Paramedicine and the prehospital space have evolved drastically over the last few years. From 2022 to 2023 we saw a to our first responders. We have unfortunately seen a culture of under-reporting, leaving our front-line carers vulnerable and some, unwilling.
Yet despite this, mechanical restraint methods paramedics rely on haven't fundamentally changed in decades. There has been an upsurge in front-line training and preparedness when dealing with occupational violence. Whilst the campaign was a great initiative providing the correct training to deescalate and protect paramedics against outside threats; we still haven't seen a disruption and change to the way we restrain violent patients.
The use of mechanical restraint presents a complex and often precarious balance between ensuring the safety of both patients and clinicians, a balance that, when disrupted, can leave either party exposed to harm. Unfortunately, we have witnessed some cases where the training and/or resources are far from adequate for staff and patients alike. The increased presence of police in violent situations is pulling resources away from the community and aggravating patients, often leading to confrontational encounters with two of our front-line branches. There are many ethical implications of untrained and inadequate mechanical restraint practices that Australia has seen. We have seen injury to patient and provider and psychological trauma from restraints that can't be used humanely solely due to an outdated, medieval construction. Concerningly, there have This challenging outcome raises an important question: if training were conducted correctly, would we be in this position?
Violence against paramedics isn't just a workplace and Occupational Health and Safety issue, rather a sign that our emergency care systems aren't adapting fast enough to the complexity of modern crises – mental health, substance abuse and community trauma. One under-explored example from hospital and psychiatric care is the Pinel Patient Safety System. Designed and intended for clinical safety rather than control, this mechanical restraint system represents a hospital-grade solution. Could adapting systems like this reduce harm in prehospital settings?
Why Hospitals Have Better Mechanical Restraint Systems Than Ambulances?
There's a peculiar disconnect in emergency care. Walk into a psychiatric facility or emergency department, and you'll find restraint systems designed by clinicians who've spent decades studying how to keep people safe during crisis. These systems exist because hospitals learned, often through tragedy, that improvisation and brute force don't work. The Pinel restraint system emerged from this painful evolution – quick to apply, designed around human anatomy, built to prevent the very outcomes we still see in ambulances.
Yet step into the back of an ambulance, and paramedics are often working with tools that haven't fundamentally changed in decades. The question isn't really about equipment. It's deeper than that. Why do we accept different standards of care depending on where someone happens to need help?
When restraint becomes necessary in a prehospital setting, we must ask: are we prioritising patient safety and dignity, or simply maintaining tradition? Are we choosing patient safety and dignity, or are we choosing what's familiar, what's always been done? The difference between a patient arriving at hospital with injuries from the restraint itself versus arriving safely secured is more than operational. It asks us to consider whether we believe crisis intervention should look the same everywhere, or whether the chaos of the field somehow justifies accepting higher risks.
The potential shifts are worth considering. What would it mean for a patient's dignity if restraint didn't require prolonged physical struggle? How might paramedic safety change if the tools matched the complexity of the situations they face? What becomes possible when restraint is standardised not around tradition, but around evidence? Yet before we can address these practical questions, we must first confront the emotional and historical baggage surrounding restraint itself.
Overcoming the Stigma Around Mechanical Restraint
We carry ghosts with us when we talk about restraint. The word itself conjures images of abuse, of power misused, of people stripped of their humanity in the name of control. This history is real, and the scars it left on our collective consciousness run deep. Perhaps this is why we've been reluctant to evolve our approach – better to avoid the topic altogether than risk repeating past wrongs.
But avoidance has its own cost. When we refuse to distinguish between humane, clinical restraint designed for safety and the punitive measures of the past, we leave a vacuum. That vacuum gets filled with improvisation, with inconsistent practices, with paramedics making impossible decisions without adequate support. The question we might ask ourselves is this: does avoiding the conversation about modern mechanical restraint protect patients, or does it leave them more vulnerable?
There's something profound in reframing restraint through the lens of trauma-informed care. . Their violence often stems from terror, from a nervous system in overdrive, from experiences that taught them the world wasn't safe. In these moments, what does safety really look like? Is it the absence of restraint, even when that absence means prolonged struggling, potential injury, or the arrival of police? Or could safety sometimes mean swift, humane intervention that allows medical care to proceed while preserving dignity? Consider the young person experiencing acute psychosis, terrified and combative in the back of an ambulance. In that moment, what matters most? The paramedics face a cascade of impossible choices with inadequate tools.
