as to how well these alternate techniques were working.

In my opinion, if such a ban is to be put in place then it will mean a serious overhaul of our whole mental health system if we want to keep patients and staff safe.  Patients who are seriously mentally disturbed need to be in facilities that are locked (as in, locked rooms which many facilites forbid), access to chemical and manual restraints, and intense psychiatric services.  Unfortunately, not many facilities exist and most do not allow for the long-term treatment many of these patients require.  While I'm genuinely sorry for those that have lost loved ones during restraints I have to argue that I believe that in most cases they were incorrectly conducted and that a ban will not solve the problem.  In fact, I think banning them will lead to much more dangerous situations for staff and patients.