“Okay, so, he’s big,” the E.R. nurse said. “And he’s pissed off. Plus, he bit his cheek, and he’s been spitting blood at people. You might want to, you know, handle him with care.”
My partner, Doug, who had been an EMT longer than I, nodded thoughtfully, as though giving deep rabbinic consideration to the question of violent hospital patients. Doug appreciated, in a way that I did not, the rich and strange varieties of human behavior available to us on a given day.
“Right…uh-huh…sure,” he said solemnly, bobbing his head.
“Is he pissed off about something?” I asked, and immediately regretted the question. It suggested uneasiness, which emergency medical personnel weren’t supposed to show. Also, it implied a scope of interest that wasn’t rightfully mine. An EMT’s job—in Boston, in the winter of 1989, in the middle of the night, when faced, say, with a combative patient awaiting delivery to a psychiatric facility—was to provide safe and efficient transport, without asking into the irrelevant details that he, the EMT, couldn’t possibly do anything about.
The nurse shrugged. “He just doesn’t like being him right now,” she said. It sounded like a line she used often. “Anyway, you’ll want to keep him tied down, obviously. You guys have what you need?”
Doug reached into his pocket and produced four triangular bandages—kerchiefs, essentially, but more durable, and bleached into the particular off-white shade that people associate with hospitals. He showed them to the nurse, holding them up by the tips, as if displaying four garter snakes he’d just caught.
The nurse nodded approvingly. Then she pointed to one of the curtained exam areas. “He’s over there,” she said.
Harvey, as I’ll call him, was indeed big. Not gargantuan, not especially tall, but thick and broad, well-muscled, full. He also had the chewed-up look of someone who’s been in and out of mental-health institutions: his skin was weathered, his hair long and snarled and dirty, his clothes discolored with ground-in filth. For the moment, he wasn’t agitated or even particularly alert; strapped to the bed by his wrists and ankles, he didn’t writhe or howl but stared straight ahead, his face fixed in a kind of moony expressionlessness. It wasn’t altogether surprising. I knew that psych patients, the most difficult ones, the ones suffering from schizophrenia or bipolar disorder or dementia, operated according to their own unaccountable rhythms, revving up for no explainable reason and downshifting into silence just as unpredictably.
Another nurse was standing next to his bed. “You caught him at a good moment,” she whispered to us.
“Sure, sure,” Doug said understandingly.
“Harvey…” There was a lilt in the nurse’s voice now. “You’re going to go with these nice gentlemen, okay?”
“Okay,” Harvey said, focusing nowhere in particular.
“We’re just going to help you get onto the stretcher,” Doug said, angling it alongside the bed.
Moving Harvey from the bed to the stretcher required a certain kind of deftness, since it meant freeing his ankles and wrists, letting him shimmy across, then tying him down again, all without actually letting go of him, without relinquishing our custody of his limbs. We did it quickly, afraid that he might suddenly decide to explode out of our grip like a freshly caught fish.
“That feel okay?” the nurse asked once we’d secured him.
“Tight,” Harvey mumbled, still not making eye contact with anyone. Doug and I had lashed him down with singular dedication, tugging on the knots with our entire bodies, the way you’d secure a mattress to your car’s rooftop.
“It’s a short ride,” I offered.
“Good luck, Harvey,” the nurse said.
“I’ll be driving,” Doug explained to Harvey as we got the stretcher underway. “Dave here will ride in back with you.”
Harvey looked at us glassily. He may or may not have nodded.
Becoming an EMT wasn’t difficult. Boston was a hospital-rich city, serviced by perhaps a dozen different ambulance companies. One of them offered a six-week training course, with a guarantee of employment if you passed the certification exam. I can’t fully explain my motivation for signing up, except to say that I was a recent college graduate, needed work, and had no other plans for the future. Somewhere in my thinking, too—having been a good student, or at least an able reader of literature, but also fidgety and uncommitted—was an awareness of what I keenly didn’t want, which was the tired business of going on for graduate studies in English and becoming a teacher. This, at least—working as an EMT—wasn’t that.
