COMMENTARY

First, Do No Harm: Let's Talk About Physical Restraints and Asphyxia

Steven (Kelly) K. Grayson, AGS, NRP, CCP

Disclosures

June 01, 2021

An Addendum to Primum Non Nocere

"First, do no harm."

It's a maxim that forms the principal precept of bioethics that we know as nonmaleficence: that often, to do nothing carries the greatest benefit to the patient with the least risk. Voltaire said it with more poetry when he wrote, "The art of medicine consists of amusing the patient while nature cures the disease."

The skill of clinical restraint is something that often takes a long time to acquire for medical practitioners, and most certainly for paramedics. We're taught to do something. My teachers called it "decisiveness," but most outside of EMS would call it "arrogance." Learning why not to do something is the threshold of clinical wisdom for many of us in the healthcare professions.

Yet, when it comes to a society being driven apart by racial injustice and the rising number of police in-custody deaths, nature isn't curing the disease. The outward symptoms may have dissipated a bit with the conviction of Derek Chauvin for the murder of George Floyd, but the infection still festers. Think of it as a patient who stops taking the prescribed course of antibiotics as soon as his symptoms have abated. The infection may be subacute, but we know the hardiest of the bacteria remain, multiplying, passing on their resistant genes, biding their time to flare up as something nastier, harder to kill.

Injustice works the same way.

The answer isn't defunding the police. Skyrocketing crime rates in the cities who have recently tried it have demonstrated that. Racial disparities in policing are indeed a problem, but the causes are multifactorial. Pick any inner city in America, and you'll find that the highest percentage of crime relates to drug abuse. Drug crime goes hand-in-hand with poverty, which goes hand-in-hand with lack of education and limits the ability of most to break the cycle and escape. All of this afflicts the Black and brown people in our society to a far greater degree than White persons. Unfortunately, the real role models for our children in inner cities are the successful drug dealers. Plunk down into this stew of despair the police officer, the sworn enemy of the drug dealer. It's a recipe for unrest.

"To protect and to serve."

It's a motto emblazoned on patrol cars around the country, and as professional maxims go, it's as noble as any. Sir Robert Peel, the father of modern policing, emphasized the civilian nature of policing and the principle of policing by consent, and yet, the militarization of our police in the past generation has seen law enforcement stray ever farther from its Peelian roots. The labor pool of police officers in our country draws heavily upon combat veterans of the last two wars in Iraq and Afghanistan. Soldiering in itself is an honorable pursuit, but the combat mindset is starkly more adversarial than the traditional role of police officer as envisioned by Sir Robert Peel.

It wasn't supposed to be that way. Scratch a rookie police officer and underneath you'll find an idealist, someone who believes in morality and ethics, who believes in his or her role in protecting the good people of their communities from the bad ones. No police officer starts with the goal of becoming a jaded racist, and the vast majority never do. But the job often conspires to make them that way, corrupting their idealism every bit as surely as a long career in the emergency department erodes the faith in humanity of the doctors and nurses who work there, replacing it with cold, world-weary cynicism. Cops are as susceptible to moral injury as we are.

The answer to the problem, as it is to most of society's ills, is education. People on both sides of the debate in our country have developed a new lexicon of words they barely understand, such as traumatic asphyxia, excited delirium, or positional asphyxia. They shout at each other over social media, each selectively misusing the phrases to support their own biases. Largely absent from the debate are the voices of healthcare professionals, most likely because we see those screaming matches and rightly think, "Not my circus, not my monkeys." We lurk silently instead, watching the spectacle with all the detachment of an animal handler witnessing a monkey-feces fight at the zoo.

Except, this fight does not end on its own. We must speak out, in the same way we steadfastly correct anti-vaxxers, countering their Google-powered "research" and hysteria with measured tones and a calm presentation of the facts and relevant data that vaccines save lives.

