Advisory for Care Providers
Exploring the Dangers of Positional Asphyxia
By Tina DiDino, REM Ohio, Health Services Coordinator
Mary K. Ziccardi, REM Ohio, Administrator
Jane is on her way home from
work. Her supervisor, Jim, calls you to say he noticed his candy
bar was missing from the top of his desk and that Jane was seen
near his desk just prior to the bus arriving.
Jane arrives home; you meet her at the door. Her breath smells
of chocolate, the corners of her mouth are brown, and there’s
caramel stuck in her teeth.
You say to Jane, “You took Jim’s candy bar off his desk this
afternoon.”
She becomes loud and defensive. “No I didn’t!”
You say, “You’re lying! There’s chocolate on your face and
caramel in your teeth.”
She becomes increasingly upset, yelling that she isn’t lying.
She begins calling you obscene names for accusing her. She
stomps around, slams her lunch box on the table, then shoves a
chair under the dining room table.
You say to her, “Stop this and calm down. You know better than
to slam things and call people names.”
She is non-compliant and clearly a “behavior problem.” Cursing
and slamming things shows she’s out of control. You know what
you have to do. You glance at your co-worker, Joe, and give him
the nod. Just as you were taught, you and Joe quickly grab her
arms, place your hand on her back to ease her fall, and each put
a leg behind hers. You nod again and you both push her backward
so she’s off balance. Ease her to the floor, flip her onto her
stomach (so she can’t hurt you, and so she doesn’t choke), put
her arms at her sides and lean across her back to prevent her
from getting up. Now you explain to her that you wouldn’t have
had to do this if she would have calmed down when you told her
to, but you’ll let her up as soon as she is calm.
Jane’s still putting up quite a fight, screaming, struggling to
get up and trying to buck you off her. You ask Joe for help. Joe
lies horizontally across her thighs and you lay across her back.
After a few short minutes she stops fighting. Whew…. You tell
her she’s done a good job calming down and you’re going to
release her now. You slowly release one of her arms. Her nail
beds are blue.... She doesn’t seem to be breathing!
Safely using physical restraint
Recently, one of our families lost a child as the result of a
prone restraint. The purpose of this article is to address the use
of physical restraint, and when needed, how to practice it safely.
Often school and vocational organizations and residential agencies
are trained to use face-down restraint procedures. This type of
restraint greatly increases the risk of positional asphyxia, which,
simply stated, means that the position of one’s own body interferes
with the restrained person’s ability to breathe and the person
cannot get enough oxygen.1
Further, any interference with respirations, either by the
positioning of one’s own body or by an external force, may result in
asphyxia. The danger of death is so great that many police
departments are now conducting officer training of alternative
restraints and have banned the use of prone restraint. According to
EMT Charly Miller,2 one case study showed the average time between
beginning a prone restraint and the onset of death was only 5.6
minutes. Use of this restraint, even for short periods of time,
presents serious risks. Multiple factors place a person at risk for
death or serious injury from positional asphyxia.
Risk Factors and PWS
Primary risk factors for a person with Prader-Willi syndrome
include:
• one’s body position during restraint, particularly prone
• obesity3
• prolonged struggle or physical exertion4
• respiratory conditions, including asthma and bronchitis4
• pre-existing heart disease, including an enlarged heart and other
cardiovascular disorders 3,4,5
General Risk Factors
When a prone restraint is used, each of the following factors
may put a person at risk:
The individual may become upset, and his/her heart rate, blood
pressure, and rate of breathing will increase.
As the physical struggle occurs, the person becomes out of breath.
More oxygen is needed to fuel the struggling muscles.
As the person’s body is trying to get more oxygen to fuel the
muscles, the person is placed in a face-down position on the floor,
causing compression of the chest and limiting the person’s ability
to expand the chest cavity and breathe5,6
In addition, the abdominal organs may be pushed up, restricting
movement of the diaphragm, further limiting the available space for
the lungs to expand.6,7
Also, excessive body weight makes it more difficult to move the
chest wall and expand the lungs, especially when in the prone
position.4
All muscles, including the heart, require oxygen to function. When
the heart doesn’t get enough oxygen, it may begin to beat faster, or
out of rhythm, potentially leading to death.
According to a case study,8 forensic pathologist Dr. Werner Spitz
indicates that there is a greater chance of positional asphyxia with
increased body mass and an enlarged heart. The amount of fat located
under the navel is indicative of the thickness of the fat layer
under the skin, and this is associated with excess fat inside the
abdominal cavity. In the prone position, the excess fat, together
with the abdominal organs, push against the diaphragm, causing it to
be immobilized, and ultimately interferes with breathing. Dr. Spitz
concludes that the more agitated a person is, the less time it will
take for suffocation to occur.