In class, we learned how to accurately measure a patient’s vital signs; we practiced CPR on pliant-chested mannequins; we watched footage of women giving birth so that we would know how impossibly bloody it was. We trained for every foreseeable emergency, and we imagined ourselves, as they say, “in the field,” winding bandages around people’s head wounds and pumping life into helpless victims as they lay next to the smoldering wreckage of their vehicles. In truth, emergencies would constitute only a small percentage of our work. The bulk of our time, it was explained to us, would be spent providing non-urgent transportation to patients of a different sort, the ones who were not, at that particular moment, dying, but who were instead caught in the slow, leechy grip of illness: people with appointments for chemotherapy or kidney dialysis or radiation therapy; people being sent (again) to residential treatment centers to address their alcoholism or drug abuse, their eating disorder, their habit of carving neat parallel lines into their forearm; people being redelivered to nursing homes after the emergency-room visit to confirm that their hip was indeed broken, their bones being by now as delicate and brittle as rice cakes—people, in other words, who circulated like platelets through the city’s medical-industry bloodstream, keeping the system alive. These, primarily, were our clients. Our customers. The company’s profit makers.
One small complication, it was further explained to us, was that a certain number of people, much as they clearly needed medical treatment, wouldn’t want medical treatment and would physically resist all efforts at being transported anywhere. These people, for their own safety and well-being, would be restrained. They would be seized, tied down, and conveyed against their will to their proper destination.
Patient restraint was allowed by Massachusetts law, which gave health-care providers the authority to prevent people in their charge from hurting themselves or others. Suicidal patients, of course, were candidates. But so were defiant minors. So, too, were people with delirium tremens, and those who had been made belligerent by medication, and those who were in the capture of Alzheimer’s disease (they could thrash around with surprising violence), and those who were just plain angry or haywire, offering threats, putting up a fight. Understandably, most patients didn’t have to be restrained at all; they went willingly, if not exactly happily, to their treatments. But it was also made clear to us that on some occasions, in the natural course of our jobs, we would have to restrain patients. It was something to be ready for, a skill to be learned and practiced—a standard part of EMS work, like splinting a broken arm or taking an accurate blood pressure reading.
Our instructor reviewed the mechanics of patient restraint at some length. The first step, he said, was to gather enough people to do the restraining, ideally one for each limb. “You don’t want a fair fight here,” he explained. He walked us through a textbook “takedown” by having one student stand in the middle of the room with his arms at his sides while four of us lined up opposite him in a mini phalanx, two rows of two. “Now everyone walk right up and grab an extremity,” the instructor coached. “And then just keep walking, especially those of you holding the legs.” And with a fluidity that felt a little bit goofy—as though we were dancers lifting a songstress during a glitzy musical number—we literally swept our quarry off his feet, hoisting him so that he was high and horizontal, chest-side down. We carried him to the waiting stretcher, put him on his back, and then learned how to secure him using strips of cloth. There were different knots we could employ, each one clever in the way it self-tightened if the patient struggled to get loose. And there were certain tricks to know, such as putting the most uncooperative patients on their stomachs and tying them down with their arms and legs splayed in different directions, to dislocate their center of gravity.
“It’s something of an art,” our instructor said, demonstrating a particular knot, working the cloth as speedily as a rodeo cowboy tying up a calf. “There’s a procedure to it, but everyone has their own preferred method, too.”
Once I started working for the company, I did indeed participate in the restraining of patients—not many, not often, but each time memorably. One was a yowling woman who, when she was on the stretcher, wheeled her legs like a squirmy infant in an attempt to prevent us from grasping her ankles. Another was an elderly man who rode good-naturedly to the hospital but, once there, decided he didn’t want to stay there, and made a slow, pitiable run for it. Another was a teenage girl at a group home who’d tried to cut her wrists, and who didn’t put up a fight at all when Doug and I arrived but wordlessly scooted onto the stretcher and offered up her limbs—an old pro. Each instance was unpleasant and sad, of course. And foreign-seeming. I was a college kid from the suburbs, quiet and untough, not used to manhandling people. Not yet adjusted to this business of helping people by force.
Packed into the ambulance, Harvey seemed even bigger than he had in the hospital bed. His forearms, I decided, were as large as good-sized pieces of cordwood, his biceps more ample than my neck. He was still quiet and glazy-faced, but he was beginning to show an interest in his surroundings, eyeing the walls and the ceiling, occasionally looking at his bound-up wrists. An emergency room physician had once told me that the best way to assess a patient’s dangerousness was to examine his hands; Harvey’s hands were raw and bruised, and swollen on several knuckles.
“Things good back there?” Doug called from the front.
