Death by Suffocation

photo credit-Steve Brandon

Kristina Chew referred on her blog to an article today about an autistic individual who died while being subdued by police. According to the article:

...Mitchell died in a hospital last July following a struggle with deputies at his Perris home. Deputies responded to the residence after his mother called 911 saying she needed authorities to pick up her son. ...

The article was prompted by the mother filing a wrongful death lawsuit against the police. As might be expected, there are two different versions of what caused the incident:

...Sheriff's officials contend Mitchell died from autism-induced "excited delirium syndrome," a condition that leads to sudden cardiac arrest. ...

..."That's what they always say," attorney Carl Douglas said.

Douglas believes Mitchell died of positional asphyxiation after several officers piled on top of him. ...

Before I go any further, let me state for the record that I am generally supportive of law enforcement. I have expressed concerns about their level of training and how police interact with autistics, but I have also given praise when I felt they deserved it. They have a tough job, and have to make some tough decisions in rapid succession. They also aren't always trained as well as they should be to deal with "special case" situations, such as dealing with autistics.

After seeing the post on Kristina's blog today and reading the article, I just had to make some comments.

As a physician, I had never heard the term "Excited Delirium Syndrome" until I heard it bandied about as a defense when subjects had died in police/emergency workers custody shortly after being forcibly subdued by them. And I had never heard autism ever mentioned as something that might induce such a "syndrome". Personally, I don't think it exists as a separate syndrome.

Excited delirium syndrome has been used when a person dies in custody after being forcibly subdued. Typically the person that died was also under the influence of illegal drugs such as PCP, cocaine, and methamphetamine. All of these drugs can put a stress on your heart before, during, and after a forcible struggle with the police. While I do understand that sometimes force is required to subdue violent individuals, I believe that there is inadequate recognition of the possible negative outcomes that can result from forcibly subduing someone, which results to force being reverted to too often, and more importantly, improper after care once force has been applied.

Here is what I think happens in a "typical" death from "Excited Delirium Syndrome":

1) Police are summoned to take into custody a violent or potentially violent person. Being the police, they are expected to actively take action to deal with someone, especially if they are actively violent at the time. Sometimes I think that they take physical action too quickly when the person they are dealing with is not actively violent. This may be due to what we term "production pressure" in medicine (the push to get things done so you can move on to other important things), or it may be due to inadequate training.

In a typical scenario, once police arrive they typically want to control the situation as quickly as possible. Lack of control means too many variables, and too many variables means too many chances for someone to get hurt. So they rapidly progress thru their "use of force continuum" until they get control of the situation. This continuum differs a little from jurisdiction to jurisdiction, but typically looks something like this (from Wikipedia):

1. Presence
2. Verbalization
3. Empty hand control
4. Intermediate weapons (e.g., chemical, electronic or impact weapons)
5. Deadly Force (any force likely to cause permanent injury or death)

What I believe typically happens is that the officer, thru physical presence (man standing confidently in uniform with gun) and verbalization (may start with asking for compliance, rapidly progressing to orders of compliance-"come here, turn around, get down on your knees, etc.)tries to get compliance from the subject. Not getting the desired result, I think most officers resort to

2) Hands on techniques. Usually these start innocently enough as a gentle laying of their arm on the suspects arm or shoulder to get them to comply or come along, but then progresses to joint locks, arm bars, hair pulls, and other techniques to coerce compliance. I think it is at this point that things start escalating quickly. The police officer involved certainly has a lot of endogenous epinephrine (adrenaline) flowing in his veins, making it more difficult for him/her to judge how much force they are applying and for how long. The subject, especially if they have a hard time understanding what is happening (either because of drug/alcohol intoxication, language difficulties or cognitive disabilities) also has gone into a "fight or flight response" and starts fighting for their life. The police officer(s) now involved sense what is a very disorganized scene and rapidly escalate their responses to gain control. This may involve choke holds (which have been banned from many departments) or may involve multiple people striking the subject and/or "piling on" them to subdue them. This leads to what is a critical juncture, namely

3) Loss of ability to breathe for the subject. If a person has not been fighting forcefully up to this point, then they certainly will now. I've seen 80 year old sweet grandmothers become markedly violent when they can't breathe. It's a primal instinct. We can only go 4 minutes at rest without breathing. This time is markedly shortened when we are also expending maximum energy in trying to regain our airway. Officers may or may not recognize that they have compromised a person's airway at this point. I suspect that they are focused on subduing the person, not getting hurt, and not letting anyone else get hurt.

Not being able to breathe, while rapidly using up all your oxygen will predictably lead to unconsciousness. There will be a short period of time where recognizing the person is unconscious, rapidly acting to get everyone off them and open their airway, and administering mouth to mouth resuscitation will revive them. This period will be fairly short in length, though, and probably missed, leading then to

4) Cardiac arrest. At this point the person has quit struggling and the officers have spent time applying handcuffs to their wrists (and possibly restraining ankles also) with the person in the face down position. This makes it difficult for them to recognize that the person has indeed arrested, and failure to quickly resuscitate the person leads to

5) Certain death.

In analyzing the above scenario, there are a few critical points where decisions made can end up snowballing into possibly catastrophic consequences. The first point is the initial laying on of hands by police. If a person is actively trying to hurt another, then the police's hands are tied. But if they are not hurting anyone else, then I think that staying verbal longer can avoid some negative outcomes. The gentle laying of your hand on someone's arm can be soothing to many, but it can lead to atypical reactions in some populations (like autistics). Most people with autistics in their immediate family know that touching them when they are excited is not usually a good thing. At the least they involuntarily pull away, at worst they may lash out (usually indiscriminately). So even though it may take longer (sometimes a lot longer) to talk someone down, if it resolves the situation then it's a good thing.

The second critical point in the above scenario is in recognizing that the person's airway has been compromised. This is admittedly very tough in what has now become a fluid violent situation, but I think that if there is increased awareness of this possibility that there will be increased recognition and proper treatment when it happens. I also think that the police might want to borrow something from medicine.

Whenever we run a "code" on a person, if possible we designate a person the team leader, and that person does not get involved with manual tasks such as chest compressions, starting IV lines, giving drugs, etc. Their main role is to make decisions and constantly reevaluate the entire situation. The senior police officer on the scene has to try (if possible) to not become physically involved. This is admittedly very tough when the situation is not in control, but there is a greater chance of someone recognizing when things are going awry when they are not physically involved in subduing the individual. If they have to become physically involved in subduing the individual, then they need to rapidly back out of that role as soon as possible.

The next critical step is one that I do not believe occurs at present. That is, immediately after a subject stops moving in such a situation, someone needs to verify that the person is breathing. Often I suspect that the police, having gone thru their own "fight or flight" response, are very jittery and coming down from this at this time, feeling a bit more relaxed as the suspect is restrained. But this is a critical point in the confrontation, when seconds lost can have disastrous consequences for the subject. While there may be a feeling of "they got what they deserve" for fighting back at the time, as police can also be injured in these events, I don't think that upon calm reflection any police officer would think that any person "deserved" immediate death on the street for resisting arrest. Increased recognition of loss of airway commonly occurring in these situations needs to be stressed in training of officers, as well as ways to recognize and deal with it to prevent further injury to the subject.

In light of the above, and since police officers are not really trained to act as first responders for medical issues, I would think that policy should be changed such that paramedics are on the scene before any person that is not violent is approached with physical measures. This suggestion will certainly result in a large uproar from those in emergency services. But I think that in terms of preventing lives lost it may be necessary.