As the individual continues to struggle, more weight is added and
the grip is tightened to further gain control. As the person
continues to struggle to get away, exhaustion is a factor and
breathing becomes more difficult. Life is threatened.
PWS Adds to Risks
In children and adults with Prader-Willi syndrome, poor muscle
tone and excess weight add to the risk of prone restraint. When an
authority figure assumes a “control model” mentality, restraint may
become the accepted way of handling a crisis. Restraint is then used
as intimidation, punishment and convenience, or for control, as
opposed to a final option if imminent physical danger exists.
As a parent exploring residential, educational, and vocational
opportunities for your child, it is important to ask questions
regarding the support staff’s philosophy in restraint use.
Are restraints used to prevent immediate harm or as threats,
punishment, or control? If restraint is deemed appropriate by the
team, is it part of an overall Behavior Support Plan, and have all
applicable authorizations been completed? How have staff who will be
implementing the restraint been trained? In extreme cases, restraint
must be used to protect someone from imminent danger. Ultimately, it
seems advisable to teach support staff safe and appropriate physical
restraint techniques. This may prevent even well-intentioned support
staff from harming someone out of anger, fear, or frustration.
Prevention is Key
Consistency, structure, trust and positive feedback are critical
to building supportive relationships with people with Prader-Willi
syndrome. Some additional positive strategies may include:
• Always reward the positive! High-fives, enthusiastic praise and
small tangible reinforcers go a long way.
• Warn in advance when there is going to be break in the routine or
a schedule change.
• Do not nag! This may only increase agitation and frustration.
• Acknowledge when you are wrong and apologize. It is helpful to
know that we all make mistakes.
• Build a relationship that accepts and values each person.
• Acknowledge and empathize when a situation is unfair or upsetting,
and follow up with appropriate responses and potential solutions.
• Anticipate questions and try to predict solutions during
transition times.
• Don’t hold a grudge! Learn to treat each minute as a new
opportunity. Sometimes, it’s the only way to survive.
• Never promise something that has the potential to change.
• Handle sneaking food or other crises in a matter-of-fact way. It’s
their nature to try and it’s our job to prevent!
• Don’t minimize the difficulty the person is having. While it may
seem trivial to you, it can be of great importance to an individual
with Prader-Willi syndrome.
• Anticipate the outcome you are trying to generate. For example, is
there value in getting the person to admit to telling a tale? Avoid
unnecessary power struggles simply to prove a point.
People providing services and
supports to those with Prader-Willi syndrome are strongly encouraged
to explore alternatives to prone restraint. Restraint use should be
considered as a safety response, not as a therapeutic technique or
substitute for a comprehensive treatment plan. It is critical to
remember that when all is said and done, this is a human life —
someone’s child, sibling, grandchild and friend — and this person,
too, has value.
References
1 Schaars,Christopher; (Hampton Roads, Virginia) Daily Press;
April 13, 2003.
2 Charly Miller is an internationally
known EMS instructor and a restraint asphyxia expert witness. The
information above is referenced from an article on her web site
“Restraint Asphyxia-Silent Killer,” updated August 2002.
3 Paterson, B., Leadbetter, D., and
McCornish, A.; “Restraint and Sudden Death from Asphyxia,” Nursing
Times (94 44), pgs. 62-64, Nov. 4, 1998.
4 O’Halloran, R.L. and Frank, J.G.;
“Asphyxial death during prone restraint revisited: A report of 21
cases,” The American Journal of Forensic Medicine and Pathology,
21(1) pgs. 39-52, March 2000.
5 Paterson, et al.; O’Halloran, et
al.; and Stratton, S.J., Rogers, C., Brickett, K. and Gruzinski, G.;
“Factors associated with sudden death of individuals requiring
restraint for excited delirium,” The American Journal of Emergency
Medicine, 19,(3), pgs. 187-191, May 2001.
6 Parkes, J; “Sudden death during
restraint: a study to measure the effect of restraint positions on
the rate of recovery from exercise,” Medicine, Science, and the Law,
40(1), pages 39-44, January 2000.
7 Reay, D.T., Howard, J.D., Fligner,
C.L. and Ward, R.J.; “Effects of positional restraint on oxygen
saturation and heart rate following exercise,” The American Journal
of Forensic Medicine and Pathology, 9(1), pages 16-18, 1988.
8 Case study in Protection and
Advocacy, Inc. Investigations Unit report by Dr. Werner U. Spitz,
“The Lethal Hazard of Prone Restraint: Positional Asphyxiation,”
Publication No. 7018.01, p. 26, Oakland, CA, April 2002.
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