Restraint Asphyxia Near-Death Case Study


This case exemplifies the Classic Set-Up for a restraint asphyxia death. The patient experienced each of the “Three Phases of Extreme Muscle Exertion and Energy Expenditure” that I identify in my restraint asphyxia article.

[To learn more about these Phases, see Part Two of “Restraint Asphyxia – Silent Killer”


This previously healthy, 20-year-old male spent an unknown period of time running around a middle-class residential area while nude and in a state of “excited delirium” (also called, “agitated delirium”). Due to the time of day (midnight to 0100 hours) and type of neighborhood, it is likely that the patient may have engaged in this hyperactivity and extreme physical exertion for up to an hour, prior to someone noticing him and becoming concerned (irritated) enough to call the Police.

This activity represents the “Pre-Intervention” Phase of activity that traditionally precedes all known restraint-related positional asphyxia deaths.

NOTE: This call occurred in the month of August – a warm, “summer” month. However, in Denver, Colorado, temperatures often dip well below 50?F at one o’clock in the morning – even in August. Oblivious to the cold temperature, the patient had removed all of his clothing, and was “running all over the place” (according to 911 dispatch information). It is entirely unknown whether the hypothermia that likely accompanied this individual’s respiratory arrest may have effected him in a positive manner – delaying his restraint asphyxia cardiac arrest – or not.


Police officers arrived. Their attempts to control the patient with verbal cues were completely unsuccessful. A brief chase ensued, and the patient had to be “tackled” in order to take him into custody. Thus, the patient experienced a Second Phase of Extreme Physical Exertion while running from the Police and then struggling with them after being taken down to the grass.

His wrists were handcuffed behind his back, but the individual persisted in extremely forceful and violent, very threatening, combativeness. The officers report him screaming and calling out unintelligible phrases. It is likely that the initiation of forceful prone restraint occurred during this period of time. Once one of the officers had recuperated and had a hand free, he took his radio off of his belt, and called for his supervisor and a nonemergent ambulance.

It is unclear whether the patient’s facial trauma was present before Police intervention, or occurred during Police intervention – and I’m NOT going to go there! The dark color of the bruising I observed about the patient’s right eye could indicate trauma that was over an hour old (thus, might not be attributable to police intervention trauma). Easily, multiple superficial body abrasions and contusions could have occurred either during the patient’s activity prior to Police contact, or during the Police tackle and subsequent wrestling match on the residential front lawn.

The violent muscular activity that occurs during the first two phases of extreme energy expenditure (continuing into the third phase) causes an excessive production of various body chemicals and hormones (“catecholamines”). The systemic “hypercatabolic state” that results from all these chemicals and hormones weakens all of the body's muscles – especially the respiratory muscles.

Dr. Reay et al report, "Energy that is expended by the contractile machinery (the arms, legs, back and abdomen) of the body is subtracted from the respiratory muscle needs. Muscle fatigue may induce the central nervous system to shunt energy to contracting muscles. A deficit in energy supply to respiratory muscles can influence their performance. A decrease in chemical energy supply to respiratory muscles will hasten their failure as well as the failure of other muscle groups."(1)

Additionally, Dr.s O'Halloran and Lewman conclude, "First, the psychiatric or drug-induced state of agitated delirium coupled with police confrontation undoubtedly places catecholamine stress on the heart. Second, the hyperactivity associated with agitated delirium coupled with struggling with police and against restraints undoubtedly increases the oxygen delivery demands of the heart and lungs."(2)

Translation of the above two paragraphs: Such extreme energy expenditure leads to serious muscle fatigue, energy-depleting chemicals and hormones racing through the person’s system, diminished respiratory system function, increased stress upon the heart, and diminished oxygen delivery to the heart. And that’s just phases one and two!


In spite of handcuff application and multiple officers physically restraining his prone body, this individual persisted in forceful attempts to defeat and escape restraint, presenting a continued threat of harm to himself and others. At this point, the officers decided that maximum restraint (hobble restraint) was required. If forceful prone restraint did not occur prior to this time, it certainly began now. Whenever forceful prone restraint was initiated, from that moment on, the patient’s physical ability to breathe became seriously impaired.

Upon my arrival, one officer was kneeling with one knee pressed against the patient’s head while it was turned to the left side – pushing it into the grass.

It is possible that this forceful head-to-the-side-maneuver may have produced carotid vagal stimulation similar to that of a “choke hold.” Carotid vagal stimulation slows the heart. The longer vagal stimulation is continued, the slower the heart beats – until it stops.

Upon my arrival, the patient had a pulse somewhere around 120 per minute.

Thus, I am NOT inclined to consider “vagal stimulation” a contributing factor to the patient’s respiratory arrest. It remains likely, however, that the forceful head-to-the-side-maneuver may have diminished the size of the patient’s airway. Thus, this head restraint method, in combination with forceful prone positioning, could have increased the patient’s inability to breathe.

