Frail 49-year-old Maria lay in her bed, thin and weak. Her bronze skin and swollen belly belied a history of alcohol abuse, and the breathing machine she could not abandon was there thanks to years of smoking. The right side of her neck and chin were covered with dark brown, leathery skin that was gradually rotting away.  The alcohol and cigarettes had caused squamous cell cancer of the neck, throat and jaw, and surgeons had dissected away the cancerous tissue, leaving a huge hole that they filled by grafting a piece of her back muscle onto her neck.  Sadly, the muscle graft had died, and now she awaited another surgery to try again.  She breathed through a hole at the base of her neck, a tracheostomy tube, because the swelling in her mouth would have cut off her air supply.  I like caring for patients who have gotten their tracheostomy from a head and neck surgeon -  they’re neat, and they suture them in place, so I have no worries about the tube flying out during a hard coughing spell. A neat, secure tracheostomy is a little gift from a surgeon to an ICU nurse.

Maria seemed calm now. She even asked my name when I entered the room, writing in barely-legible print on her white board. Who would have guessed that yesterday she tried to commit murder? 

Sharon, one of the most experienced nurses on the Trauma ICU, was caring for her yesterday.  There were clues that this was not to be a usual day. First, Maria’s sister, who had not yet kicked the mood-altering substance habit, came to visit. She was carrying a bucket with a handle.  Her erratic behavior told Sharon not to even ask, but the visitor volunteered her reasoning anyway:  if she left the ICU to use the bathroom, we would not allow her back in, so the bucket was a necessity.  When I received report from the night nurse the following day, she simply said, “There are so many things wrong with that statement, let’s not even discuss it.”  So true.

After the strange sister departed, Sharon noted that Maria was no longer pulling at her tubes or trying to bolt from the bed, so it seemed safe to remove her wrist restraints. Some ICU nurses restrain nearly anyone; if there is any chance of pulling out an important tube, they think restraining protects the patient. There’s not much good research on this topic, but what little exists suggests that restraints are actually more harmful than helpful. (Wouldn’t you resist if you were tied down?) Old practices die hard, though, so Maria’s wrists were encircled by bands of cloth that were tied to the bed frame.  Sharon untied the restraints from the bed frame, but left the wristbands in place in case she had to quickly replace the restraints.    

Sharon left Maria’s room to care for her other patient, but kept her ears open for any indication that Maria was getting restless. Then she heard it. The bed alarm went off; this meant Maria was trying to get out of bed -- intravenous lines, feeding tube, ventilator and all. Sharon sprinted to the room and was trying to urge Maria back into bed when Maria took her by the neck and squeezed. Sharon tried to shout, but could not. Fortunately, another nurse had heard the bed alarm and came to help.  She was able to pry Maria’s hands from Sharon’s neck, and together the two nurses put Maria back in bed. And tied her wrists again.

To a layperson, restraints may seem cruel.  They are not always used correctly, and even when properly applied, restraints cause injuries, and even deaths.  To mitigate these dangers, nurses remove the restraints, exercise the restrained extremity, check circulation, and examine the skin every 2 hours.  These are all good ideas, but none of these interventions prevents the agitation, anxiety and outright anger caused by being tied down.  Most people in restraints are too confused to understand explanations as to why, and being restrained may aggravate their confusion.  Sharon had to decide between the twin evils of restraining Maria when the patient was calm and cooperative and of risking an unsteady exit from bed, pulling out tubes along the way, and just maybe trying to kill her nurse.  Sharon chose to give Maria the benefit of the doubt, and, had Maria been stronger, Sharon may have been seriously injured.  

In documenting nursing care, we select from a drop-down menu our reason for restraining someone. Among the choices are “behavior hinders treatment plan,” “pulling at lines/tubes/dressings” and “exiting bed without appropriate assistance.”   Assault and attempted murder is not on the list, but perhaps it should be.  

(Names and minor details are falsified to protect confidentiality.)