«Note: When this report was originally published, we were known as Protection & Advocacy, Inc. (PAI). In October 2008, we changed our name from PAI to ...»
THE LETHAL HAZARD OF PRONE
Note: When this report was originally published, we were known as Protection &
Advocacy, Inc. (PAI). In October 2008, we changed our name from PAI to Disability
PROTECTION & ADVOCACY, INC.
433 HEGENBERGER ROAD, SUITE 220 OAKLAND, CALIFORNIA 94621 TELEPHONE: (800)776-5746 April 2002 Publication #7018.01
INVESTIGATIONS UNIT STAFF
LESLIE MORRISONSupervising Attorney, Investigations Unit – Oakland PAUL B. DURYEA Senior Investigator – Los Angeles
CHARIS MOOREStaff Attorney – Oakland
ALEXANDRA NATHANSON-SHINNStaff Attorney – Los Angeles
EMILY ROSE Support Staff – Oakland Editing and Production Protection & Advocacy, Inc. (PAI) encourages and gives permission to copy and distribute this report for training and educational purposes so long as such publication is not done for profit; if the report is not published in its entirety, PAI is acknowledged as the source of the material.
TABLE OF CONTENTSI. INTRODUCTION
II. EXECUTIVE SUMMARY
A. POSITIONAL AND RESTRAINT ASPHYXIA
B. PRONE CONTAINMENT VS. PRONE RESTRAINT
C. AGITATED DELIRIUM
IV. CASES SCENARIOS
A. CRYSTAL M.
B. ANTHONY N
C. SAM R.
D. NORMAN H
E. LAURAJEAN T.
F. KEVIN M.
G. RICK G.
V. RESTRAINT ASPHYXIA
A. VENTILATION AND THE EFFECT OF PRONE RESTRAINT POSITION
B. EFFECT OF RESPIRATORY COMPROMISE ON CARDIACFUNCTIONING
C. RESTRAINT AND VENOUS BLOOD RETURN
D. AGITATED OR EXCITED DELIRIUM
E. CONTRIBUTION OF MEDICATION
VI. RESTRAINT TRAINING PROGRAMS
VII. PAI’s INVESTIGATIONS
Page 4 of 35 VIII. FINDINGS AND CONCLUSIONS
A. EACH OF THE DEATHS OR INJURIES DESCRIBED ABOVE WAS
LIKELY DUE TO POSITIONAL ASPHYXIATION DUE TO PRONERESTRAINT OR CONTAINMENT.
B. PRONE IS A HAZARDOUS AND POTENTIALLY LETHAL
RESTRAINT POSITION, PARTICULARLY FOR INDIVIDUALS WHO ARE
OVERWEIGHT OR WHO HAVE BEEN AGITATED AND STRUGGLING.24IX. RECOMMENDATIONS
A. INDIVIDUALS MUST NEVER BE PLACED IN THE PRONE POSITIONWHEN RESTRAINED.
B. TEMPORARY PRONE CONTAINMENT SHOULD ONLY BE
ATTEMPTED WHEN ALL OTHER TECHNIQUES ARE INEFFECTIVE TO
PREVENT IMMINENT SERIOUS HARM, AND WHEN THERE ARE
SUFFICIENT SAFEGUARDS IN PLACE TO PROTECT THE INDIVIDUALFROM POSITIONAL ASPHYXIATION.
C. RESTRAINT AND CONTAINMENT MUST BE VIEWED AS THE
RESULT OF A TREATMENT FAILURE, NOT A TREATMENTINTERVENTION.
D. ALL FIRST RESPONDERS MUST BE EDUCATED REGARDING THE
RISKS OF POSITIONAL ASPHYXIATION WITH PRONE RESTRAINT....32
Protection & Advocacy, Inc. (PAI) has investigated a number of deaths or serious injuries sustained while the victim was restrained face down or prone.
PAI’s medical expert has concluded that these deaths or injuries were most likely caused by positional asphyxiation and, specifically, the prone restraint position.