First, we need to educate the police. Anyone watching the video of Derek Chauvin kneeling on the shoulders and neck of George Floyd for over 9 minutes realizes it was excessive, a sentiment also held by most police officers. But what many of them don't believe, not deep down, is that it is deadly. They believe that positional asphyxia is not a "thing," mainly because there is no shortage of medical experts willing to testify so in court, backed up with actual research. They will point out to the jury that there is no scientific evidence that demonstrates that prone, hog-tied restraint with a weight of 25-50 pounds placed upon the neck and shoulders significantly impairs oxygenation, ventilation or cardiovascular parameters in healthy, compliant study participants. All that plaintiff's attorneys have to counter with are case reports of in-custody restraint deaths which, though voluminous, do not rise to the reliability standard of peer-reviewed, controlled research.

What is not said is that police aren't called upon to restrain compliant, healthy people. Their cohort is the one we can't study formally: the obese, violent patient under the influence of potent sympathomimetic drugs, often with significant underlying health issues, such as hypertension and heart disease. As the saying goes in medical and research circles, "Absence of evidence does not equate to evidence of absence." This is a nuance lost on the layperson, including police officers. Officers need to internalize the belief that prone restraint, even if sometimes necessary, is inherently risky and should only be used as briefly as possible, as a last resort.

We need to educate our prehospital colleagues on the fallacy of "If you can say you can't breathe, then that is proof that you indeed can breathe." The ability to phonate does not indicate respiratory sufficiency. We need to correct other healthcare providers who quote the original George Floyd autopsy report of no findings to indicate traumatic asphyxia or strangulation. I suggest that whenever you hear someone using the terms "traumatic asphyxia" or "strangulation" in relation to the George Floyd case, you employ the Tao of Inigo Montoya: "You keep using that word. I do not think it means what you think it means." Traumatic asphyxia describes the sequelae of a sharp spike in intrathoracic pressure — an inadvertent Valsalva maneuver combined with crush injury. It is a cardiovascular phenomenon, not a respiratory one.

Likewise, strangulation usually results from vascular compression of the great vessels of the neck, resulting in rapid loss of consciousness. It is the mechanism of the "choke hold" used by mixed martial arts artists. Manual or ligature strangulation, however, results in crush injury to the soft tissues and trachea, and is apparent on autopsy. It also takes a great deal of force — roughly six times that of the vascular compression of a choke hold.

We also need to educate medical professionals and legislators alike that excited delirium, although the mechanism is poorly understood, often results in deadly sequelae. To counter the hypersympathetic state and the arrhythmias and acidosis that often result, early chemical restraint and sedation is paramount. The goal is to stop the fight. Physically restraining the patient merely changes the combatants from patient vs medical providers to patient vs restraints. Sedation is necessary.

We also need to educate the police, paramedics, and EMS medical directors that an unruly or noncompliant person does not equate to excited delirium. Inappropriate sedation of in-custody subjects by paramedics at the request of police has resulted in deaths and has spurred calls by legislators to restrict the prehospital and emergency department use of ketamine. We need to keep ketamine in our formulary, but it needs to be understood that the decision to sedate someone is a medical one, not a law enforcement one.

Above all, we need to speak, if for no other reason than to eliminate the medical misconceptions that broaden the divide in the debate on policing and race in our country. If we are truly concerned about the health of our patients and our society in general, perhaps primum non nocere needs the addendum etiam non silentium: "Also, do not remain silent."

Steven (Kelly) Grayson, AGS, NRP, CCP, is a critical care paramedic in Louisiana. He has spent the past 24 years as a field paramedic, critical care transport paramedic, field supervisor, and educator. He is president of the Louisiana Society of EMS Educators, a board member of the Louisiana Association of Nationally Registered EMTs, and a member of the EMS1 Editorial Advisory Board. He is the author of En Route: A Paramedic's Stories of Life, Death and Everything In Between and the popular blog A Day In the Life of an Ambulance Driver.

You can follow him on Twitter (@AmboDriver), Facebook, and LinkedIn.

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