Hennepin medics will no longer handcuff combative patients

Hennepin Healthcare is phasing out the use of handcuffs by its paramedics to secure unruly patients, after its leaders checked and discovered that its urban ambulance agency was among the last in the nation to still use them.

The switch should take place this summer, after medics have been trained on alternatives that can protect them from being assaulted by agitated or delirious patients, said Dr. Nick Simpson, medical director for Hennepin County EMS. The elimination of handcuffs is part of the agency's broader shift to clarify roles of first responders at emergency scenes.

"This is just an attempt to make sure law enforcement does law enforcement duties and EMS does EMS duties," he said. "That's kind of at the heart of where the change away from handcuffs came from."

It's a substantial change; Hennepin EMS reported that handcuffs were used on more than 2,000 patients last year, or about 2.5% of ambulance runs.

Some medics balked at the change when it was announced this spring, arguing that they should reduce the use of handcuffs but still carry them as a last resort because of the increasingly hazardous environment in which they work. Rising drug overdoses and mental health crises have resulted in more threats to medics during ambulance runs.

A survey of paramedics by their union found about 80% still wanted to use handcuffs, which with a "click and a clack" can secure threatening patients faster than other restraints, said Shane Hallow, president of the Hennepin County Association of Paramedics and EMTs. He viewed Hennepin EMS as a model for how to use handcuffs appropriately to protect medics and patients, even if it has become an outlier nationally.

"It's not all the time, but in certain circumstances we are dealing with incredibly violent people, or people under the influence of drugs or alcohol who have incredible amounts of strength," Hallow said.

Handcuffs weren't used or have been phased out by many ambulance agencies, including Robbinsdale-based North Memorial health. The Edina Fire Department stocks them on ambulances and receives police training on how to use them. The National Association of EMS Physicians allowed for their limited use in its policy guidance for two decades, but stated in a 2021 update that "rigid restraints, such as handcuffs, should not be used by EMS providers." If patients are handcuffed by police officers, the national organization recommends that the officers ride along in ambulances.

Hennepin medics will have other physical restraints at their disposal, such as heavy Velcro straps that secure patients' wrists or keep them bedbound during ambulance rides. The agency is reviewing other options, such as oversized mitts that prevent patients from hitting or scratching anyone.

The switch recognizes that handcuffs are different, both in their severity as restraints but also as symbols of criminal wrongdoing.

"Their use in a medical setting seems out of place and sends the wrong message," said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness. "People are not being arrested, they are receiving care and being brought to a hospital."

Handcuffs can evoke "profound historical trauma" in the impoverished and racial minority groups that make up many of Hennepin's patients, said Dr. Tim Kummer, assistant medical director of Hennepin EMS, but also a "sense of false security" for the medics who carry them.

"It is not what they think it is" in terms of the protection they afford, he said.

High-profile legal cases have motivated EMS agencies to protect themselves and their medics from civil or even criminal liability related to overused or misused restraints. Colorado paramedics were convicted in December for giving a fatal sedative overdose to an agitated man being subdued by police.

Sacramento, Calif., reached a $4.4 million settlement last month with the family of a man who was handcuffed by police officers because he was acting out amid a diabetic episode. Media reports indicate that firefighters and paramedics should have relied on their training and intervened, instead of allowing officers to cuff the man with his hands behind his back and place him in a medically hazardous face-down position. The man died of cardiac arrest.

Training in hospital and pre-hospital settings increasingly has focused on de-escalation strategies that rely on words and body language to calm patients without physical confrontation. It doesn't always work. Kummer said he is adept at these techniques, and yet he was "punched, tackled and strangled by a patient" whose attitude shifted within seconds in the Hennepin emergency room last year.

Kummer took four months of leave to recover, but he said an overcorrection toward more use of punitive restraints isn't the right choice. His hospital often subdued agitated patients with sedative injections, but Kummer said it has switched and found success by offering sedative pills and telling patients why it will help if they take them on their own.

"You see patients light up with empowerment and that has been really powerful for us," Kummer said.

Research has identified medical concerns with restraining patients with their arms behind their backs, including the risks of breathing problems and asphyxia and the delays in taking vital signs and freeing patients in order to provide tests and treatments. Some EMS agencies require that patients, placed by police in handcuffs, be switched to medical restraints for their ambulance rides. However, there is limited research on handcuffs specifically and whether they produce better or worse safety and medical outcomes than other restraints.

Medics are concerned that they will be forced to increase their use of controversial chemical restraints. Federal authorities faulted Hennepin EMS in 2021 for overusing a sedative called ketamine in real-world research to see if it subdued agitated patients.

Hallow, the union president, said that Hennepin leaders already told him that his medics likely will be administering more sedatives, despite the recent increase in de-escalation training. Simpson, the medical director, disagreed with that assessment. Chemical restraints are rarely used independently, he said, so he doubts their use will increase just because medics are using less-invasive physical restraints.

Many EMS agencies got their beginnings a half-century ago as arms of police departments or law enforcement agencies, while others were formed by hospitals or funeral homes that dispatched hearses to transport patients. Simpson said the origins of EMS agencies often explain how likely they have been to incorporate law enforcement tools such as handcuffs into their work.

Simpson said he is coordinating with local police departments and sheriff's offices in his efforts to uncouple his medics from quasi-law enforcement situations in which they end up assisting officers in subduing people. That includes empowering medics to call police and ask for help if they arrive at a scene where a patient appears unstable — even when a dispatcher has declared a scene as a "code 4″ that is supposed to present no imminent threats. Medics should be using restraints of any kind only to safely transport patients for treatment, he added, and not for criminal apprehension.

Star Tribune staff writer Andy Mannix contributed to this story.