At least two officers were pushing down on the patient’s trunk while he was prone. With his chest and abdomen forcefully compressed to the ground, this patient was unable to easily expand his chest or move his diaphragm (the major muscle of respiration). Thus, every breath that this patient attempted to take required an ominously extreme effort.

Additionally, according to several officers’ initial (unguarded) reports, the individual was still “screaming and struggling” (expending energy and breath) as an officer tied his ankles together and drew them up to his restrained wrists.

Since he had already experienced phases one and two of extreme energy expenditure, this patient had very little (if any) physical energy left to breathe with. Once his chest and abdomen were prevented from moving (by virtue of the forceful-prone-restraint inflicted upon him), this patient rapidly became lethally exhausted and entirely unable to breathe. As I witnessed: even prior to the hobble restraint being fully connected to his posteriorly-bound, handcuffed, wrists; this patient entered respiratory arrest. He stopped breathing and began to DIE.

SIDEBAR: I sincerely believe that this patient
Survived ONLY due to SHEER LUCK.

Denver paramedics are not “required” to monitor police radio traffic. Some of us do, some of us don’t. I do – sometimes. Lucky for this patient, I happened to be listening-in when this police investigation was aired, and recognized a situation representing the precursors for restraint asphyxia.

Additionally, not all Denver paramedics go enroute to a Police ambulance request until we are actually “dispatched” to do so. Lucky for this patient, I recognized that we were the closest unit, and decided we might as well start driving toward the scene. If I had waited to be “dispatched” to this call, our scene arrival (and subsequent intervention) would have been delayed by at least another two or three minutes.

I sincerely believe that this patient would have been in full cardiopulmonary arrest if we had waited to be “officially” dispatched. And, when one looks at the documented occurrences of this sort of death, patients who die from restraint-related positional asphyxia stay dead! You can’t get them back – even when they arrest in the lap of an experienced paramedic!(1, 2, 3)

Lucky for this patient, we just happened to arrive before he went into full arrest, “accidentally” giving him the opportunity to survive.


Physical examination, X-rays, CT scans, and laboratory (toxicology) reports revealed that this was a healthy, well nourished, 20 year old male, with no alcohol in his system.
(I find that amazing! But, it’s true.)

The only “drugs” found in his system were caffeine, marijuana, and mushrooms – NONE of which would have caused his respiratory arrest! No narcotics, barbiturates, benzodiazepines, PCP, methamphetamines, or other hallucinogens were found in this patient’s system.

This patient had no signs of closed head injury, no indications of significant chest trauma. This patient had no medical history of respiratory disease, or any other chronic medical or psychiatric disorder. This patient had no medical, traumatic, psychiatric, or toxicological reasons for his breathing to have stopped.

Because ALL other potential causes of respiratory arrest were
explored and found ABSENT, the only remaining explanation of
why this patient stopped breathing and nearly died, is
Restraint-Related Positional Asphyxia.

If you are divinely inspired to read more MEDICAL DETAILS about the Hospital-Care aspects of this case, go to any or all of the following pages:

And then, Come Right Back!


This case study’s patient went into respiratory arrest only because he was placed on his stomach and forcefully held there (subjected to forceful-prone-restraint), following a prolonged period of extreme physical energy expenditure and excited/agitated delirium. If this patient had gone into full cardiopulmonary arrest, it would likely have been impossible for me to have resuscitated him. (And, I’m an experienced – aggressive – emergency care provider!)

If this case study’s patient had died, the City and County of Denver’s Police Department would have been sued. Every Police officer involved with the application of restraint would likely have suffered Serious Litigation Trauma (perhaps losing their jobs, in the process).

The ONLY reason serious litigation did not accompany this individual’s case, was because he didn’t die. And, since he didn’t die, NO ONE, other than the emergency responders and ED personnel, EVER KNEW THAT HE HAD BEEN IN RESPIRATORY ARREST at one point. TO THIS DAY, the patient and his family remain entirely OBLIVIOUS to the fact that this kid was “half-dead” (“almost dead”) at one point!

Regarding This Case:

Did this incident (experienced and witnessed by several Denver Police Officers – including at least one DPD Supervisor) result in any DPD restraint procedure changes? … any DPD restraint protocol changes? … or, any OTHER DPD actions,
to prevent a similar death from occurring?

NO! It Did Not!
No “Foul” = No Action.
I am NOT HAPPY about that.

As Police Officers, Fire and EMS personnel, we are responsible for the protection of citizens, the protection of ourselves, and the reasonable protection of individuals threatening citizens and ourselves! In order to provide public- and self-protection, we often have to resort to extreme restraint. But, how can we protect ourselves (and our employers) from the incredibly expensive (life-mutilating and career-ending) litigation that will follow our contribution to someone’s Restraint Asphyxia death?

There are two GOLDEN RULES to Preventing
Restraint Asphyxia Deaths and Related Litigation:



Such seemingly SIMPLE rules! Yet, so few services are willing to provide responders with the education that can accomplish realization of these practices! And, EDUCATION is the vital KEY to accomplishing change!