“Everything’s just fine,” I said. And idiotically, I patted Harvey’s arm, as if I were a grandmother riding the subway with her grandson.
I wanted to be like Doug. I envied his comfort, his at-homeness, in the work we did. I wanted to enjoy driving unhappy people to unhappy places in the preposterous belief that things would get better for them. And I wanted to feel that it was righteous, or at least not unrighteous, to tie a person to a gurney against his or her will. It was something that Doug and I bickered about during the boring stretches of inactivity that came with late-night shifts—a theoretical discussion, a time passer, not meant to be weighted with significance, though for me, privately, it was. Privately, the job was beginning to make little sense. Or the wrong kind of sense.
But none of that concerned me as I continued the ambulance ride with Harvey. What instead occupied my attention was this: gradually but unmistakably, with the slow, outer-spacey movements of someone whose mind is foggy but who knows exactly what he’s trying to do, Harvey was beginning to work his wrists free.
In William Carlos Williams’s story “The Use of Force,” a doctor is called to a family’s home to examine their child; suspecting diphtheria, but faced with an unobliging patient, he must struggle his way into the little girl’s mouth. The focal point of the story is the doctor’s unseemly ramping-up of emotion as he fights with her. “I…had got beyond reason,” he reflects. “I could have torn the child apart in my own fury and enjoyed it.” But Williams seems to reserve his truest disdain for the child’s parents, who can’t bring themselves to help the doctor in any meaningful way, so intimidated are they by their daughter’s shrieky resistance. (The father is described as “almost fainting,” while the mother paces uselessly, “raising and lowering her hands in an agony of apprehension.”) The sentiment, apparently, is that people should buck up and do the unpleasant work that needs to be done.
For me, it’s a stinging criticism. But is it true? The story can read, at first, like an exasperated sigh of a tale: someone has to put aside their lofty ideals and get their hands dirty, it seems to say. And it’s hard to disagree. Williams was himself a pediatrician, and he knew what it meant to help people who didn’t want to help themselves. What the story fails to explain is how, after pushing past the child’s defenses, leaving her with “tears of defeat,” the doctor quite lives with himself. What he did was indisputably necessary, but so what? When did “necessary” ever undo the cruelty of a deed? When did it wash away the dirt of self-condemnation?
And anyhow, diphtheria stacks the deck, doesn’t it? Dire situations call for action, and no one ever blames the lifesaver, the hero, the guy who did what incontestably had to be done. The tougher question is what to think about the poor schlub who did what probably had to be done, or at any rate what he was paid to do. He wanted to be a lifesaver, but, well, rookies get the shitwork. Surely, he tells himself, there’s some value in taking sick people where they need to go—by force, if necessary. Surely he’s in the right. Otherwise, he’s something very different from what he intended to be. He’s the rescuer who only makes things worse. He’s the answer to the prayer that no one prayed.
I watched while Harvey wriggled his bound-up hands—not jerkily, not angrily, but with patience and a sort of loopy concentration, working slack into the knots that Doug and I had assumed were impregnable. I watched this for many seconds, maybe even as long as a minute, mesmerized. It was like watching a magician perform a trick.
I didn’t, at first, imagine that I might be in danger. In fact, I didn’t see any connection at all between me and the large, unstable man in front of me. A restrained individual, no matter how sizeable or intimidating, is so fundamentally different from the restrainer, so very unfree to move about as you and I are, so bound to his own experiential territory, that it’s hard to conceive of him in any other condition. A foundational premise of patient restraint would be: the patient remains restrained.
This, of course, when everything goes well. Which, I suddenly realized, wasn’t now.
EMS professionals make a distinction between their methods of restraint and those employed by police officers. Because they’re fighting for their lives, or at least their personal safety, police officers use any number of techniques. They use choke holds and wrist locks; they mash their antagonists against the ground, driving a knee into the shoulder or the small of the back; they punch or kick, or if necessary bring weapons into play. But EMTs—generally, mostly, unless something has gone very wrong—aren’t at personal risk and aren’t expected to subdue anyone per se. Restraint, for an EMT, is an extension of patient care, a gifting of safety; even as a belligerent patient is being wrangled into compliance, an EMT is required to be mindful of the health risks: to keep a patient’s airway clear and his breathing uncompromised, to not cause or exacerbate injuries, to inflict as little trauma as possible. The implication, not altogether wrong, is that an EMT uses a kind of physical finagling, whereas a cop shoves people around.
