“I Can’t Breathe” Means EMERGENCY – Avoiding Restraint Deaths

Written by Andrew Hogan 

Spoon Feed
Restraint in the prone position is commonly used by law enforcement officers, but this technique impairs effective ventilation and increases the risk of death for restrained individuals. Take “I can’t breathe” statements seriously in this population.

A strategy prone to (ventilatory) failure
The deaths of Elijah McClain, Eric Garner, and George Floyd in custody have placed a spotlight on the risks of improper restraint techniques. Although ACEP has disavowed the term “Excited Delirium,” the phenomenon of metabolic acidosis caused by physical exertion against restraints (and exacerbated by stimulants) remains very real. After struggling against restraints, acidotic patients with otherwise healthy lungs hyperventilate to clear excess CO₂ from the body. This compensatory response fails when chest wall excursion is restricted by prone positioning with hands cuffed behind the back and a knee between the scapulae. Sedating a patient in these circumstances spells further doom by blunting their respiratory drive. Footage from these tragic incidents demonstrates clear signs of respiratory distress and a common refrain of “I can’t breathe” from the victims. The maxim, “If you’re talking, you’re breathing,” is a myth. Emergency clinicians should remember their ABCs – speech indicates airway patency (A) – not effective ventilation (B). We recognize the risk of underventilation in cases of salicylate toxicity or DKA. Why don’t we recognize similar pathology when a patient states the problem unambiguously? The authors note a widespread lack of education among both law enforcement entities and emergency clinicians regarding the risks of improper restraint.

They propose best practices to prevent further unnecessary restraint-associated deaths:

• Designate a ‘safety officer’ for all physical takedowns.
• Minimize prone patient positioning.
• Protocolize sedation to include pre-assessment, monitoring, and contingency plans.
• Avoiding sedation for restrained patients with red flags
• Take “I can’t breathe” statements seriously.

How does this change my practice?
Emergency clinicians must understand the risks of improper restraint techniques and sedating physically struggling, restrained patients. They must also recognize signs of impending ventilatory failure in these individuals.

Source
Handcuffs and Unexpected Deaths – “I Can’t Breathe” as a Medical Emergency. N Engl J Med. 2024 Nov 30. doi: 10.1056/NEJMp2407162. Epub ahead of print. PMID: 39620456