First, we must educate and train all personnel to recognize situations that cause any individual to be at risk for Restraint Asphyxia:

  1. Anytime someone has been running around in a hyperactive and “crazy” manner, expending extreme physical energy for any period of time before you get there –
    that individual is at risk for restraint asphyxia.

  2. Anytime you have to chase and/or tackle someone, and then have to wrestle with them (even while they’re on the ground and already minimally restrained) –
    that individual is at risk for restraint asphyxia.

  3. Anytime that having their wrists handcuffed behind their back, with or without ankle restraint, is not enough restraint to protect citizens and providers from an individual’s violent combativeness –
    that individual is at risk for restraint asphyxia.

  4. [Subsequent to this case study, I have discovered that another “indicator” of someone significantly at risk for restraint asphyxia, is the individual who seems “immune” to pepper spray (or Freeze-Plus P – a combination of pepper spray and CS (tear gas)!]

Next, we must change our manner of restraining threatening individuals – especially those who are at risk for restraint asphyxia.

Unfortunately, promoting ANY kind of CHANGE in any long-practiced method of operation is enormously difficult. (All of us hate change!) But, if we want to protect ourselves from suffering the emotional and legal consequences of killing someone, we have to change our methods of restraint. And it CAN be done!

What’s really fun!: The only CHANGE, the only modification of the time-honored methods of Police (Fire and EMS) restraint that is needed, is to


Alternative Restraint Methods For POLICE PERSONNEL:

Chase them, tackle them, jump on them – do whatever you have to do stop their violent rampage, and to protect the public and yourself from immediate threat.
But, keep them on their side while you’re doing it!

Pull their arms behind their backs and put the handcuffs on. But, then IMMEDIATELY roll them to their side. If they continue to be violently combative, apply more restraint!
But, keep them on their side while you’re doing it!

Sit on their shoulders … Sit on their hips… Sit on the side of their chest – “DOG PILE” on them if you have to! Just keep them on their SIDE. As long as they remain on their side, they will be safe, and YOU will be safe. As long as they have the front of their belly free to breathe with,
they will NOT die of “restraint asphyxia.”

Tie their ankles together and even apply a hobble restraint if their degree of combativeness requires one. Do whatever you have to do to keep everyone safe,
But, keep them on their SIDE while you’re doing it!!!

This “keep them on their side” rule
will not necessarily prevent INJURY to the restrained individual!

BUT, it will prevent them from DYING due to restraint asphyxia!

By now, you should be getting the idea that you are “SAFE” only as long as you don’t Kill Them! And, if you keep them on their SIDE, you won’t “kill them.” If you keep them on their side, they will not die from restraint asphyxia. If they don’t die from restraint asphyxia, you won’t be litigated by the family and friends of this person who was threatening the lives of citizens and yourself.

Alternative Restraint Methods For FIRE and EMS PERSONNEL:

Because we also apply restraints, we are subject to the same restraint-asphyxia-death (and litigation) threat as Police Officers. Happily, Fire and EMS personnel have the luxury of things such as long back boards or wheeled stretchers to use when restraining a violently combative patient. With these devices, the individual can be restrained in a SUPINE manner – without any chest or abdominal restriction.

However, Fire and EMS personnel require an even greater degree of restraint – “immobilization” than do Police Officers. All that Police Officers require is enough immobilization to prevent the threat of harm to the individual or others. Medical personnel (Fire and EMS) require a total-body-immobilization restraint.

In order for medical personnel to accomplish a thorough examination, and to ensure the unimpeded performance of all necessary medical care procedures, the patient cannot be able to move at all! We must be able to safely and completely access their entire body. Someone restrained on their belly cannot – at all – be thoroughly examined or treated. Someone restrained on their side is NOT easily, completely, or safely examined, or adequately cared for. Thus, Fire and EMS personnel must restrain the patient SUPINE – on their back – and in a manner that completely prevents them from moving.

Successful and safe restraint of patients in a supine position requires an understanding of restraint kinetics and the use of very specific restraint techniques. Such techniques are thankfully quite simple and easy to accomplish! Unfortunately, very few emergency medical care providers (or police officers) receive TRAINING (EDUCATION) in such techniques. In spite of this common education and training deficit, methods and techniques for safe and effective prone restraint DO exist.

[To read about the safest and most effective methods of restraint, see Parts 1, 2, & 3 of “All Tied Up & No Place To Go!” on my RESTRAINT ASPHYXIA NEWZ Directory.]


The only way we can avoid causing Restraint Asphyxia death is to
Educate all personnel about the causes of Restraint Asphyxia,
AND, alter the manner in which we restrain people!

[These ALL can be found in my Restraint Asphyxia Library]

  1. Reay DT, Fligner CL, Stilwell AD, Arnold J: Positional asphyxia during law enforcement transport. Am J Forensic Med Pathol, 1992;13(2):90-97.

  2. O'Halloran RL, Lewman LV: Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol, 1993;14(4):289-295.

  3. Stratton SJ, Rogers C, Green K: Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med, May 1995;25:710-712.

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