The issue of positional asphyxiation has been discussed extensively in the law enforcement community, particularly related to the hog-tie position (Chan, Vilke, Neuman, & Clausen, 1997, p. 579; Morrison & Sadler, 2001, p. 46; O’Halloran & Frank, 2000, p. 289; Paterson, Leadbetter & McComish, 1998, p. 62). Yet, little has been written in psychiatric and emergency response literature regarding the danger of death with persons restrained in the prone position (Mohr & Mohr, 2000, p. 288; O’Halloran & Frank, 2000, p. 50).
PAI releases this report as part of its ongoing educational efforts to:
- Improve the safety of people with disabilities;
- Publicize the hazards of prone restraint;
- Encourage health care professionals to eliminate the use of prone restraint and minimize prone containment; and
- Discuss the paradigm shift from viewing restraint and containment as a treatment intervention to a treatment failure.
PAI is an independent, private, nonprofit agency that protects and advocates for the rights of persons with disabilities. Under federal and state law, PAI has the authority to investigate incidents of abuse and neglect of persons with developmental and psychiatric disabilities. 42 U.S.C. §§ 10801 and 15001, et seq.;
Welf. & Inst. Code §§ 4900, et seq.
II. EXECUTIVE SUMMARY
A number of these cases involved restraining the individual prone, either during containment or while mechanically restrained to a bed. PAI consulted with Werner U. Spitz, M.D., a forensic pathologist, board certified in Pathologic Anatomy and Forensic Pathology and an expert in excited delirium and positional asphyxia. Dr. Spitz concluded that the prone restraint position was a significant contributing factor in the demise of the individuals restrained. Literature shows that sudden death during prone restraint, particularly for those in a state of agitated delirium (a clinical syndrome described below), is not an uncommon phenomenon but one infrequently reported in medical literature. The mechanism of death is a sudden fatal cardiac arrhythmia or respiratory arrest due to a combination of factors causing decreased oxygen delivery at a time of increased oxygen demand.
PAI’s investigations determined that prone is a hazardous and potentially lethal restraint position and likely contributed to the deaths or injuries of each of the individuals described in this report. Based upon its investigations, PAI
- Individuals must never be placed in the prone position when restrained;
- Temporary prone containment should only be attempted when all other techniques are ineffective to prevent imminent serious harm and when there are sufficient safeguards in place to protect the individual from positional asphyxiation;
- Restraint and containment must be viewed as the result of a treatment failure, not a treatment intervention; and
- All first responders must be educated regarding the risks of positional asphyxiation with prone restraint.
Page 7 of 35
A. POSITIONAL AND RESTRAINT ASPHYXIAPositional asphyxia is insufficient intake of oxygen as a result of body position that interferes with one’s ability to breathe (Mohr & Mohr, 2000, p. 289;
National Institute of Justice Program [NIJP], 1995, p. 1). Restraint asphyxia is a form of positional asphyxia that occurs during the process of subduing and restraining an individual in a manner causing ventilation compromise (Stratton, Rogers, Brickett & Gruzinski, 2001, p. 190).1 As a consequence of the restraint application, respiration is compromised causing insufficient oxygen in the blood to meet the body’s oxygen needs or demands (hypoxia) which then results in a disturbed heart rhythm (cardiac arrhythmia) (Patterson, et al., 1998, p. 62).
Research studies and the literature have suggested a combination of factors
that place a person at risk of positional asphyxia. They include:
- position during restraint, particularly the prone position (Paterson, et al., 1998, p. 62);
- agitated delirium syndrome (O’Halloran & Frank, 2000, p. 48);
- obesity (Paterson, et al., 1998, p. 62);2
- prolonged struggle or physical exertion (O’Halloran & Frank, 2000, p. 49;
Paterson, et al., 1998, p. 62);
Restraint application may involve mechanical restraints, meaning the application of a restraint device such as leather restraints, or physical restraint, meaning “hands-on” physically restricting a person’s freedom of movement (Paterson, et al., 1998, p. 62).
If a subject is obese, the excess fat tissue is forced upwards into the abdominal cavity, pressing on and immobilizing the diaphragm (Parkes, 2000, p. 40; Paterson, et al., 1998, p. 63). Further, excessive body weight makes it harder to move the chest wall and expand the lungs, especially while prone (O’Halloran & Frank, 2000, p. 49). Obesity may also contribute to the hyperthermia seen with agitated delirium by contributing to body insulation (O’Halloran & Frank, 2000, p.
