The Weight of Restraints

The following is the winning submission from the sixth annual Section on Pediatric Trainees essay competition. This year’s competition was informed by the 2021–2022 Section on Pediatric Trainees Advocacy Campaign: “Rx Against Racism,” which encouraged trainees to focus on racism as a public health crisis, with the goal of improving health equity for their patients, training programs, neighborhoods, and broader communities. In titling the essay competition “Beyond Bearing Witness,” we asked writers to reflect not only on the effects of systemic racism on children, but also on how pediatricians can address these issues in venues ranging from patient encounters to training programs to public policy. We were impressed by the thoughtfulness and vulnerability of trainees in sharing their experiences regarding this critically important topic. The winning essay, by Dr Jeffrey Edwards, highlights inequities in the use of physical and chemical restraints among pediatric patients in health care settings. In doing so, this essay sheds light on the broader societal problem of racialized oppression. This essay is also a whole-hearted reminder of the vital importance of using our positions as physicians, particularly the power of our words, to advocate for social justice.

Six pounds. That’s a common weight for newborn infants. It’s also roughly the weight of the physical restraints used to hold down patients in hospitals who are, as we often say, “agitated” or “escalated.” Those 6 pounds are amplified by the body weight of the individual they are intended to restrain. Those 6 pounds, slapped on wrists or ankles, are intended to deescalate, and often do anything but.

I understood the true weight of these restraints after I met Angelica (not her real name). I met Angelica as she was dragged by 2 adult male security officers back to her hospital room after an elopement attempt, kicking and screaming all the way. During the attempt, she had thrown medical supplies against the floors and walls and, unfortunately, a hospital staff member. Hit in the leg by a container of sterile water, that staff member immediately vowed to press charges for the minor injury, a threat that served the purpose of further escalating Angelica’s behavior until the security officers were able to secure her arms and limbs. She was subsequently placed in 4-point restraints on her hospital bed using soft cuffs so that she could safely receive an injection of an antipsychotic to “calm her down.”

Angelica was Afro-Latina. The security officers were White. Angelica was admitted to an inpatient medicine service with an acute psychiatric diagnosis while awaiting placement at a psychiatric facility. She had a significant sexual trauma history and often used self-harm behaviors to cope with her previous trauma. Like many other adolescents across the country, she had waited weeks in the emergency department before this admission without receiving any therapeutic interventions, only to continue this lengthy wait on the inpatient service.¹ 

This episode was merely days after the paralyzing Kyle Rittenhouse jury decision in 2021, when a White 17-year-old adolescent was found not guilty after shooting and killing 2 individuals during what had been a nonviolent protest for racial justice in Kenosha, Wisconsin.²  And it happened soon after the just but gravely insufficient Ahmaud Arbery decision in which an unarmed Black man’s White murderers were rightfully convicted of murder.³  In the latest chapter of this country’s persistent wave of violence against Black individuals, I found myself numb, unable to muster the gut-wrenching rage I experienced after Trayvon Martin’s murder in 2012.⁴ 

Strangely, as I watched Angelica be restrained, I felt like I was watching another instance of Black trauma on a television or phone screen. Each instance of racialized violence against a Black person over the years had slowly chipped away at my ability to fully reckon with and process the enormous weight of the situation, even though this instance was happening feet away from me.

Dissociated from reality, I returned to my workstation, going through the motions of intern year, calling consults, writing notes, and knocking things off my checklist for the day. I had subconsciously decided to focus on the things that I felt would advance patient care and provide a distraction as a means of coping, since I failed to prevent harm as Angelica was dragged through the hospital hall.

As my supervising resident checked in on me, excusing me from my tasks for that morning, my instinct was to compartmentalize. “I’m fine, I just have a few notes to write before lunch.”

And then I felt the wave of emotions overpower me. One sentence into writing my next note, I burst into tears. My body shook from a sense of injustice and moral injury over the fact that I wanted to help this young woman but felt complicit in this instance of violence and trauma. I felt both agonizing helplessness and profound anger at a system that had failed this patient and so many others in such monumental fashion. I felt that as a Black man who prides himself on practicing with cultural humility, I had failed to make a difference in the care of this vulnerable teen.

And yet, none of those heavy emotions compares with the weight of restraints. To be physically incapable of controlling one’s movements so that we, the health care team, can administer chemical restraints. To have your own body weaponized against you because it’s in “your best interests.” To lose trust in the people who were meant to do no harm but are causing substantial emotional and temporary physical harm at that point in time.

Personally, the most excruciating aspect of this experience was that I have no idea what the solution is to this problem. It’s hard to know where to even begin with an issue of such magnitude, at the intersection of centuries of racialized oppression and a youth mental health crisis never before experienced in this country. Remarkably, this perspective is coming from an extreme position of privilege as a health care provider with the safety net of a nurturing residency program to help me process this incident.

That day, I was surrounded by incredibly supportive team members, who each checked in on me and shared my remaining tasks to reduce my work burden. We held a multidisciplinary group debrief to process what we had experienced, providing a safe space for healing in the setting of this witnessed trauma.

Although I’m extraordinarily grateful for the support I had in that moment, I contrast that with the isolation Angelica must have felt: exhausted, betrayed, and not yet receiving the care she desperately needed and deserved.

Because of that, I feel a duty to do more, for myself and, more importantly, for this patient and all patients of color who experience the horrific nature of structural racism and who are occasionally subjected to the carceral nature of health care.

I feel empowered to advocate, offering a voice for Angelica, who had her voice silenced as she cried out for help while we physically and chemically restrained her. That advocacy may look different over time as my bandwidth waxes and wanes during residency. It could mean advocating for trauma-informed care practices for all security officers/personnel tasked with administering restraints at my local institution. It could also mean standardizing the practice of interdisciplinary debriefing sessions such as was done in this situation to normalize an expected human emotional reaction to a witnessed trauma. It could be as simple as sharing the work of my incredible colleagues who have deeply explored how to improve the experience of mental health care for children and adolescents in this country.⁵ 

Eventually, it may mean joining local advocacy groups, such as the Children’s Advocacy Network, to support legislation that increases access to mental health services across my state of residence in the setting of a national psychiatric bed shortage.^6,7  Even further, it could mean joining the American Academy of Pediatrics in supporting national legislation aimed at addressing mental and behavioral health concerns.⁸ 

Although these are important structural solutions, they will take time and don’t fully address the monumental issues surrounding the mental health crisis this country is facing. Further, they don’t accommodate for the entirety of systemic racism, of which this is only 1 manifestation.

So, for right now, advocacy means for me to move on to the next day with a renewed vigor. And weep. And write.

Although my words are not equivalent to the immense weight of restraints, they may be the first step toward beginning to alleviate that burden for patients moving forward.

Because, as a physician, my words have weight, too.