Does that make medical restraint a kinder thing than the law-enforcement type? Perhaps. But perhaps, too, the laying of hands on somebody is always what it is, aggressive and mean, and shouldn’t be gussied up to look like something nicer. Perhaps the profoundest humiliation of all is to be pawed at in the name of altruism. What I remember explicitly about restraining patients is the sad moment of compliance, the instant when the unfortunate bastard reconciles himself to captivity and stops writhing and begins (as I imagined it) a kind of bargain with his limbs, an agreement that he’s not really confined, so long as he chooses not to test it out by trying to move too much. All of this is to say that restrained patients usually surrender to their misfortune, which only makes sense. To be physically restrained is to have certain terrible truths delivered to you—about power and helplessness, about corporeal authority, about the grimness of the future, about life’s limits. In the face of such news, who can offer genuine resistance?
Once Harvey freed his hands, his first order of business was to massage his wrists where the coiled-up cloth had dug into his skin and left deep red marks. It was an unexpected gesture, almost feminine-looking, and I might have found it oddly funny if I hadn’t been, at that moment, brain-numbingly afraid.
What can be said, really, about such a moment? Only that you encounter it, for all your panic, with a surprising lack of surprise. When the giant in front of you wakes from his stupor and, having liberated himself from his shackles, looks at you for the first time with full focus, you catch a whiff of something that you can only assume is fate. This, maybe, is why you don’t call out to your partner; your sense of justice prevents it. You believe that your recent bad deeds have collected inside you like toxins and brought you to this occasion. You see a dreadful terminus ahead. You know you deserve it.
“Does it bother you?” I asked Doug one night, making plain my unease with the act—really the idea—of restraining patients.
“Bother me how?” Doug asked.
“It’s…well, it’s not the nicest thing to do to someone,” I said.
“Lots of what we do isn’t nice.”
“Okay, yes, but this…it’s sort of in a special category, right? I mean, to tie someone down and take him somewhere, even if it’s where he needs to go…” But already I could feel myself losing my footing. “It’s not…I mean, on a moral level…it can’t be altogether…it’s not a good thing. It’s not ideal. Right?”
Doug looked at me for a moment. “Maybe you’re making too much of it.”
Maybe so. Or maybe I thought that the act of restraining a person, if it absolutely had to happen, should be made much of. My girlfriend at the time worked at a school for troubled youngsters, and she came home with her own stories about restraint, about kids who shoved and spit, who threw tantrums and punches, and who were hauled to a special room with mattresses where they were held down until they calmed. There was also, as I understood it, a kind of script to be followed, a placating chatter that counselors were expected to employ (“Michael, we’re holding you because you’re acting out…”), and though I thought the entire practice creepy, I envied its ritual. A “restraint room,” a devoted space, conferred the proper importance on the act: it captured its largeness, its starkness, its promise of woe, its particular brand of almost-violence. Its paradoxical right-and-wrongness. I imagined my girlfriend and her colleagues taking a strange but certain comfort in the ceremonial—shall one say liturgical?—nature of the operation.
In prisons and detention centers, where the stakes are higher, the methods of restraint are even more ritualized, bringing into play certain grotesque pieces of furniture. A “restraint table” is exactly what it sounds like, and what’s notable about it isn’t its design, which is fairly straightforward (a long rectangular surface, some straps), but the majesty it seems to lend to an otherwise nasty job. A “restraint chair,” by contrast, is compact and intricate-looking, space-agey, something that might be used to represent a time machine in a low-budget movie. Both items have a severity to them, and no doubt they’re put to brutal use; the chair, in particular, has been an object of controversy, since prisoners have died in its clutches, victims of neglect or abuse. (Amnesty International has spoken out against the restraint chair.) And yet, there’s something perversely honest about these devices, an acknowledgement of the miserable things we do to one another and the disturbingly specialized ways we think to do them. When I consider my own brief history restraining people, and my anguished relationship to that chore, I see how much of my distress was about the casualness of it, the veneer of incidentalness. Both during my time as an EMT and for years afterward, I wondered why we used triangular bandages to tie patients down, rather than the thick leather straps that are designed for the job. Cost, probably, was a factor. But at risk, too, I suspect, was our sense of identity, our need to see ourselves, and to be seen, as medical professionals and not ruffians. And fairly so—except for the times when the boundary was blurred. To be sure, we were kinder than prison guards; we treated our patients with care and afforded them every possible dignity. But when it was necessary to wrestle people into place, we did it (to our credit, we thought at the time) without commotion: without reverence or rite, without too much hassle, without causing a stir. We operated with a weary half-interest, as if the exercise of power were unremarkable. As if it were—as indeed it was—a job.
