CHAS' REVIEW of Death of a Psychiatric Patient During Physical Restraint. Excited delirium – A Case Report

CHAS' REVIEW CITATION:
Miller CD. Review of Death of a psychiatric patient during physical restraint.
Excited delirium – A case report. March, 2005.
http://www.charlydmiller.com/LIB05/2001psychcasereview.html

CITATION of Reviewed article:
Morrison A, Sadler D;
Death of a psychiatric patient during physical restraint. Excited delirium – A case report.
Med Sci Law 2001 Jan;41(1):46-50.

Morrison and Sadler did a very, very good job of reporting the case information that generated their Case Report article. They provided ALL the most vital information related to the pre-restraint period, the period of lethal restraint application, and the autopsy findings.
Unfortunately – although they never actually STATED SO – the wording of their Case Report "introduction," and the wording of their case-related literature discussion, strongly seems to infer that they surmised excited delirium to be responsible for the death in this case.
Yet, from the case information they provided, it is abundantly clear that this gentleman died ONLY due to restraint asphyxia.

FIRST:

Plz remember that there NEVER has been a published case study describing someone who died SOLELY due to excited delirium. There NEVER has been a published case study describing someone who died due to excited delirium in the ABSENCE of a lethal amount of trauma (such as a jump from a building), or in the ABSENCE of an asphyxial form of restraint being employed at the time of death.
The Farnham and Kennedy letter that Morrison and Sadler cite to support their statement that "sudden deaths have also been described in cases of hypomania and schizophrenia" does NOT support it.(1) Farnham and Kennedy didn't provide a single case reference in their letter to support such a statement. In fact, within their letter, Farnham and Kennedy failed to "reflect the forensic literature fairly," ... omitted "evidence from key publications," ... and "twice misattributed statements to a paper that specifically excluded such deaths from the reported study."(2)

NEXT; consider the case information:

Morrison and Sadler describe a "25-year-old man of muscular build" who was the victim of a "witnessed street assault." When the police arrived, he was discovered "stripped to the waist and exhibiting violent, aggressive and threatening behavior. He was extremely agitated, running around, punching house and car windows and repeatedly chanting 'Vietnam' and 'Space'. He was apprehended by two police officers but slipped from their grasp due to his upper torso and arms being heavily smeared with his own blood. When apprehended again he was struck twice with a truncheon and finally handcuffed by the collective efforts of nine police officers. He was placed prone in a police van for transport to the local police station."
I find it amazing that the victim didn't die during the handcuffing restraint procedure performed on scene by "nine police officers!" (Clearly, this had to involve a lengthy episode of forceful-prone-restraint. I can only presume that the officers managed to allow the victim to roll from side-to-side often enough to continue being able to breathe.) Furthermore, the only reason that the victim didn't die enroute to the police station was because he likely was able to roll OFF of his belly after having been tossed, prone, into the police van.
"Overnight his mental state varied from calm to agitated with incoherent chanting of 'Motorbike' and 'LSD'. The police surgeon attended again at 08.30 and arranged admission to a local psychiatric hospital ... Following an intramuscular injection of Droperidol 20mg, he remained calm during transfer and also throughout the afternoon, accepting two further oral doses of Droperidol 20mg. However, at 21.00 [in the psych hospital] he became aggressively threatening and was given 20mg of Droperidol without effect. He struggled against physical restraint for a period of approximately 90 minutes, during which time he was given two injections of Chlorpromazine, 50mg."

NEXT; consider the restraint information:

"The method of restraint used throughout by the [psych hospital] nursing staff was later reconstructed at the direction of the police officer who had taken their statements. Although positions and grips altered, the patient spent most of this time pinned on his right side with his torso twisted so that the pelvis and anterior thighs were flat on the bed. Both legs and the right arm were held flat on the bed by a nurse at each site ..."
If someone's "pelvis and anterior thighs" are forcibly held "flat on [a] bed," that person's ABDOMEN is compressed by the weight of several individuals, and the function of his DIAPHRAGM is significantly interfered with! Thus, this was NOT a "SIDE" positioned restraint maneuver. This was a form of forceful-prone-restraint – a form of asphyxial restraint – and it was maintained for "approximately 90 minutes."

"...a fourth nurse held the left arm obliquely across the left side of the chest and a fifth nurse applied a neck hold to prevent him from biting. During controlled release, after he had finally quieted, it was noticed that the patient had stopped breathing. Attempts at resuscitation were unsuccessful."
This victim's death is NO surpriZe.
This victim "stopped breathing" long before he "quieted," because his struggle against restrainers continued even after he went into respiratory arrest – even after he lost consciousness.(3,4) Thus, he wasn't released from restraint until after respiratory arrest caused his HEART TO STOP BEATING – because THAT was when his body finally stopped struggling and he "quieted."(3,4)
Furthermore, had the victim merely been in "respiratory arrest" (had the victim merely not been breathing) when he was released from restraint, resuscitation likely would have been SUCCESSFUL.(5)

LASTLY; consider the AUTOPSY FINDINGS:

