Prone positioning: Therapy or apathy?

Any conscientious EMS provider who watched the police body cam video preceding the death of Earl L. Moore, Jr. in Springfield, Illinois, should be sickened by the attitude and apathy of the EMS providers involved. The patient died during transport and, judging from the lack of interest of the EMS providers in the bodycam video, I’m not sure they even realized it.

The Sangamon County coroner determined that Earl Moore, Jr. died of compression and positional asphyxia.

The facts surrounding his death will no doubt come out in court as both providers were charged with first-degree murder. While many of us who read the story question the appropriateness of a first-degree murder charge, Illinois law does not require premeditation [1]:

A person who kills an individual without lawful justification commits first-degree murder if, in performing the acts which cause the death:

1. He or she either intends to kill or do great bodily harm to that individual or another, or knows that such acts will cause death to that individual or another; or
2. He or she knows that such acts create a strong probability of death or great bodily harm to that individual or another; or
3. He or she, acting alone or with one or more participants, commits or attempts to commit a forcible felony other than second degree murder, and in the course of or in furtherance of such crime or flight therefrom, he or she or another participant causes the death of a person.

Read Section 2 again. If today, in 2023, you don’t know that prone positioning can cause great bodily harm or death in some patients, you are either irreparably stupid or you have been pencil-whipping your continuing education for 20 years.

Either way, you don’t belong in EMS.

There may be a place for prone positioning in EMS transport – some ventilated patients with respiratory illness come to mind, as do some cases of patients with severe facial trauma and possible airway compromise – but the key component of those exception is thorough assessment and frequent reassessment.

Does anyone who saw that video believe that thorough and frequent assessment was performed on Earl Moore, Jr.? EMT Peggy Finley did absolutely no assessment of the patient in the house; all she did was write down a few demographics and speak to the patient in a surly and apathetic manner. EMT Peter Cadigan didn’t even come inside. What kind of EMS crew splits themselves up on a call where they have only one patient and adequate help?

Even more concerning is this: nobody wakes up one morning and decides to be the world’s crappiest EMS crew. The attitude displayed in that bodycam video is not an anomaly for that crew. The question must be asked, what did their employers know about their past behavior, and if there were incidents, what did they do about them?

From a broader perspective, what does it say about the prevalence of fatigue and burnout in our profession that a crew this apathetic is still rendering patient care?

This is a symptom of a systemic illness in EMS that our agency leadership and public officials need to address, and one that no amount of pizza parties is going to fix.

Prone positioning and positional asphyxia

Positional asphyxia is an impairment of respiration and ventilation, typically occurring with prone positioning of large or obese patients, particularly those with a protuberant abdomen. Crossed-arm restraint in large men can also interfere with chest excursion and cause a similar effect. Tidal volume is decreased due to limited chest expansion, and a host of sequelae follow; respiratory acidosis, atelectasis, pulmonary edema, organ and tissue ischemia, and so on. Any pre-existing cardiovascular or respiratory condition that can be exacerbated by hypoxia can and will be exacerbated by positional asphyxia.

There are a number of peer-reviewed studies that demonstrate that prone positioning and restraint with up to 25-50 pounds of weight placed between the shoulders does not impair respiratory or cardiovascular parameters in healthy and non-struggling volunteers [2-3].

Healthy and non-struggling volunteers.

Change that to unhealthy combative patient – like for example an excited delirium patient on sympathomimetic drugs, or an alcoholic patient with delirium tremens – and you can add metabolic acidosis, hyperkalemia and rhabdomyolysis to the list of harmful sequelae.

Yes, there are a number of case studies and reports of in-custody deaths of proned subjects, but that does not rise to the level of randomized, peer-reviewed research [4-6]. We have no randomized, double-blinded studies that demonstrate the medical dangers of prone restraint in unhealthy, combative patients.

Then again, absence of evidence does not equal evidence of absence.

As Bryan Bledsoe once said, “You don’t have to run a Chi Square test on common sense.”

Would transporting Earl Moore, Jr. in the semi-Fowler’s position with limb restraints have prevented his death? We have no way of knowing.

But we certainly wouldn’t be having this conversation if it had.

References

1. Illinois General Assembly. Illinois Compiled Statutes. Available at https://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=072000050K9-1
2. Chan, Theodore C. MD*; Neuman, Tom MD*†; Clausen, Jack MD†; Eisele, John MD‡; Vilke, Gary M. MD*. Weight Force During Prone Restraint and Respiratory Function. The American Journal of Forensic Medicine and Pathology 25(3):p 185-189, September 2004. | DOI: 10.1097/01.paf.0000136639.69128.bc
3. Savaser DJ, Campbell C, Castillo EM, Vilke GM, Sloane C, Neuman T, Hansen AV, Shah V, Chan TC. The effect of the prone maximal restraint position with and without weight force on cardiac output and other hemodynamic measures. J Forensic Leg Med. 2013 Nov;20(8):991-5. doi: 10.1016/j.jflm.2013.08.006. Epub 2013 Aug 30. PMID: 24237806.
4. Stratton SJ, Rogers C, Green K: Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med May 1995;25:710-712
5. Ross DL. Factors associated with excited delirium deaths in police custody. Mod Pathol. 1998 Nov;11(11):1127-37. PMID: 9831212.
6. Samuel J. Stratton, Christopher Rogers, Karen Brickett, Ginger Gruzinski. Factors associated with sudden death of individuals requiring restraint for excited delirium. The American Journal of Emergency Medicine, Volume 19, Issue 3, 2001, Pages 187-191, ISSN 0735-6757.