For a moment, Harvey seemed undecided on the question of whether to unleash himself at me, to enact whatever form of violence a liberated prisoner is supposed to enact on his captor. As for what precisely was at stake in those seconds—my life? my dignity? nothing at all?—I’ll never know, since Harvey never attacked. He stared and appraised and finally seemed to come to some private determination about me. Then he put his attention back to his chafed wrists, where it remained for the duration of the trip.
In the end, patient restraint is a mundane act. It’s routine and necessary, not particularly difficult to perform, perhaps not even very traumatizing to the person on whom it’s carried out, since he or she is likely to be drugged or addled or simply downtrodden and already familiar with life’s sharp edges. But it’s still an act of aggression, and it carries a moral weight. Having restrained someone, you feel uncleaner than you were; you don’t exactly have blood on your hands, but you feel filmy with wrongdoing. For that reason, patient restraint is one of those deeds—of which, I would eventually learn, there are many in life—that should probably be done full-bore or not at all. The doctor in William Carlos Williams’s story, despite his misgivings, puts himself utterly to the work of overpowering the little girl, giving up his most decent self to do it; we can’t approve of his wrath, but we can admire his willingness to occupy the moment unreservedly. It’s the way we throw ourselves headlong into the world’s particular tasks, or else the way we devise elaborate resistances, that determines where we belong and what we should or shouldn’t do with ourselves.
But that wasn’t my thinking many years ago. And my experience with Harvey only scuttled whatever clear feelings I might have had about the strange practice of tying people down and hauling them from place to place. For a long time afterward, of course, I would wonder why Harvey showed me the forbearance that he did. My belief, though I admit it’s a belief fed by hope, is that he recognized in me something more decent than the role I happened to be playing at that moment. But it’s also possible that he simply took pity on me, or decided that violence against me wasn’t worth the effort or consequences; it’s possible, too, that he was under the direction of odd inner voices whose counsel I can’t imagine. Whatever the exact case, the incident left me with plenty of emotional remains to sort through: relief, humiliation, gratitude, self-indictment, confusion.
As if to underscore the cockamamie nature of it all, I ended up helping Harvey refasten his own restraints. Only a few miles before we reached our destination, I could see him fussing clumsily with the bandages, and I realized that he was trying to re-loop them around his enormous wrists and through the metal arms of the stretcher and then knot them—a feat requiring impossible dexterity. With a plainness of action that surprised even myself, I reached over and helped him finish the job. There was nothing cooperative or reconciliatory about it; we didn’t make eye contact, and I retied the knots as gingerly as if I were fashioning a bow on a child’s birthday present. I don’t recall feeling any guilt for colluding with him to hide his misbehavior, though I likely suffered a last pang of dishonor at my own servitude.
At the receiving institution, a nurse and several orderlies met us in the lobby. Harvey was more or less vacant-faced again, and we untied him and transferred him over without any pageantry. “You take ’er easy,” Doug said as they wheeled him away. And of course I resented Doug for his ignorance of my ordeal, and for what seemed to me his easy glide through everything.
On the drive back, though, he looked at me curiously. “You okay?” he asked. “You’ve been quiet.”
I nodded. “I’m fine.” I just don’t like being me right now, I wanted to add, but it would have inaugurated the very conversation I hoped to avoid. Besides, I could already feel the distant tug of other things. Just a few months later, I would quit my job as an EMT, leave Boston, and make my way back to school. Eventually, perhaps inevitably, I would become a college English teacher, an occupation that I’ve held for many years, and which has brought me greater pleasure than I can express without sounding mawkish.
But for the time being, I worked on an ambulance. Several more times, I would be asked to help restrain patients, all of whom were considered, in one way or another, crazy or volatile, a hazard to themselves and others, undeserving of their physical agency. In each instance, I gave myself to the mechanics of the process, but also withheld something—a fullness of intent, a believer’s heart. Those were never mine to begin with.