The victim's autopsy revealed "no significant acute natural disease or internal trauma to account for death." He didn't have any form of respiratory or cardiovascular disease that could be considered responsible for his death ... the trauma he suffered couldn't be considered responsible for his death ... and, he wasn't lethally poisoned or overdosed on drugs or alcohol.
The victim's traumatic findings at autopsy consisted primarily of "numerous scattered bruises ... minor superficial abrasions." And, it couldn't be definitively determined which of these non-lethal bruises and abrasions occurred due to the assault he suffered prior to police intervention; or occurred due to the "assault" he suffered DURING police intervention.
HOWEVER! "The most significant injuries were to the left side of the chest. On the skin surface there was a triangular bruise, imprinted with a pattern resembling the weave of the jumper provided to him on arrival at [the psych] hospital. Reflection [peeling-back] of the skin revealed deep bruising in the left lateral pectoralis [breast] muscle, dislocations of the left second, fourth and fifth costochondral junctions and fractures of the left third and sixth ribs anteriorly. [PLZ note that the victim's costochondral dislocations and rib fractures could have occurred during CPR performance!] There was bruising in the subcutaneous fat and muscle along the medial aspect of the left upper arm. Together, these injuries can be simply explained by the left upper arm being pulled obliquely across the left chest during restraint."
AND: "Toxicological analyses revealed a subtherapeutic level of paracetamol [acetaminophen ... aka "Advil"] in the blood and therapeutic levels of chlorpromazine in the blood and liver. Screening for Droperidol and drugs of abuse was negative." FINALLY: "The cause of death was given as 'positional and restraint asphyxiation in acute psychotic delirium', the latter due to an acute exacerbation of his pre-existing psychiatric illness and concomitant drug abuse."

Considering all the above case information, WHO in their right mind would attribute this death to anything OTHER THAN restraint asphyxia? Only someone interested in absolving restrainers from "responsibility" for having caused the death – that's who.

As To Morrison and Sadler's DISCUSSION of restraint asphyxia literature:

Morrison and Sadler appropriately and admirably describe Chan et al.'s 1997 clinical study report(6) as being of NO VALUE to the investigation of this – or ANY other – "real life" case of death occurring during restraint.(7)

"...15 healthy adult males were monitored during four minutes of exercise and 15 minutes of restraint, failed to demonstrate any 'clinically relevant' changes in heart rate, oxygen saturation or ventilation parameters. However, studies of this type contribute little to our understanding of restraint-related fatalities since they cannot reproduce the extreme physiological changes, psychological stresses, struggle and exhaustion of a prolonged real life capture-restraint situation."

Basically, most of the time, Morrison and Sadler offered appropriate and admirable discussions of the literature. But, in spite of this, they contradicted their own discussions by ultimately electing to attribute a greater importance to "stress" having caused the death, than to the actual manner of restraint application having caused the death.

As To Morrison and Sadler's PREVENTION section (their "SUMMARY"):

I entirely agree with them that, "Acute excited states should be regarded as a psychiatric emergency with an associated mortality." What Morrison and Sadler fail to identify, however, is that "acute excited states" are only associated with "mortality" (death) when the victim is subjected to an asphyxial form of restraint.

I entirely agree with Morrison and Sadler that, "Increased awareness of the features of acute excited states and adequate training of exposed clinical staff in the use of ... safe control and restraint techniques are essential to the safe management of excited states. If restrainers aren't ADEQUATELY educated as to the causes of restraint asphyxia, they cannot possibly hope to perform methods of SAFE RESTRAINT.

I entirely agree with Morrison and Sadler that, "All sudden unexplained psychiatric deaths should be reported to the Procurator Fiscal or Coroner so that a clear view of their true incidence and causative factors can be established. Medico-legal investigation requires detailed witness accounts, photographic evidence of the scene, full post-mortem examination and toxicology. Only with such complete information can the pathophysiology and mechanism of death be reconstructed."

I entirely agree with Morrison and Sadler that, training staff to "avoid direct neck" pressure is essential.

But, regarding Morrison and Sadler's statement that, "The most important practical measures are to minimize the length of time an individual is held prone and to avoid direct ... chest pressure": This statement clearly demonstrates that Morrison and Sadler ENTIRELY MISUNDERSTAND THE PATHOPHYSIOLOGICAL CAUSE OF RESTRAINT ASPHYXIA!
Forms of restraint that cause "Chest pressure" are NOT the killer. The killer is forms of restraint that cause ABDOMINAL compression ... forms of restraint that cause interference with the ability of the DIAPHRAGM (the largest respiratory muscle) to function.(4)
AND, simply indicating that "the length of time an individual is held prone" should be "minimized" entirely fails to identify HOW MUCH TIME is "minimal" to kill someone.

REVIEW SUMMARY:

Morrison and Sadler effectively provided case study information identifying yet another incident of restraint asphyxia death. Unfortunately, apart from their admirable provision of case-facts, their article is somewhat detrimental to the goal of STOPPING restraint asphyxia deaths.

YOURS, CHAS

REVIEW REFERENCES:

(1) Farnham FR, Kennedy HG. Acute excited states and sudden death - much journalism, little evidence. BMJ November, 1997;315:1107-1108.

(2) Pounder D. Death After Restraint Can Be Avoided. BMJ April, 1998; 316: 1171.

(3) Swann HG and Brucer M. The cardiorespiratory and biochemical events during rapid anoxic death – Obstructive asphyxia. The Texas Reports on Biology and Medicine, 1949;Vol. 7; pgs 593-603.

(4) Miller CD. Restraint asphyxia – silent killer; Parts one and two. Feb 1998 – Sep 2004.
http://www.charlydmiller.com/RA/restrasphyx01.html

(5) Miller CD. Restraint-related positional asphyxia "near-death" - a case study. August, 1998.
http://www.charlydmiller.com/RA/neardeath01.html

(6) Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional asphyxia. Ann Emerg Med, November 1997;30:578-586.

(7) Miller CD. A comprehensive review of frequently misinterpreted and misrepresented restraint research. February, 2005.
http://www.charlydmiller.com/LIB05/2005chasresearchreview.html

Email Charly at: c-d-miller@neb.rr.com
(Those are hyphens/dashes between the "c" and "d" and "miller")