Monday, December 29, 2014

A Medical Perspective on the Negligent Homicide of Eric Garner

I am not going to get into the larger sociopolitical issues surrounding the death of Eric Garner.  I don't want anything to distract from sharing one observation that has not been widely reported, and which may lead to at least one change that every police department in the country should implement.

Eric Garner was not choked to death by Officer Daniel Pantaleo.  He died of positional asphyxia due to being restrained facedown on the sidewalk with multiple individuals piled on top of him.  Positional asphyxia is a phenomenon whereby an individual's work of breathing is too high to be sustained due to their position.  Think of it like this: a swimmer treading water can kick and kick and keep themselves above water.  Some people (particularly those with a good amount of fat) can do this easily, as they are naturally bouyant and float.  But some individuals (ironically, including many fit ones) have a much harder time.  Those people may eventually tire, and if they can't keep going- they drown.  Think of positional asphyxia as kind of like treading water.  If they are forced to lie facedown, most (thin and relatively fit) people can keep breathing.  But more obese individuals have a lot of weight pressing down on their lungs.  Their diaphrams are not that strong.  Sooner or later, they may tire and be too tired to keep breathing if forced to lie in that position.  Add in multiple people on top of them, and it gets far worse.  Add in asthma triggered by the stress of being arrested, and ALL bets are off.  Indeed, if one looks at the video, it becomes clear that Eric Garner does not say "I can't breathe" until after Officer Pantaleo has released his "chokehold"- he starts saying it when he is lying face down with officers piled on top of him.  This explanation is a bit of a simplification, but an excellent reddit post by a serving police officer goes into the science of breathing and why Eric Garner died.

There is a common myth that abounds that 'if you can say, "I can't breathe", then by definition, you CAN breathe'.  This myth has gotten people killed in police custody before, arises from CPR training which all police officers receive, and is actually partially true.  If someone is coughing and saying "I'm choking" or "I can't breathe" after swallowing something, they are actually not choking, and no one should do a Heimlich maneuver on them- or pat them on the back/intervene in any way.  Choking is defined by a loss of air movement through the trachea- which means a loss of movement of air through the vocal cords which produce sound.  Constrict the windpipe to the point where you choke someone, and they will not be able to move air through that windpipe either.  So, if you are choking- you indeed will be unable to say "I can't breathe".  But Eric Garner was trying to communicate something different- that he felt like he was being killed by a boa constrictor as his lungs could not physically get enough air in.  The officers on scene probably assumed Eric Garner was lying- since a person who is talking by definition can not be choking, and missed the seriousness of the situation- they had no idea that a person who is restrained facedown on the ground is at risk for an entirely different way of being unable to breathe.

Most emergency medical providers and mental health workers who deal with the possibility of restraining patients are given one absolute dictum: NEVER EVER restrain a patient facedown.  Even as an EMT-Basic this was pounded into me by my excellent instructor, a veteran paramedic who had seen the results of it first hand.  If restrained facedown, the patient may tire, become unconscious, become unable to sustain respirations (aka keep breathing), and die.

Per a retired high ranking police officer I chatted with recently, this is not emphasized at all in the police curriculum.  He had never even heard of positional asphyxia.  This is corroborated by comments by many other Law Enforcement officers on that science article I linked to earlier.  And most of the time, police officers can get away with not knowing.  If we assume that the people police officers arrest are by and large young, healthy, and on the ground for a short time- most will not run into problems.  But throw in obesity, throw in the dog-pile of officers, throw in a possible history of asthma and it's a recipe for disaster.

This is somewhat reminiscent of the awareness of Serotonin Syndrome in the medical community.  Before the death of Libby Zion in 1984, the drug interaction known as serotonin syndrome was unknown to the vast majority of doctors.  Multiple chairs of departments of medicine at various prestigious schools testified under oath that they had never heard of it at the trial over the death of Libby Zion who was prescribed an anti-depressent and a sedative with seritonergic properties.  Now, every medical student in the country has it pounded into their head that if they ever prescribe two anti-depressants or one anti-depressant and a list of other drugs that act at serotonin receptors they WILL kill someone.

Officer Pantaleo did not choke Eric Garner to death, but he and every other officer on that scene are responsible regardless.  Multiple officers have commented that Pantaleo's technique as seen in the video was proper and designed to use leverage to force a large individual to the ground without targeting the airway.  The real problem was what happened afterwards.  Police officers need to become more aware of a rare but deadly result of their standard tactics, and modify their behavior accordingly- especially as more and more Americans become overweight.  Obese individuals should not be forced by officers to lie facedown on the ground- ever.  Police Departments need to find a way to modify their standard tactics- whether that is increased use of tasers, more people, new tools, or something else.  Departments need to cut down on the use of prone restraint- and if it is used, it needs to be ended as quickly as possible and the people subjected to it monitored for breathing problems.  I suggest as an alternative hand-cuffing someone while they are lying facedown, and immediately having them turn over onto their backs and then close their eyes.  I don't know if this is logical or feasible- perhaps a serving police officer will find some obvious (to them) fault with this solution, but something needs to change before more people die.  Above all else, police officers should be taught to listen carefully to people claiming that they are unable to breathe- and that the ability to talk IS NOT IN ANY WAY an absolute indication that someone can breathe.