All Tied Up In Knots!

It's a hot Friday night in the city and your ambulance and the engine company stationed at your engine house are dispatched to an assault on the street. You are provided with a staging area and you wait there until the police have secured the scene.

After several minutes in staging, the dispatcher informs you that the scene is secure and you can proceed in. Once on the scene, you see three police officers wrestling with a large man who is face down on the ground. The patient appears to be under the influence of drugs or alcohol and is kicking, cussing and spitting at the police officers. One officer is kneeling on the man's back while the other two are attempting to wrestle his arms behind his back so they can handcuff him. Some of the engine company members are helping to restrain the patient by holding down his legs.

Finally, the man is handcuffed and the police officer who was kneeling on his back asks you for something he can use to tie up the suspect even more. You hand him some Kling bandage, which he ties around the patient's ankles, then raises his legs and ties the Kling to the man's wrists. Your patient is now "hog tied." As everybody steps back, the engine company captain tells the police officers that he has heard something about restraining patients in this manner, and that they can die.

Fire personnel who have restrained patients in various methods for their own safety have found themselves the subject of lawsuits as a result of wrongful deaths when the patients died. Some of these deaths have been labeled as "positional asphyxia," "restraint asphyxia" or "in-custody sudden death."

From time to time, I am called upon as an expert witness to defend fire and EMS personnel who are being sued as a result of their methods of restraint. Some cases are very defendable, while others cause you to wonder what they were thinking? One "What were you thinking?" case involved an engine company and ambulance crew who "sandwiched" a handcuffed patient between two backboards, handcuffed the backboards together, and then went to the hospital with no police officer in the back of the ambulance or following in a police car. Unfortunately, the patient arrested enroute to the hospital. Medics were unable to access the patient since nobody had a handcuff key. Only after arriving at the hospital did a security guard with a handcuff key free the patient from between the backboards.

The term "positional asphyxia" was coined by Dr. Donald Reay, chief medical Examiner for King County, WA, several years ago to describe patients who died in custody while being restrained. Reay conducted a study in 1988 to determine the oxygen recovery rate of the body when influenced by extreme exertion (such as when a patient fights or becomes violent with police or fire personnel). The main purpose of the study was to determine if the oxygen level in the body decreased after exercise. Even more significant, he studied what effect might body position, specifically weight on the chest and stomach, have on one's ability to recover to a normal heart rate and blood oxygen level. He also studied whether the way in which one is restrained and the position of the body can impair the mechanical respiratory process in inhaling and exhaling.

Based on Reay's findings, many police and fire departments took the information at face value and changed procedures for restraining patients. There were no scientific studies to dispute or validate Reay's findings. However, that all changed in a 1998 court case involving family members of a person who died while in police custody.

San Diego County sheriff's deputies got into a violent confrontation with an individual who was exhibiting unusual behavior and was suspected of being under the influence of a drug. To control the violent individual, the deputies placed him face down, handcuffed with his hands behind his back. However, he continued to resist, struggle, yell and kick at the deputies. To control the kicking, the deputies bound his legs together with shackles. Nonetheless, he continued to kick at the deputies. To further control him, the deputies held him down with their body weight and connected the leg shackles to the handcuffs with a second pair of handcuffs. At this point, the individual was in a four-point restraint, or "hog tied."

The individual continued to show signs of violence, including banging his face into the ground repeatedly. At some point, he began turning blue, so the deputies called for the fire department. The medics arrived within minutes, but found the patient pulseless and not breathing. Subsequently, he died. The family filed suit, alleging excessive force, wrongful death, assault, battery and negligence. One of the main focuses of the trial was the phenomenon of "positional asphyxia," including testimony from Reay about his previous findings. In response to his testimony, the defense counsel requested a new study be conducted at the University of California, San Diego (UCSD).

The UCSD study identified weaknesses in the methodology of Reay's study and concluded that his results were invalid. The study determined that the blood needs no replenishment after exercise because it already has adequate oxygen. Reay agreed that the UCSD test was valid and some parts of his study appeared to be flawed. As a result, the U.S. District Court, Southern District of California ruled that the "hog tie restraint was not considered deadly force" under this particular case.

The key word to handling any violent patient is "safety." As violence against fire and medical personnel continues to rise, more training is needed on managing violent patients. Fire personnel must learn proper assessment techniques to determine threats and methods for restraining patient to prevent injury to themselves and their patients.

Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, serves as the director of emergency services for Jefferson County, MO. He retired as chief paramedic from the St. Louis Fire Department after serving the City of St. Louis for 24 years. Ludwig has trained and lectured internationally and nationally on fire and EMS topics. He also operates The Ludwig Group, a professional consulting firm. He can be reached at 636-789-5660 or via