Page 8 of 35
- drug and/or alcohol intoxication, in particular cocaine and methamphetamine intoxication or cocaine-induced psychosis (NIJP, 1995, p. 1; Stratton, et al., 2001, p. 191; O’Halloran & Frank, 2000);
- mania (Paterson, et al., 1998, p. 62);3
- respiratory syndromes, including asthma and bronchitis (Paterson, et al., 1998, p. 62);
- exposure to pepper spray (capsicum) (Paterson, et al., 1998, p. 62); and
- pre-existing heart disease, including an enlarged heart (hypertrophic cardiomyopathy) and other cardiovascular disorders (O’Halloran & Frank, 2000, p. 51; Paterson, et al., 1998, p. 62; Stratton, et al., 2001, p. 187).4
B. PRONE CONTAINMENT VS. PRONE RESTRAINTFor the purposes of this report, PAI will distinguish between prone containment and prone restraint. Prone containment is the brief physical holding of an individual prone, usually on the floor, for the purpose of effectively gaining quick control of an aggressive and agitated individual. Prone restraint is the extended restraint (either physical or mechanical) of an individual. This may include holding an individual past the time of immediate struggle. It also includes restraint to a bed using restraint devices, such as leather cuffs.
C. AGITATED DELIRIUM
Sudden deaths involving physical restraint have long been associated with a syndrome called agitated delirium (O’Halloran & Frank, 2000; Paterson, et al., 1998; Stratton, et al., 2001). Agitated delirium (also known as excited delirium or acute excited states) is a condition of extreme mental and motor excitement characterized by aggressive activity with confused and unconnected thoughts, hallucinations, paranoid delusions and incoherent or meaningless speech (Farnham & Kennedy, 1997, p. 1107; O’Halloran & Lewman, 1993, p. 292; O’Halloran & Persons with mental disorders, especially drug-induced or psychotic illness-induced agitated delirious states, seem to be at greater risk (O’Halloran & Frank, 2000, p. 51).
An enlarged heart renders an individual more susceptible to a cardiac arrhythmia under conditions of low blood oxygen and stress (NIJP, 1995, p. 2).
Page 9 of 35 Frank, 2000, p. 48). Victims display extraordinary strength and endurance when struggling, apparently without fatigue (Farnham & Kennedy, 1997, p. 1107).
Hyperthermia, or extremely high body temperature, is often part of this syndrome (O’Halloran & Lewman, 1993, p. 292; Paterson, et al., 1998, p. 62). Agitated delirium has been described in persons with psychosis, chronic schizophrenia, mania, and high blood concentrations of cocaine, methamphetamines or other stimulants (Farnham & Kennedy, 1997, p. 1107; O’Halloran & Lewman, 1993, p.
292; Paterson, et al., 1998, p. 62).
IV. CASES SCENARIOS
A. CRYSTAL M.
Crystal was a 16-year-old girl, diagnosed with mild mental retardation, major depression and an impulse control disorder. Crystal, a ward of the court, had been placed in a residential facility with an on-site school program for children with psychiatric disabilities. Crystal was 5 feet 8 inches tall, weighed 293 lbs and was diagnosed with obesity.
On the day of her death in February 1999, Crystal began arguing with another student in the school program. She was escorted by staff to the “timeout room.” A struggle ensued. Staff attempted to physically contain Crystal against a wall. As she continued to struggle, she complained that she could not breathe. She was lowered to the floor in a seated position and, ultimately, physically restrained prone on the floor. After 30 minutes on the floor, Crystal stopped struggling. Staff released their hold. When she failed to respond to staff’s request to adjust her pants, Crystal was rolled onto her back and found not breathing. Cardiopulmonary resuscitation (CPR) was performed but Crystal did not respond. She was pronounced dead when she arrived at the local hospital. The medical examiner found her cause of death as “cerebral hypoxia due to positional asphyxia during physical restraint.” Petechiae or petechial hemorrhages were found in both eyes.
B. ANTHONY N.
In November 1999, Anthony N. was 40-years-old when he was taken to the local county psychiatric emergency services for evaluation. Earlier that day, Anthony had assaulted a customer at an automatic teller machine. He told law enforcement that he was hearing voices and believed he was Genghis Khan. He was 6 feet tall and weighed nearly 190 lbs.