None of these options feels right because they're all born from a system that hasn't caught up to what we now understand about crisis, trauma, and safety. What if the real question isn't about restraint at all, but about why we're still forcing frontline clinicians to improvise solutions to predictable problems?
What Would It Take to Change?
Change in healthcare rarely comes from a single innovation or policy. It comes from shifting how we think about problems. If we started to view mechanical restraint in paramedicine not as an unfortunate necessity to be minimised and hidden, but as a clinical intervention requiring the same rigor as any other procedure, what would need to be different?
Education:
Would need to evolve beyond technique into ethics, into the psychology of crisis, into honest conversations about power and vulnerability. Paramedic students would need to grapple with difficult questions about when mechanical restraint serves the patient and when it serves only convenience or safety theatre.
Culture:
Breaking the silence around restraint incidents would need to crack open. What gets reported, measured, and discussed can be improved. What stays hidden in shame and under-documentation stays broken. But creating space for honest reporting requires trust that documenting these difficult moments won't be weaponised against the clinicians making split-second decisions in impossible circumstances.
Communication:
Perhaps most critically, we'd need paramedics, policymakers, and healthcare leaders in the same room, speaking the same language. Too often, frontline experience and policy decisions exist in parallel universes. The paramedic who's been spit at, struck, and forced to choose between inadequate options rarely sits at the table when guidelines are written. The policymaker drafting protocols may have never felt the adrenaline spike of a patient becoming violent in a confined space with no backup.
Pilot programs testing different approaches could generate not just data, but stories. Numbers matter, but so do the experiences of paramedics who feel safer, of patients who arrive at hospital without additional trauma, of families who receive a different phone call about their loved one's crisis.
The Future of Mechanical Restraint in Australian Paramedicine
Violence against paramedics persists not because anyone wants it to, but because the systems meant to protect them haven't evolved at the pace of the challenges, they, are all increasing, while the tools and training paramedics receive often remain rooted in a different era.
The conversation about mechanical restraint sits at the uncomfortable intersection of patient rights, worker safety, and the messy reality that sometimes caring for people requires limiting their movement. We've grown comfortable discussing de-escalation and verbal intervention – and we should, because these skills matter enormously. But we've been less willing to discuss what happens when those approaches aren't enough, when restraint becomes necessary, and what our responsibility is to ensure that mechanical restraint happens as humanely as possible.
Safety, respect, and dignity sound like abstract values until you're the paramedic trying to provide care to someone who's violent, or you're the patient who regains clarity hours later and learns how you were restrained. In those moments, the specifics matter. The difference between outdated equipment and modern, clinically-designed alternatives isn't academic – it's written on bodies and minds.
Hospital emergency departments made choices about restraint based on evidence, liability, and a recognition that how we treat people in crisis reflects our values as a healthcare system. Those same crises happen every day in ambulances, on street corners, in homes. The environment is different, certainly – more chaos, less backup, constantly changing variables. But does that mean the standard of care should be different, or does it mean we need to work harder to extend the same standards to the prehospital space?
If hospitals use humane mechanical restraint for safety, why don't ambulances? The answer to that question might reveal more about what we value, what we're willing to invest in, and who we believe deserves protection than we're comfortable acknowledging.
FAQ:
How common is violence against paramedics in Australia?
Violence against paramedics is unfortunately extremely common. In 2022 – 2023 we saw a 14% upsurge in violence against paramedics. Reports suggest that 87.5% of paramedics have experienced some form of violence in the work place.
What are mechanical restraints?
Mechanical restraints are a securement device to restrict movement generally from a person who has indicated violence against another person or against themselves. Restraints traditionally are used solely for behaviour control and not for therapeutic reasons.
Why do paramedics need to use mechanical restraint?
Mechanical restraint is used as a last resort to help provide first aid and safely transport a violent patient. These patients are only restrained after being violent towards another individual or towards themselves.
What is the Pinel Safety System?
The Pinel Safety System is mechanical restraint system designed to prevent injuries to staff and patients in hospital and pre-hospital settings. The Pinel Safety System offers a more comfortable and relaxing experience for the patient whilst also allowing for clinicians to safely provide first aid to the patient.